Acute Coronary Syndromes & Management Flashcards
what is an acute coronary syndrome?
Any sudden cardiac event suspected or proven to be related to a problem with the coronary arteries (problems arise from myocardial ischaemia)
what is a major (full blown) MI?
complete coronary artery occlusion
what is a minor (warning) MI?
partial (or transient complete) coronary artery occlusion
what does the initial ECG of a complete coronary occlusion show?
ST elevation
what does the ECG of a complete coronary occlusion show after 3 days?
Q waves
what does an ECG of partial coronary occlusion look like?
no ST elevation
what does an ECG of a partial coronary occlusion look like after 3 days?
no Q waves
is unstable angina an acute coronary syndrome?
yes
is stable angina an acute coronary syndrome?
no
in a STEMI what thickness of the heart muscle is affected?
full thickness
in an NSTEMI what thickness of the heart muscle is affected?
only partial thickness damage, usually sub-endocardial
how are MIs diagnosed?
- detection of cardiac cell death by detecting positive cardiac biomarkers2. plus of the following:-symptoms of ischeamia-new ECG changes-evidence of coronary problem on coronary angiogram or autopsy-evidence of new cardiac damage on another test
what protein is used as a biomarker to detect if a major MI has occurred?
troponin BI
what protein is used as a biomarker to detect if a minor MI has occurred?
troponin B2
what are some non-cardiac causes of troponin rise?
Pulmonary embolismSepsisRenal failureSub-arachnoid haemorrhage
what is unstable angina?
unpredictable, rapidly worsening/ crescendo angina or angina at rest
is a 20 year old with elevated troponin levels but with pneumonia, in ICU and with normal ECG likely to have had an MI?
no, it is mostly due to a supply-demand mismatch of the heart causing strain and releasing troponin.
what is a type 1 MI?
spontaneous MI associated with ischaemia and due to a primary coronary event such as plaque erosion, rupture, fissuring or dissection
what is a type 2 MI?
due to imbalance in supply and demand of oxygen. Result of ischaemia but not ischaemia from thrombosis of coronary artery
what are some other causes of type 1 MI that are not atherosclerosis?
-Coronary vasospasm-coronary dissection-embolism of material down coronary artery-vasculitus (of coronary artery)-radiotherapy causing fibrosis and stenosis of coronary arteries
what can cause coronary vsospasm, possibly leading to type 1 MI?
cocaine, triptans (anti-migrain medication), chemotherapy (5-FU)
What can cause embolism of material down the coronary artery possibly causing a type 1 MI?
thrombosis from mechanical valve, tumour, AF
what may the ST segment of the ECG look like in a NSTEMI?
ST depressionT wave inversion
which ECG readings give an indication of what is going on in the high lateral portion of the heart?
SLL I, aVL
which ECG readings give an indication of what is going on in the inferior of the heart?
SLL II, SLL III, aVF
which ECG readings give an indication of what is going on in the anterior of the heart?
V1, V2, V3, V4
which ECG readings give an indication of what is going on in the lateral side of the heart?
V5, V6
what portion of the heart is not covered by the normal ECG leads?
posterior
when might an MI not show up on an ECG?
if the occlusion occurs in the RCA or the left circumflex artery
if there is an occlusion of the RCA and a posterior MI occurs, what changes may be visible?
lateral changes
what is sort of chest pain is associated with MI?
-radiating to neck and arm- may not be “pain”, more discomfort-severe but not agony-associated nausea, sweating and breathlessness
what are the risk factors for MI?
MaleAgeKnown heart diseaseHigh blood pressureHigh cholesterolDiabetesSmokerFamily history of premature heart disease
what is the order of investigations to diagnose MI?
- symptoms- ACS or not2. ECG to look for ST elevation or not3. 3-4 hours -laboratory test for troponin if not ST-elevation (yes NSTEMI, no unstabel angina)4. 1-2 days - ECG to look for Q waves (yes Qw MI, no NQMI)
with a STEMI what is the aim of treatment?
open coronary artery
what are the immediate treatments for STEMI?
- get patient to cath lab for primary percutaneous coronary intervention2. if cath lab not available, thrombolysis
what is the medication given to patients with STEMI and where a cath lab is not available?
tenecteplase given as a bolus
what are the risks of thrombolysis?
severe bleeding
when should thrombolysis not be carried out in someone with a STEMI?
recent previous stroke, previous intracranial bleedor recent surgery, on warfarin or severe hypertensive
what is the general management of suspevted ACS?
Admit to hospitalCardiac monitorGive O2 only if levels low
what are the investigations that must be carried out for ACS?
-serial ECGs-Blood testscheck not anaemiccheck kidney functioncholesterolthyroid
which medications are given if patients with ACS get more chest pain?
GTNopiates (eg. morphine)
what are the general types of medication given to patients with ACS?
anti-platelet drugsanti-thrombotic drugsBeta blockersstatinACE inhibitor
what anti-platelet drugs are given to patients with ACS and what doses?
aspirin-300mg loading dose then 75mg once a dayticagrelor-180mg loading dose then 90 mg two times a day
what anti-thrombotic drug is given to patients with ACS and what doses?
fondaparinux- 2.5 mg once a day subcutaneously
what bets blocker is given to patients with ACS and what doses?
Bisoprolol 2.5 mg od
what statin is given to patients with ACS and what doses?
Simvastatin 40 mg od
what ACE inhibitor is given to patients with ACS and what doses?
Ramipril 1.25 mg bd
which patients with NSTEMI require a coronary angiogram?
patients at high risk
what are the risks of coronary angiography/angioplasty/stenting?
BleedingBlood vessel damageMyocardial infarctionCoronary perforationStrokeDye can affect kidneys (“contrast nephropathy)
when is a coronary bypass graft performed?
-three vessel disease-left main stem disease-disease not amenable to PCI
what are the potential complications of MI
-Arrhythmia-Cardiogenic shock-Myocardial rupture-valve dysfunction due to papillary muscle dysfunction/rupture-acute ventricular septal defect
what must be carried out predischarge of an ACS patient?
Check on correct medicationsAddress risk factorsCardiac rehabilitationFollow-up plans
what medication is given after a coronary stent is put in?
dual anti-platelet therapy for anything from 1 month to 12 months(to prevent thrombosis on stent before endothelium covers it)
what are the possible long term complications of a coronary stent?
-Higher risk of bleeding as on anti-platelet drugs-Increased risk of further myocardial infarction/death-Cardiac failure
