Acute Coronary Syndromes:Presentation and Management Flashcards
What is an Acute Coronary Syndrome?
• Any sudden event suspected or proven to be related to a problem with the coronary arteries, which can arise due to myocardial iscahaemia
What is a Myocardial Infarction
Death due to ischaemia and can be partial or complete occlusion of coronary artery
What is a cardiac arrest
Abnormal heart rhythm not compatible with life such as VF, tachycardia, asystole
When can cardiac arrest occur (3)
During acute phase of MI
Late after an MI
Unrelated to MI
Chronic Ischaemic Heart Disease
• Stable angina
Acute Coronary Syndromes (2)
• Unstable angina
• Myocardial infarction (plaque disruption and platelet aggregation:
-NSTEMI
-STEMI
Initial ECG of transmural MI and after 3 days
ST elevation and Q wave
Initial ECG of subendocardial MI and after 3 days
No ST elevation and no Q wave
Diagnosis of MI (5)
Detection of cell death or injury (troponin)
Symptoms of ischemia
New ECG changes
Evidence of coronary problem on coronary angiogram or autopsy
Evidence of new cardiac damage on another test
Non-coronary causes of troponin rise (6)
Pulmonary embolism Cardiac contusion Anaemia Sepsis Renal failure Sub-arachnoid haemorrhage
Type 1 MI
Spontaneous
Associated with ischaemia due to plaque erosion, rupture, fissuring or dissection
Type 2 MI
Due to imbalance in supply and demand. Result of ischaemia but not due to thrombosis of coronary artery
Type 3 MI
Sudden cardiac death
Symptoms of ischaemia
ST elevation
LBBB
Type 4a MI
Associated with percutaneous coronary intervention- increase biomarkers 3 X 99th percentile of the upper reference limit
Type 4b
MI associated with verified stent thrombosis via angiography
Type 5 MI
MI associated with CABG (plus new Q waves or LBBB or imagine evidence of new loss)
Causes of type 1 MIs not related to coronary atherosclerosis (5)
Coronary vasospasm Coronary dissection Embolism of material Inflammation Previous radiotherapy
Causes of coronary vasospasm
Cocaine, triptans, 5-FU
Embolism of material
Thrombus or tumour
Inflammation of coronary arteries is known as
Vasculitis
Previous radiotherapy to chest causes
Fibrosis and stenosis or coronary arteries
Presentation of ACS (5)
Chest pain May radiate to neck and arm More discomfort than pain Severe but not in agony May be associated with nausea, sweating and SOB
Cardiac Risk Factors (8)
- Male
- Age
- Known heart disease
- High BP
- High cholesterol
- Diabetes
- Smoker
- Family history of premature heart disease
Examination (5)
- May look unwell
- May look completely fine
- Often no specific features to find
- Check HR, BP
- Listen for murmurs, crackles in chest
Key investigation
ECG
T wave in NSTEMI
T wave inverted
T wave in STEMI
hyper-acute T waves
what occlusion is easily missed
LCx
Anterior MI ECG
V1-V4
Lateral MI ECG
V5-V6
Inferior MI ECG
II, III, aVF
High Lateral MI ECG
I, aVL
Posterior MI
V1-V2 (opposite changes in the leads opposite those looking at that area)- some inferior ST elevation
Diagnosis
Symptoms
ST elevation?
Troponin elevation
Q wave?
Typical angina for >20 minutes
yes- Acute coronary syndrome
No- stable angina
ST elevation
Yes- STEMI
No- test troponin level
Troponin elevated
Yes- NSTEMI
No- unstable angina
After 3 days Q wave?
Yes- QwMI
No- MQMI
Posterior ECG leads
V7, V8, V9
Inferior MI
RCA
Anterior MI
Left anterior descending coronary artery
Lateral MI
Circumflex coronary artery
Mechanical Reperfusion therapy
Angioplasty and stenting in cath lab
Pharmacological Reperfusion Therapy
Thrombolysis (Tenecteplase)
Risks of Thrombolysis
Bleeding Recent stroke/intracranial bleed Recent surgery On Warfarin Sever Hypertension
During STEMI within 2 hours what treatment can you give
PCI
During STEMI after 2 hours what treatment can you give
Thrombolysis then transfer
NSTEMi compared to STEMI (4)
Seen in older patients
Previous CABG/MI/PCI
More likely to have medical problems
Presentation may not be obvious or clear
Signs and symptoms during unstable angina (5)
Convincing anginal symptoms Rapidly worsening (crescendo) Occurring at rest ECG may be normal or abnormal No cell death so troponin is not elevated
General management of ACS
Hospitalisation
Cardiac monitoring
Oxygen if levels are low
Investigations
ECGs
Posterior leads
Blood tests (troponin, kidney, Hb, cholesterol)
Treatment
GTN (vasodilators)- sublingual IV infusion
Opiates (morphine) reduce anxiety venodilator
Anti-thrombotic drugs (anti-platelet) (3)
Aspirin
Clopidogrel
Ticagrelor
Anti-coagulant drugs (3)
LMWH
Unfractionated Heparin
Fondaparinux
Other Drugs
Beta Blockers
ACEI
Do patients with NSTEMI also need a coronary angiogram (2)
Ideally within 48 hours
Use risk calculator to assess risk
Risks of coronary angiography and angioplasts/stents (6)
Bleeding Blood vessel damage MI Coronary perforation Stroke Contrast nephropathy
What is CABG used to treat (2)
3 vessel disease
Left main stem disease
Management in hospital (3)
Home within 3-4 days
Keep monitor for first 24-48 hours
Get an echo
Course in Hospital (2)
Listen for murmurs and signs of HF
Secondary prevention drugs
Complications following an MI (4)
Arrhythmia
Myocardial rupture
Acute ventricular septal defect
Mitral valve dysfunction due to papillary muscle rupture
Pre-discharge arrangements (5)
Check correct medications Address risk factors Smoking cessation Arrange cardiac rehabilitation Make follow up plans
Anti-platelet therapy precautions(4)
Takes time for stent to become endothelised into coronary artery wall
Blood exposed to metal stent can thrombose and block off stent
Antiplatelets required for 1-12 months
Premature discontinuation can be fatal
Longer term complications
High risk of future MI/death
Cardiac failure
Risk of bleeding (anti-platelets)
Will have to delay other operations due to being on antiplatelet drugs
