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Cardiovascular > Acute Coronary Syndromes > Flashcards

Acute Coronary Syndromes Flashcards

1
Q

What conditions does ACS cover?

A

Unstable angina, NSTEMI, STEMI.

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2
Q

What would an acute coronary syndrome with no ST elevation and normal troponin indicate?

A

Unstable angina

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3
Q

What would an acute coronary syndrome with no ST elevation and elevated troponin indicate?

A

NSTEMI

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4
Q

What would an acute coronary syndrome with ST elevation and elevated troponin indicate?

A

STEMI

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5
Q

Causes of ACS? (Main cause and others)

A
  1. Main reason is rupture of atherosclerotic plaque and consequent arterial thrombosis

Other causes:

  • Stress-induced (Tako-Tsubo) cardiomyopathy
  • Coronary vasospasm without plaque rupture
  • Drug abuse (amphetamines, cocaine causing prolonged vasospasm)
  • Dissection of coronary artery spontaneously due to connective tissue disorder (Marfans)
  • Thoracic aortic dissection (high risk situation)
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6
Q

What is unstable angina?

What is the typical heart pattern?

A 
Reduced oxygen supply to heart causing chest pain which occurs during rest. 
Crescendo pattern (increasing sound)
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7
Q

What is a reciprocal change in ST elevation? Why is it useful in diagnosing STEMI?

A

In STEMI, we see reciprocal changes in ST elevation in inferior leads. Seeing this change assures us of STEMI as other causes of ST elevation do not cause this reciprocal change.

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8
Q

What is the main cause of MIs?

A

Atherosclerosis and atherothrombosis

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9
Q

Symptoms of MI

A
  • Chest pain which is unremitting
  • Usually severe but may be milder or absent
  • Occurs at rest
  • Associated with sweating, breathlessness, nausea and vomiting
  • One 1/3rd of MIs occur at night in bed
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10
Q

Hospital management of acute STEMI

A 
Make diagnosis of MI
Attach 12 lead ECG
O2 if hypoxic <95% or breathless
IV access for bloods, fbc, u&e, glucose, lipids, troponin
Brief assessment of hx, risk factors for IHD, examination (pulse, BP, JVP, murmurs, signs of CCF)
Aspirin 300mg
Ticagrelor 180mg
Morphine, antiemetic
Primary PCI if ST elevation on ECG
Fibrinolysis if non ST elevation on ECG
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11
Q

What is troponin and when is it released?
Which troponin is most sensitive for cardiac muscle injury?
What other conditions can cause an increase in troponin?

A

Troponin is a protein complex which regulates actin and myosin contraction.
It is released when myocardium is damaged.
Troponin I is most sensitive for cardiac muscle injury whereas T is strongly associates with non-cardiovascular disease death.

Other causes for increased troponin

  • PE
  • gram negative sepsis
  • myocarditis
  • heart failure
  • arrhythmias
  • cytotoxic shock
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12
Q

How does aspirin work as an anti-platelet drug?

How effective is it at reducing risk of coronary events?

A

Aspirin irreversibly inhibits COX-1 which suppresses thromboxane A2 production preventing platelet aggregation.
Shows 30-50% reduction in future coronary events

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13
Q

How do fibrinolytic drugs work?

A

Fibrinolytic drugs work on the fibrinolytic system where tPA is administered which converts plasminogen to plasmin to break down fibrin into fibrin degradation products.

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14
Q

Platelet targeted therapies - anti-platelet drugs

When are GPIIb/IIIa antagonists used? Examples of GPIIb/IIIa antagonists?

A

Abciximab, tirofiban, eptifibatide
Only used IV
They are used in combination with P2Y12 inhibitors in management of patients undergoing PCI for ACS
They increase the risk of major bleeds so their use has been greatly reduced. They are still useful in STEMI patients undergoing PCI to cover delayed absorption of P2Y12 inhibitors.

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15
Q

How do anticoagulants work? Example?

A

They target formation of and activity of thrombin and inhibit formation of fibrin and platelet activation.
Fondaparinux used in NSTE ACS prior to coronary angiography.
Heparin used for those with CABG surgery.

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16
Q

Name 3 P2Y12 inhibitors
Which do we mainly use and why?
(Benefits and cons on the 3 P2Y12 inhibs)
Side effects of P2Y12 inhibs?

A

Clopidogrel, prasugrel and ticagrelor

  • *P2Y12 inhibitors have greatly reduced long term risks for patients with ACS!**
  • We would use ticagrelor or prasugrel unless CI.

Clopidogrel

  • irreversibly binds to p2y12 receptor
  • pro drug so needs to be metabolised by CYP450 in liver (some people (30% pop) do not have the CYP219C enzyme so they do not metabolise it & it is ineffective)
  • once metabolised = a lot of drug turned into ineffective metabolite
  • Carry out angiogram first as causes irreversible binding to p2y12

Prasugrel

  • Irreversibly binds to p2y12 receptor
  • More effective as a prodrug than clopidogrel as it is converted into intermediate form rather than inactive.
  • Used in preferance to clopidogrel in ACS patients
  • More effective than clopidogrel at reducing MI and CV death risks than clopidogrel
  • Carry out angiogram first as causes irreversible binding to p2y12

Ticagrelor

  • Oral reversibly-binding p2y12 antagonist
  • more rapid onset and higher level of platelet inhibition than both prasugrel and clopidogrel
  • Loses effect quicker as it binds reversibly
  • More effective than clopidogrel at reducing MI and CV death risks than clopidogrel
  • Ticagrelor causes more spontaneous bleeding than clopidogrel.

When would we use clopidogrel?
- Ticagrelor & prasugrel cause more spontaneous bleeding than clopidogrel so we would opt to use clopidogrel in patients with AF for example.

Side effects of all P2Y12 inhibs?
- Rash, GI disturbance, bleeding.

17
Q

What is the treatment of choice for STEMI?

A

Primary PCI (Introduce wire and open up the vessel by inflating the balloon along RCA which opens the artery and increases blood flow, introduce stent which remodels the artery)

18
Q

What is the treatment of choice for NSTE ACS?

A

PCI (80%), CABG (10%)

19
Q

How long do we continue anti-platelet therapy for?

A

Usually 1 year but longer in high risk patients

For those patients with low risk, stop aspirin after 3 months for reduced risk of bleeding.

20
Q

Primary prevention for ACS?

A

Lifestyle factors
- stop smoking
- increase physical exercise
- lose weight
- increase consumption of fish, fruit, veg, nuts
- reduce salt intake
Statins prescribed to those at risk of CAD
Blood pressure control
Beta blocker in LV dysfunction, HF or ischaemia.

21
Q

Prognosis of those with ACS?

A
  • Patients who have experienced NSTEMI have a high risk of morbidity and death from a future event.
  • The rate of sudden death in patients who have had a myocardial infarction (MI) is 4-6 times the rate in the general population.
  • Risk varies significantly with individual factors such as diabetes, smoking, extent of infarction, treatment given and compliance with long term treatment etc.
  • Statins and revascularisation has decreased mortality and morbidity by reducing the likelihood of cardiogenic shock, recurrent MI and death

Cardiovascular (16 decks)

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