Acute Coronary Syndromes Flashcards by Tim Resch

What are the risk factors for ACS?

Male
Family history
Smoking
Hypertension
DM
Hyperlipidaemia
Obesity
Sedentary lifestyle
Cocaine use

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Define ACS

Acute Coronary Syndromes

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What are the three different ACS’?

Unstable Angina
ST segment elevation myocardial infarction (STEMI)
Non-ST segment elevation myocardial infarction (nonSTEMI)

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What are the common underlying pathology of all ACS’?

Plaque formation in coronary arteries
Plaque rupture and platelet aggregation
Thrombosis, vasoconstriction, thromboembolism
ISCHAEMIA

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What is Unstable Angina?

Angina occurring at rest OR sudden increased frequency/severity

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What is the cause of Unstable Angina?

Plaque rupture and platelet aggregation

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What are the two types of Acute Myocardial Infarction?

STEMI

NSTEMI

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What are the three patterns of AMI?

Regional Myocardial (90%)
Regional Subendocardial
Circumferential Subendocardial (10%)

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Define a Regional Myocardial AMI

Infarct of one segment of ventricular wall

Usually due to thrombus formation

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Define a Regional Subendocardial AMI

Infarct limited to subendocardial zone

Associated w/ thrombus lysis

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Define a Circumferential Subendocardial Infarction

General hypoperfusion of all coronary arteries

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What is required for a diagnosis of AMI?

Elevated troponin + 1 of:

ST elevation/new LBBB (STEMI)
No ST elevation/LBBB (NSTEMI)

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What are the key coronary arteries?

Right Coronary
Left Coronary
Circumflex
Left Anterior Descending

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What area does the RCA supply?

RA, RV, post septum
AVN/SAN
Gives post/inf MI –> Leads II, III, aVF

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What area does the LCA supply?

Antero-Lateral –> Splits into circumflex and LAD

Gives antero-lateral MI –> Leads I, aVL, V1-V6

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What area does the circumflex supply?

LA, LV

Gives a lateral MI –> Leads I, aVL, V5/6

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What area does the LAD supply?

LV, ant septum

Gives antero-septal MI –> Leads V1-V4

What is the end result of MI, with regards to cardiac tissue?

Replacement of necrotic area w/ collagenous scar

10 days-several months

What are the absolute contraindications to thrombolysis?

Previous intracranial haemmorhage
Ischaemic stroke <6/12
Cerebral malignancy
Recent major trauma
GI bleeding <1/12
Known bleeding disorder
Aortic dissection
Non-compressible punctures

What are the relative contraindications to thrombolysis?

TIA <6/12
Oral anticoagulant therapy
Pregnancy/<1/12 post partum
Refractory hypertension
Advanced liver disease
Infective endocarditis
Peptic ulcer
Prolonged/traumatic resuscitation

What are the 1st line thrombolytic agents in ACS?

Tissue plasminogen activators (alteplase)

What are the causes of ACS?

Atherosclerosis
Thrombosis
Inflammation
Less commonly
-emboli
-coronary artery spasm
-vasculitis

What is the mortality of STEMI ACS?

7% before discharge

- 50% of deaths w/i 2 hours,

What is the mortality of non-STEMI ACS?

1-2%

15% for refractory angina

What is the immediate pathway of care w/i the hospital for STEMI?

Record ECG Get i.v. access Assessment of CVD, examination, identify CIs Give Aspirin 300mg Give Morphine 5-10mg i.v. + 10mg metoclopramide GTN spray Either PCI or Fibrinolysis

What is the immediate pathway of care w/i the hospital for NSTEMI/UA?

``` Give low flow O2 if SaO2 <90%/SOB Analgesia (Morphine 5-10mv i.v. + anti emetic) Nitrates Aspirin (300mg) Fondaparinux/Clopidogrel Elective PCI ```

What are the TIMI/GRACE scores?

TIMI - categorises risk of death/ischaemia/basis of therapeutic decision making GRACE - helps assessment of future risk of death due to MI in patients w/ ACS

What are the symptoms of ACS?

Severe crushing, gripping, heavy chest pain >20 minutes Radiates to L.arm, neck, jaw Associated dyspnoea, nausea, fatigue, sweatiness, palpitations

What are the signs of ACS?

Sympathetic Activation --> Tachycardia, HTN, pallor, sweating Vagal Stimulation --> Bradycardia, vomiting Myocardial Impairment --> Hypotension, narrow pulse pressure, raised JVP, basal creps, 3rd heart sound

What are the ST changes in a non-reperfused STEMI?

5 mins --> Tall, pointed T waves 30 mins --> ST elevation >2hrs --> T wave inversion, Q waves develop (pathognomic) Days --> ST normalises Weeks --> T wave may normalise, Q wave remains

What is the long term management of ACS?

``` Aspirin 75mg OD (for life) Bisoprolol (for life, titrate to 60bpm) Clopidgorel 75mg OD (1yr) Atorvostatin 80mg ON Ramipril 2.5mg BD ```

What are the immediate complications of AMI?

Arrhythmias (VT/VF/AF) | Bradycardia/AV block

Whar are the short term complications of AMI?

``` Pulmonary oedema Cardiogenic shock Thromboembolism VSD Ruptured chordae tendinae Rupture of ventricular wall (2-10/7) ```

How does pulmonary oedema present?

Extreme dyspnoea, sweating, anxiety, frothy cough w/ blood stained sputum) PO2/PCO2 fall (PCO2 later rises)

What is VSD associated with?

Development of severe LVF

What is a ruptured chordae tendinae associated with?

Mitral valve incompetence

What is a ruptured ventricular wall associated with?

Haemopericardium Cardiac tamponade Death

What are the long term complications of AMI?

Heart failure Dressler's syndrome Ventricular aneurysm formation

What is Dressler's syndrome?

Immune mediated pericarditis

What is the treatment for Dressler's syndrome?

High dose aspirin/NSAIDs

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Acute Coronary Syndromes Flashcards

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