Acute coronary Syndromes Flashcards
What are risks of CVD?
smoking
hypertension
hypercholesterolaemia (high cholesterol)
diabetes
obesity
male sex
family history of early coronary artery disease
ethnicity
social deprivation
Why have death rates due to CVD declined?
fewer people smoking
screening and treatment for other CV risk factor
improved treatments for CV disease
statins do what?
a group of medicines that can help lower the level of low-density lipoprotein (LDL) cholesterol in the blood
What are modofiable risk factors?
smoking
hypertension
hypercholesterolaemia (high cholesterol)
diabetes
obesity
What are non-modifiable risk factors?
male sex
family history of early coronary artery disease
ethnicity
social deprivation
What are 3 types of symptoms for CVD?
stable (stable angina)
ACS - acute coronary symptoms
atypical/non-cardiac symptoms
What are stable symptoms of CVD?
chest pain/tightness on exertion - reproducible
may radiate to either arm or jaw - small minority of pts may think they have dental disease
often described as dull, heavy, tight, pressure, indigestion
angina equivalent - often breathlessness. much less specific
What is CVD stable symptoms described as?
often described as dull, heavy, tight, pressure, mistake for indigestion
What is angina equivalent?
often breathless
don’t have typical symptoms
hard to know whether it is the heart
What symptoms are more severe stable or ACS?
acute coronary symptoms
Describe the symptoms for ACS?
Chest pain/tightness, persisting at rest at rest or onset after very minimal exertion
pain is not always severe, especially in NSTEM (non-stem)
associated symptoms - nausea, vomiting, sweating, breathless
What are symptoms of ACS?
nausea, vomiting, sweating, breathless
Are pts undergoing cardiac arrest always in severe pain?
not always
What are the atypical/non-cardiac symptoms?
sharp pain - can locate a specific location
pain localised to small area of the thorax
worse on inspiration
chest wall tenderness/pain worse on movement
syncope (blackouts)
with regards to atypical pain, what do you call pain on inspiration?
Pleuromeia
What is the disease that CVS pts have?
atherosclerosis
Describe atherosclerosis?
blood vessel = 3 layers
endothelium gets damaged e.g. high blood sugar, diabetes, smoking
now lipids get into the wall of the vessel and for a plaque - atherosclerotic plaque (yellow)
Describe atherosclerotic plaque?
lipids at the core and fibrous coating around the outside
In stable coronary disease, what is the atherosclerotic plaque formation like?
gradual - the artery becomes gradually more narrowed
ischemia of myocardial tissue and cardiac arrest
In unstable coronary disease, what is the atherosclerotic plaque formation like?
more sudden
often an area with mild plaque - the fibrous cap over the top ruptures open
lipid core exposed to blood
then a cascade of platelet activation - thrombus form on top and blocks artery and causes sudden chest pain at rest
What happens if the thrombus completely blocks the artery?
causes ST-elevation myocardial infarction (STEMI)
an event in which transmural myocardial ischemia results in myocardial injury or necrosis
LESS SEVERE HEART ATTACK
What is STEMI?
an event in which transmural myocardial ischemia results in myocardial injury or necrosis
ST-elevation myocardial infarction (STEMI)
3 types of acute coronary syndrome?
STEMI
Non-STEMI
unstable angina
symptoms of STEMI?
chest pain
ST elevation on ECG
rise in troponin
symptoms of non-STEMI?
chest pain
no ST elevation on ECG
rise in troponin
symptoms of unstable angina?
unstable chest pain
no ST elevation on ECG
no rise in troponin
What is angina?
Angina is where you have attacks of chest pain caused by reduced blood flow to your heart.
What is cardiac troponin?
troponin T and I are cardiac regulatory proteins that control calcium mediated interaction between actin and myosin
2 types of cardiac troponin?
T and I
What does elevated troponin mean?
serum levels indicate myocardial damage
What can you do if a pts history is suggestive of MI?
serum troponin is used to either confirm or exclude the diagnosis
Can cardiac troponin be elevated due to other reasons other than MI?
YES
What are the 3 parts of an ECG to be aware of?
P wave
QRS complex
T wave
What does the P wave highlight on ECG?
atrial depolarisation
= contraction
What does the QRS complex highlight on ECG?
ventricular depolarisation
What T indicate on the ECG?
ventricular repolarisation
What does ST elevation mean?
ST segment is elevated
Normal or not normal ECG?
NORMAL
P wave
QRS complex
T wave
What is the name of the line the arrow is pointing to?
isoelectric line
Normal or not normal ECG?
NOT NORMAL
person having a STEMI
How can you tell this person is having a STEMI?
first column - THE SEGEMBNT ABOVE THE ISOELECTRIC LINE
artery in heart is blocked
What is VF?
a type of irregular heart rhythm (arrhythmia)
VENTRICULAR FIBRILATION
unorganised electrical activity
What does VF always cause?
MI
pt usually unconscious
What is the treatment for VF?
CPR + DC cardioversion (ALS algorithm) from defibrillator
Medications to treat ACS?
Aspirin - antiplatelet
other antiplatelet drugs - clopidogrel, ticagrelor, prasugrel
statins
ACE inhibitors
MRA - mineralocortocoid receptor antagonists
beta-blocker
What do the alternative antiplatelet drugs act upon?
P2Y12 receptor inhibitor
Does aspirin or the alternative antiplatelet drugs have a higher risk of bleeding?
the alternative antiplatelet drugs
clopidogrel, ticagrelor, prasugrel
Why are statin prescribed for ACS?
inhibit the production of LDL from the liver - BAD CHOLESTEROL
Examples of statins?
atorvastatin, rosuvastatin, simvastatin
Why are ACE prescribed used for ACS?
ramipril
perindopril
lisinopril
What drug is used to treat pts with heart failure after MI?
mra - mineralocorticoid receptor antagonists
What beta-blockers are prescribed for ACS?
bisoprolol
atenolol
metoprolol
Why prescribe beta blockers for ACS?
are drugs used to treat angina, lower blood pressure, protect against recurrent heart attacks
prevent VF
What is an alternative to medications for ACS?
revascularisation
What are to ways to achieve revascularisation for ACS?
- percutaneous coronary intervention (PCI)
- Coronary artery bypass surgery (CABG)
What is PCI?
small metal cage delivered on a wire in the artery
it squashes the plaque out the way
allows blood flow down the artery
What is CABG?
2 ways:
harvesting a vein form the leg - stitching it on to the aorta and to the coronary artery beyond the narrowing - restoring the blood flow
using arteries within the chest wall - can be used as well
CABG vs PCI?
CABG doesn’t do anything directly to the plaque causing the blockage
When is the bypass sugery good to use?
when a pt has 2 or more major coronary arteries affected or left main stem stenosis
and diabetic
What is DAPT?
dual antiplatelet therapy
= aspirin with one of the other ACS drugs
What does ST elevation indicate?
occurs due to occlusion of one or more coronary arteries, causing transmural myocardial ischemia which in turn results in myocardial injury or necrosis.
