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INTERNAL MED 3+ conditions > Acute Coronary Syndromes > Flashcards

Acute Coronary Syndromes Flashcards

1
Q

Define ACS

A

A spectrum of acute myocardial ischaemia/infarction

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2
Q

3 conditions in ACS

A
  • Unstable angina
  • NSTEMI
  • STEMI
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3
Q

Definition for unstable angina

A
  • New ST segment depression OR T wave inversion in the presence of ischaemic symptoms
  • NO CK-MB or troponin (cardiac biomarkers)
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4
Q

What does unstable angina present as

A
  • Angina at rest
  • New-onset angina
  • Increasing angina
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5
Q

Definiton for NSTEMI

A
  • New ST segment depression OR T wave inversion PLUS CK-MB or troponin

NOTE - CK-MB or troponin may be raised several hours after presentation

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6
Q

Definition for STEMI

A
  • ST segment elevation OR new left bundle branch block PLUS elevated cardiac biomarkers
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7
Q

What is CK-MB

A

Creatinine kinase - muscle brain

  • Cardiac biomarker
  • Bound combination of 2 variants (M and B) of the enzyme phosphocreatine kinase
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8
Q

What is troponin

A

TnT

  • Protein found in muscle that helps it contract
  • Damage to heart muscle leads to cTnT and cTnI being released into the blood
  • Increased troponin means cardiac muscle cell death
  • Can also indicate sepsis, GI bleeding and CO/cyanide poisoning
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9
Q

When does troponin rise with cardiac cell necrosis

A
  • Elevation starts 2-3 hours post-event
  • Peaks at 24 hours
  • Persists 1-2 weeks
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10
Q

Describe LBBB

A
  • Normal direction of septal depolarisation is reversed - right ventricle to left ventricle
  • Tall R waves
  • Deep S waves
  • Left axis deviation
  • M wave in 1, V5, V6
  • Elongated QRS
  • Absent Q wave
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11
Q

2 aetiology - unstable angina

A
  • Coronary artery narrowing - thrombus

- Intense vasospasm of coronary artery (variant angina) - vascular SM or endothelial dysfunction

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12
Q

Pathophysiology - ACS

A
  • CAD - plaques, thrombi etc
  • Occlusive - available collaterals??
  • Myocardial supply/demand mismatch - increased O2 demand, decreased BF or decreased O2 delivery
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13
Q

Clinical presentation ACS

A
  • Chest pain - increased frequency and severity
  • Retrosternal chest pain - may radiate to jaw, arm or neck
  • Diaphoresis
  • Nausea
  • Increased HR
  • Carotid bruit
  • Poor peripheral pulses
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14
Q

Atypical presentation ACS - who and what is it

A

Elderly, women, DM

  • Epigastric pain
  • Recent onset, indigestion
  • Stabbling chest pain
  • Pleuritic chest pain
  • Isolated dyspnoea
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15
Q

ECG and ACS

A
  • May be normal
  • ST depression (angina, NSTEMI)
  • T wave inversion
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16
Q

Imaging for suspected ACS

A
  • CXR
  • Echo
  • Stress testing
  • CTA (coronary artery anatomy and perfusion)
17
Q

Define ACS in terms of time

A

> 20 minutes of symptoms

18
Q

Score used for ACS prognosis

A

GRACE score

- Death or recurrent MI in the next year

19
Q

Unstable angina risk factors

A
  • Female
  • Personal CAD history
  • Older
  • Family history
  • Chronic kidney disease
  • Elevated CRP
  • Hypertension
  • Smoking
  • Diabetes
  • Hyperlipidemia
  • Peripheral vascular disease
  • Mediastinal radiation

Less risky

  • Obesity
  • High altitude
20
Q

DDx unstable angina

A
  • Stable angina
  • Variant/vasospastic angina
  • NSTEMI or STEMI
  • Congestive heart failure
21
Q

Acute management unstable angina

A
  • Antiplatelets
  • Antithrombotics

Initially - O2, aspirin, Clopidogrel, morphine, GTN

  1. Antiplatelet
  2. Beta/Ca channel blocker
  3. Statin
  4. IV nitrates
  5. ACEI
22
Q

Ongoing management of unstable angina

A
  1. Antiplatelet
  2. Statin/Ezetimibe
  3. Beta-blocker
  4. ACEI
  5. Cardiac rehab
23
Q

Epidemiology NSTEMI

A
  • NSTEMI > STEMI
  • NSTEMI 70% of ACS
  • Mortality 6 months = 4-8%
  • 10% have an adverse cardiovascular event within 12 months
24
Q

5 causes of NSTEMI - aetiology

A
  • Near complete or transient occlusion
  • Dynamic obstruction - artery spasm
  • Severe progressive atherosclerosis
  • Drug use
  • Post-percutaneous coronary intervention
25
Q

Factors determining the severity of myocardial damage

A
  • Duration of ischaemia
  • Time to reperfuse
  • Extent of underlying atherosclerosis
  • Presence of collateral blood flow to affected area
  • Diameter of affected coronary vessel
  • Degree of occlusion
  • Presence of other comorbidities
26
Q

What does the TIMI score measure

A

Risk of death and non-fatal cardiac ischaemic events - 7 risk indicators

27
Q

What are the 7 risk indicators in the TIMI score

A
  • Age >65
  • Presence of >3 CAD risk factors
  • Prior coronary stenosis >60%
  • ST deviation on ECG
  • Elevated cardiac biomarkers
  • > 2 anginal episodes in the past 24 hours
  • Aspirin use past 7 days
28
Q

Acute treatment NSTEMI

A
  1. Antiplatelets + oxygen
    - GTN
    - Morphine
    - Beta and calcium channel blockers
29
Q

Ongoing treatment NSTEMI

A
  1. Cardiac rehab
    - Antiplatelets
    - Beta blocker
    - Statin
    - ACEI
    - Aldosterone antagonist
    - Anticoagulant
30
Q

ECG definition of STEMI

A

ST elevation in 2+ ECG leads (with symptoms)

31
Q

What % of STEMI patients die as a result

A

15% (half in the first hour)

32
Q

STEMI epidemiology

A
  • Affects men at a younger age
  • Incidence increases in women after menopause
  • Average age 65 males and 72 females
  • Make up 38% of ACS
33
Q

STEMI risk factors

A
  • Male
  • Smoking
  • Hypertension
  • Diabetes
  • Obesity
  • Metabolic syndrome
  • Dyslipidemia
34
Q

Acute treatment STEMI - haemodynamically unstable

A
  1. Revascularisation - PCI, CABG
  2. Anticoagulation
  3. Aspirin
  4. Morphine
  5. O2
35
Q

Acute treatment STEMI - haemodynamically stable

A
  1. Revascularisation
  2. Hypothermia
  3. Anticoagulation
  4. Beta blocker
  5. Statin
36
Q

Ongoing management STEMI

A
  • Dual antiplatelet - Aspirin, Tricagrelor
  • ACEI
  • Beta blocker
  • Statin
37
Q

STEMI prognosis

A
  • Elevated troponin = worse prognosis
38
Q

What is an important complication of STEMI

A

Often go into cardiogenic shock

INTERNAL MED 3+ conditions (18 decks)

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