Acute Coronary Syndromes (ACS) Flashcards
ACS
What diseases does this term encapsulate?
- unstable angina
- NSTEMI
- STEMI
ACS
How is UA defined?
evidence of myocardial damage (e.g. chest pain at rest) in the absence of changes to cardiac biomarkers.
ACS
How is NSTEMI defined?
evidence of myocardial damage with elevated cardiac biomarkers but no ST elevation on ECG.
It represents a partial-thickness infarct.
ACS
How is STEMI defined?
evidence of myocardial damage with elevated cardiac biomarkers and persistent ST elevation on ECG
It represents a full-thickness infarct.
ACS
Name 7 modifiable risk factors.
- Smoking
- Type 2 diabetes
- Hypertension
- Hypercholesterolaemia
- Obesity
- Sedentary lifestyle
- Cocaine use
ACS
Name 3 non-modifiable risk factors.
- Increasing age
- Male
- Family history
ACS
Name some symptoms of ACS
- Central or left-sided “crushing” chest pain which may radiate to jaw or left arm
- Shortness of breath
- Sweating
- Nausea & Vomiting
Note that there may be atypical presentations (e.g. dyspepsia, absence of chest pain) in females, diabetics or the elderly.
ACS
What are some bedside investigations that can be done?
- Basic observations
- Serial ECGs - STEMI: ST-elevation in certain leads depending on area of infarction
ACS
What artery supplies the lateral heart territory?
Left circumflex artery
ACS
What artery supplies the anteroseptal heart territory?
Left anterior descending artery
ACS
What artery supplies the inferior heart territory?
Posterior descending artery which is from right coronary in 80%
or
left circumflex in 20%
ACS
What artery supplies the posterior heart territory?
Posterior descending artery which is from right coronary in 80%
or
left circumflex in 20%
ACS
What leads on an ECG will show ischaemic changes if the LCx is occluded?
I, aVL,V5 and V6
ACS
What leads on an ECG will show ischaemic changes if the LAD is occluded?
V1 – V4
ACS
What leads on an ECG will show ischaemic changes if the inferior heart territory has been damaged?
II, III and aVF
ACS
What leads on an ECG will show ischaemic changes if the posterior heart territory has been damaged?
Reciprocal changes
i.e. prominent R waves, flat ST depression and T wave inversion in V1-V4
ACS
What might you see in an ECG of someone with NSTEMI or UA?
T-wave inversion
or
ST-depression
ACS
What bloods might you do when investigating for ACS and why?
- Cardiac markers
Serial troponin is commonly taken clinically
Raised in NSTEMI and STEMI 4-6hours after injury and remains elevated for 10 days - CK-MB and myoglobin can also be measured
- FBC (anaemia)
- U&E (hyperkalaemia may cause arrythmias)
- Blood glucose and lipid profile (to assess for risk factors)
ACS
What is the diagnostic investigation of choice?
Coronary angiogram is the diagnostic investigation of choice
ACS
Why differential are you trying to exclude by doing a CXR?
to exclude pneumothorax
ACS
Why might you do an ECHO?
to assess function of heart
ACS
How to manage STEMI:
- if it has been <12hr from symptom onset and PCI is available within 2hrs
- if it has been >12hr from symptom onset but PCI is NOT available within 2hrs
- if it has been >12hr from symptom onset
- give anticoagulants + send the patient for PCI
- give anticoagulants + start thrombolysis with drugs such as alteplase.
- Offer ticagrelor with aspirin unless high bleeding risk
Consider clopidogrel with aspirin, or aspirin alone, for high bleeding risk
ACS
How to treat STEMI if <12hr since symptom onset?
ACS
How to treat STEMI if >12hr since symptom onset?
ACS
What scoring system is used to risk stratify NSTEMI or UA pts?
GRACE score
ACS
If a pt with NSTEMI has ongoing ischaemia, what 2 procedures may they undergo and under which conditions?
- PCI (if available)
- CABG
ACS
What are the indications for CABG?
- multiple vessel involvement
- left main coronary artery involvement
ACS
If GRACE score is low for pts with NSTEMI/UA what is the management?
conservative management without angiography
- Offer ticagrelor with aspirin unless high bleeding risk
- Consider clopidogrel with aspirin, or aspirin alone, for high bleeding risk
ACS
If GRACE score is high for pts with NSTEMI/UA what is the management?
immediate angiography if clinically unstable
Otherwise, consider angiography (with follow-on PCI if indicated) within 72 hours if no contraindications.
- If no separate indication for oral anticoagulation, offer ticagrelor with aspirin.
- If a person has a separate indication for oral anticoagulation, offer clopidogrel with aspirin
ACS
Longer term, how is ACS managed (prescribing)?
- Beta blocker – often bisoprolol as it is cardioselective
- ACE-inhibitor
- Dual antiplatelet for 1 year and then aspirin indefinitely (switch to 75mg)
- High dose (80mg) statin
ACS
Longer term, how is ACS managed (risk factor wise)?
- Good diabetic control
- Smoking cessation
- Good blood pressure control
- Statins for hypercholesterolaemia
- Diet and exercise
ACS
What are some features of acute heart failure?
- jugular venous distention
- crackles on lung auscultation
- new s3 gallop
- murmur
- orthopnoea
- oedema
ACS
What is MONA?
M - morphine
O - oxygen (sat >90%)
N - nitrates (subling or IV)
A - aspirin (325mg)
ACS
How do we manage ACS initially and acutely?
- iv access + obs/stats
- MONA
- high intensity statin
- beta-blocker
