Acute Coronary Syndromes (ACS) Flashcards
Describe the three types of acute coronary syndrome associated with sudden rupture of plaque within coronary artery.
Non ST segment elevation myocardial infarction (NSTEMI)
-Subtotal vessel occlusion occurs and ischaemic tissue subsequently infarcts.
ST segment elevation myocardial infarction. (STEMI)
-Complete occlusion of affected coronary artery by thrombus formation requires urgent attention.
Unstable angina.
- Defined as chest discomfort provoked by minimal exercise or at rest.
- Usually atheromatous plaque rupture causes platelet aggregation, narrowing of lumen and tissue ischaemia
What would be shown on the bloods and ECG of a patient with NSTEMI?
Px have elevated serum troponin without ST segment elevation.
T wave inversion of ST depression.
What would be found on the ECG of patients with a STEMI?
-Px present with ST segment elevation
What would be shown on the bloods and ECG of a patient with unstable angina?
- Plasma troponin and creatine kinase are normal.
- ECG normal or shows ST segment depression and/or T wave inversion.
What are the risk factors for an ACS?
Non-modifiable:
Age, male, FHx of IHD (
What are the symptoms of ACS?
MI etc
Acute central chest pain lasting >20 min.
Often assoc with:
-Nausea, sweatiness, dyspnoea, palpatations.
May present without chest pain (“silent infarct”) here presentations may include syncope, pulmonary oedema, epigastric pain and vomiting…
What investigations would you perform if a patient had suspected ACS?
Blood:
FBC, U&E, glucose, lipids.
Cardiac enzymes:
Cardiac troponin levels (TandI) are most sensitive and specific markers of myocard necrosis.
-Serum levels raised within 3-12 hrs after infarct
-Lower to baseline over 5-14 days after
ECG essential
Echocardiography useful to diagnose complications.
What signs would be found in a patient with ACS?
Distress, pallor, sweatiness, raised or lowered pulse and BP.
4th Heart sound.
May be signs of heart failure or pansystolic murmor.
Later a pericardial friction rub or peripheral oedema may develop.
What are the differential diagnoses for ACS?
Angina Pericarditis Myocarditis Aortic dissection Pulmonary embolism Oesophageal reflux/spasm
How would you manage a patient on arrival with ACS?
ABCDE
Oxygen Aspirin Clopodigrel Beta-blockade Low molecular weight heparin
Ongoing chest pain may require i.v. opiates and nitrates.
Coronary angoigraphy considered in patients presenting with unstable angina or raised troponin in NSTEMI.
How would you manage a patient with STEMI?
ABCDE
Oxygen Aspirin Clopodigrel Beta-blockade Low molecular weight heparin
Patients should be considered for either primary angioplasty or immediate thrombolysis.
Thrombolysis:
-Fibrinolytic drugs iv directly dissolve thrombus. Not all px achieve adequate reperfusion and has haemorrhage risk.
Primary antioplasty:
-May carry less risk
Successful px should be given secondary prevention and usually undergo exercise tolerance testing 6 weeks after infarct.
If positive or anginal symptoms should undergo coronary antiography or CABG
How would you manage a patient with an NSTEMI?
ABCDE
Oxygen Aspirin Clopodigrel Beta-blockade Low molecular weight heparin
Ongoing chest pain may require nitrates or iv opiates.
Medical management can be continued and coronary angiography should be considered in px presenting with unstable angina or raised troponin in the absence of ST segment elevation.
What are the possible complications of MI?`
Tachyarrhythmias Bradyarrhythmias Continuing angina Mitral regurg Ventricular septal defect Ventricular aneurysm Cardiac tamponade Cardiogenic shock.
