Acute Coronary Syndromes Flashcards
What are the risk factors for ACS?
Male Family history Smoking Hypertension DM Hyperlipidaemia Obesity Sedentary lifestyle Cocaine use
Define ACS
Acute Coronary Syndromes
What are the three different ACS’?
Unstable Angina
ST segment elevation myocardial infarction (STEMI)
Non-ST segment elevation myocardial infarction (nonSTEMI)
What are the common underlying pathology of all ACS’?
Plaque formation in coronary arteries
Plaque rupture and platelet aggregation
Thrombosis, vasoconstriction, thromboembolism
ISCHAEMIA
What is Unstable Angina?
Angina occurring at rest OR sudden increased frequency/severity
What is the cause of Unstable Angina?
Plaque rupture and platelet aggregation
What are the two types of Acute Myocardial Infarction?
STEMI
NSTEMI
What are the three patterns of AMI?
Regional Myocardial (90%) Regional Subendocardial Circumferential Subendocardial (10%)
Define a Regional Myocardial AMI
Infarct of one segment of ventricular wall
Usually due to thrombus formation
Define a Regional Subendocardial AMI
Infarct limited to subendocardial zone
Associated w/ thrombus lysis
Define a Circumferential Subendocardial Infarction
General hypoperfusion of all coronary arteries
What is required for a diagnosis of AMI?
Elevated troponin + 1 of:
- ST elevation/new LBBB (STEMI)
- No ST elevation/LBBB (NSTEMI)
What are the key coronary arteries?
Right Coronary
Left Coronary which spilts into:
Circumflex
Left Anterior Descending
What area does the RCA supply?
RA, RV, post septum
AVN/SAN
Gives post/inf MI –> Leads II, II, aVF
What area does the LCA supply?
Antero-Lateral –> Splits into circumflex and LAD
Gives antero-lateral MI –> Leads I, aVL, V1-V6
What area does the circumflex supply?
LA, LV
Gives a lateral MI –> Leads I, aVL, V5/6
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?
50% of deaths w/i 2 hours, 7% before discharge
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 - used to determine the likelihood of ischaemic events or mortality in patients with unstable angina or NSTEMI
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?
C PEAR DROP
C - Cardiogenic shock
P - Pulmonary oedema
E - Emboli
A - Aneurysm formation
R - rupture of ventricle
D - Dressler’s syndrome
R - Rupture of free wall
O - /
P - Papillary muscle rupture
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
