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Medicine Block - CVS > Acute coronary syndromes > Flashcards

Acute coronary syndromes Flashcards

1
Q

What are acute coronary syndromes?

A
  • They include unstable angina, STEMI and NSTEMI
  • They occur following a ruptureed plaque, thrombosis and occlusion and inflammtion
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2
Q

What is the pathophysiology of ACS?

A
  • Repetitive injury to the endothelium from physical stress, infection, oxidative stress, high cholesterol, toxins in cigarette smoke etc.
  • Injury increases permeability of intima to plasma proteins, these oxidise LDLs in the blood, allowing their uptake through the intima.
  • Monocytes/macrophages penetrate the endothelium and oxidise lipids becoming foam cells
  • Platelet adherence increases which allows smooth muscle cells proliferation and migration into the area à forms a fibrous cap (increased collagen synthesis aids cap formation)
    *
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3
Q

What does myocardial infarction and ischaemia mean?

A
  • Myocardial cell death that is leading to release of troponin
  • Ischaemia means lack of blood supply +/- cell death
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4
Q

What are the risk factors of ACS?

A
  • Modifiable:
    • Smoking
    • Excessive alcohol intake
    • Diabetes control
    • Hypertension control
    • Hyperlipidaemia
    • Obesity
    • Sedentary lifestyle
    • Cocaine use
  • Non-modifiable:
    • Age >60
    • Gender (males are more susceptible)
    • Family history
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5
Q

What are some controversial risk factors for ACS?

A
  • Stress
  • Type A personality
  • LVH
  • Fibrinogen increase
  • Hyperinsulinaemia
  • Increase in homocysteine levels
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6
Q

How is ACS diagnosed?

A
  • Troponin increase (cardiac biomarker)
  • ECG changes of new ischaemia (development of pathological q waves)
  • Symptoms of ischaemia
  • Loss of myocardium
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7
Q

What are the symptoms of ACS?

A
  • Crushing central chest pain that radiates to the neck, jaw, shoulder and arm, lasting >20 mins
  • Sweating
  • Nausea
  • Sweatiness
  • Dyspnoea
  • ACS without chest pain = silent (seen in elderly and diabetes)
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8
Q

What is a silent MI? How does it present?

A
  • ACS without chest pain = silent (seen in elderly and diabetes)
  • Syncope
  • Pulmonary oedema
  • Epigastric pain
  • Vomiting
  • Post-operative hypotenison
  • Oligouria
  • Acute confusional state
  • Stroke
  • Diabetic hyperglycaemic state
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9
Q

What are the signs of ACS?

A
  • Pallor
  • Distress
  • Anxiety
  • Sweatiness
  • Changes in pulse, BP
  • 4th heart sound
  • SIgns of heart failure
  • Pansystolic murmour
  • Low grade fever
  • Pericardial friction rub or peripheral oedema may develop
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10
Q

What is seen in ECG for STEMI in order?

A
  1. Hyperacute T waves
  2. ST elevation
  3. Or LBBB within hours
  4. R waves decrease
  5. T wave inversion (hours or days)
  6. Q waves form (pathological, hours or days)
  7. T waves return to normal
  8. Pathological Q waves remain
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11
Q

What signs in ECG are seen for NSTEMI and unstable angina?

A
  • ST depression
  • T wave inversion
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12
Q

How can you differentiate between unstable angina and NSTEMI?

A
  • Troponin T and I in NSTEMI not unstable angina
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13
Q

What other investigations can be carried out to diagnose ACS and what can be seen?

A
  • CXR
    • Look for cardiomegaly
    • Pulmonary oedema
    • Widened mediastinum
  • Blood
    • FBC
    • U&Es
    • Glucose
    • Lipids
    • Cardiac enzymes - troponin T and I are the most sensitive and specific markers of myocardial necrosis
  • ECHO
    • Regional wall abnormalities
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14
Q

What are differential diagnosis of ACS?

A
  • Stable angina
  • Pericarditis
  • Myocarditis
  • Takotsubo cardiomyopathy
  • Aortic dissection
  • PE
  • Oesophageal reflux/spasm
  • Pneumothorax
  • MSK pain
  • Pancreatitis
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15
Q

What would make the prognosis worse in ACS?

A
  • Elderly
  • LV failure
  • ST changes
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16
Q

Which other disease can troponin be high in?

A
  • Other causes of myocardial damage:
    • Myocarditis
    • Pericarditis
    • Ventricular strains
  • Iatrogenic
  • Discrete episodes of tachyarrythmias
  • A common cause of consistently raised troponin is in renal failure
  • Hence change in level is more important than the level itself
17
Q

How is ACS with ST elevation managed?

A
  1. Aspirin/ Ticagrelor
  2. Morphine with anti-emetic (metaclropromide - 1st line or cyclizine - 2nd line)
  3. GTN - routine use is now not recommended in the acute setting unless the patient has hypertension or acute LVF
    1. useful as anti-anginal in chronic or stable patients
  4. Oxygen
  5. Restore coronary perfusion - in those presenting <12 hours after symptoms
  6. Anticoagulation - bivalirudin is preferred, enoxiparin is 2nd line
  7. Beta blocker - useful as add on when started early
    1. Bisoprolol
18
Q

What is the reperfusion therapy used for ACS?

A
  • Primary PCI
    • Should be offered to all patients presenting within 12hrs of symptoms with a STEMI and if they can get it done within 120 mins of medical contact
    • If not possible, thrombolysis should be given and patient should be transferred to a primary PCI centre for PCI rescue or angiography
    • Can be used beyond 12 hrs if there is evidence of ongoing ischaemia or in stable patients presenting after 12-24hrs (seek specialist advice)
  • Thrombolysis
    • The benefit of this reduces tfrom the onset of pain (ie. the longer its taken to be given)
    • Do not thrombolye ST depression alone, T wave inversion alone or no ECG change
    • Best achieved with tissue plasminogen activators
19
Q

What should happen to a patient with STEMIs that do not receive reperfusion?

A
  • They should be treated with fondaparinux
  • Enoxaparin
  • Unfractionated heparin if not available
20
Q

What are the contraindications of thrombolysis?

A
  • Previous intracranial haemorrhage
  • Ischaemic stroke
  • Cerebral malignancy or AVM
  • Recent major trauma/surgery/head injury
  • GI bleeding
  • Known bleeding disorders
  • Anticoagulant therapy
  • Pregnancy
21
Q

How is ACS without ST elevation managed?

A
  • Aspirin and clopidogrel - oral anti-platelet therapy
    • The clopidogrel should be given to a select group of patients
  • Low molecular weight heparin
    • (enoxiparin)
  • Glycoprotein IIa/IIb inhibitors
    • For those with recurrent chest pain and ECG changes despite standard treatment
  • Nitrates
    • For recurrent chest pains
  • Beta blockers
    • Unless contraindicated then non-dihydropyrimidine calcium channel blockers should be used
  • ACEi - all patients unless contraindicated
  • Lipid management
    • Statin
22
Q

Which groups of patients should aspirin and clopidogrel or just clopidogrel be given to in those with ACS without ST elevation?

A
  • Raised tropinin
  • ACS already on aspirin
  • ST depression at rest ECG
  • ACS after recent MI
  • Patients being transferred for angioplasty
  • Aspiring intolerant
23
Q

When should clopidogrel not be used?

A
  • Routinely for patients with suspected cardiac pain in the absence of ECG changes or raised troponin
24
Q

What is the subsequent management for ACS?

A
  1. Bed rest for 48hrs
  2. Daily examination of heart, lungs and legs for complications
  3. Prophylaxis against thromboembolism until they are fully mobile
  4. Aspiring
  5. Long term beta blockers
    1. Again, if CI, use diltiazem or verapimil
  6. Continue ACEi
  7. Start or continue statins
  8. Address modifiable risk factors
    1. Smoking
    2. Encourage exercise - daily
    3. Optimise hypertension, diabetes, hyperlipidaemia
  9. Exercise ECG
  10. General advice:
    1. Work - return after 2 months
      1. some jobs may not be appropriate to restart (heavy lifting, airline pilot, divers, air traffic controllers)
    2. Sex - avoid for 1 month
    3. Travel - avoid for 2 months
    4. Diet - oily fish, fruit, vegetables, fibre
    5. Driving - group 1 can return to driving after 1 - 4 weeks depending on if they have had an angioplasty or not. group 2 must inform the DVLA and stop driving until they get good functional tests
25
Q

Why can you not prescribe beta blockers with diltiazem or verapimil?

A
  • Diltiazem should be used with caution if given with beta blockers due to risk of bradycardia.
  • Verapamil is used for angina, hypertension and arrhythmia; it reduces cardiac output, slows the heart rate and may affect atrioventricular conduction. It should not be used with beta–blockers.
  • When combined, they cause a further lowering in heart rate and blood pressure while prolonging atrioventricular node conduction.
  • So because of the risk of bradycardia it should be used with caution in association with beta-blockers.
26
Q

What are the complications of MI? (13)

A
  • Cardiac arrest
  • Cardiogenic shock
  • Bradycardias or heart block
  • Tachyarrhythmias
  • Heart failure
  • Pericarditis
  • DVT/PE
  • Systemic embolism
  • Cardiac tamponade
  • Mitral regurgitation
  • VSD
  • Dresslers syndrome
  • Left ventricular aneurysm
27
Q

When is revascularisation indicated in ACS?

A
  • STEMI patients
  • Very high risk STEMI patients
28
Q

Which revascularisation techniques should be used with patients?

A
  • Immediate angiography and PCI wihtin 24hrs
  • Intermediate risk patients should have angiography and PCI within 3 days
  • Low risk patients should be considered for non-invasive testing
  • Patients with multivessel disease may be considered for CABG instead of PCI
29
Q

What are the indications for CABG?

A
  • Indications to improve survival
    • Left main stem disease
    • Triple vessel disease involving proximal part of the left anterior descending
    • Abnormal LV function
  • Indications to relieve symptoms
    • Angina unresponsive to drugs
    • Unstable angina
    • If angioplasty fails
30
Q

What are the advantages and disadvantages of CABG over PCI?

A

Advantages

  • More complete long term relief of angina
  • Less repeated revasculisation

Disadvantages

  • Longer recovery time
  • Longer inpatient stay
31
Q

Describe the CABG procedure

A
  1. The heart is usually stopped and blood is pumped around artificially by a machine outside the body
  2. Saphenous vein or internal mammary artery is used as the graft
    • Internal mammary artery grafts last longer but may casue chest wall numbness
    • >50% of vein grafts close in 10 years but low dose aspiring helps to prevent this
  3. Several grafts may be placed

Medicine Block - CVS (17 decks)

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