Acute Coronary Syndromes Presentation and Management Flashcards
Acute coronary syndrome
A sudden collection of symptoms suspected or proven to be related to a problem with the coronary arteries
Acute coronary syndrome can result in
Myocardial ischaemia anf infarction
Myocardial infarction
Cell death due to prolonged ischaemia
Chronic ischaemic heart disease
Stable angina
Acute coronary syndromes
Unstable angina
MI - STEMI and NSTEMI
Complete coronary occlusion initial ECG
ST elevation
Complete coronary occlusion ECG at 3 days
Q waves
Partial coronary occlusion initial ECG
No ST elevation
Partial coronary occlusion ECG at 3 days
No Q waves
STEMI
ST elevation MI
NSTEMI
Non-ST elevation MI
Diagnosis of MI is based on
Detection of cell death/injury via biomarkers and one of:
ECG changes, symptoms of ischaemia, coronary problem evidence via angiogram autopsy or other test
Cardiac biomarkers
Myoglobin
Troponin
CK-MB
Most important cardiac biomarker
Troponin
Troponin levels are significantly higher in which MI
Large infarction - STEMI
Non-coronary causes of troponin rise
Arrhythmia Pulmonary embolism Cardiac contusion Sepsis Renal failure
Coronary problems that can lead to MI
Atherosclerosis Coronary vasospasm Coronary dissection Embolism in coronary artery Inflammation of coronary arteries (vasculitis)
MI type 1
Plaque rupture with thrombus
MI type 2
Vasospasm or endothelial dysfunction
Fixed atherosclerosis and supply-demand imbalance
Supply-demand imbalance alone
Chest pain associated with MI
Radiation to left arm and neck
Discomfort more than pain
Severe but not agony
Symptoms of MI
Chest pain
Nausea
Sweating
Breathlessness
Cardiac risk factors
Male Age Known heart disease Hypertension High cholesterol Diabetes Smoker Family history
Examination of MI
Heart rate
Blood pressure
Auscultation - murmurs or crackles
May look fine or unwell (STEMI)
Key investigations for MI
ECG
Bloods - troponin, haemoglobin, kidney function, cholesterol
Different ECG findings associated with MI
ST elevation - emergency No ST elevation ST depression T wave inversion Normal
Coronary artery involved in inferior MI
Right coronary artery
Coronary artery involved with anterior MI
Left anterior descending coronary artery
Coronary artery involved with posterior MI
Circumflex coronary artery
Posterior MI ECG presentation
Opposite changes in the leads opposite those looking at that area (V1-V2)
Treatment of STEMI (reperfusion therapy)
Mechanical - primary PCI, bypass
Pharmacological - thrombolysis
Primary PCI
Percutaneous coronary intervention = angioplasty and stenting
Thrombolysis
Tenecteplase (TNK)
Action of thrombolysis
Dissolves blood clot in coronary artery
Risk of thrombolysis
Bleeding
Be cautious of thrombolysis if
Had recent stroke or previous intracranial bleed
Had recent surgery
On warfarin
Have severe hypertension
Thrombolysis vs Cath lab
Cath lab as no risk of bleeding but waiting time is important. If long wait give thrombolysis and then transfer
Signs that unstable angina and not MI
Rapidly worsening
Occurs at rest
ECG may be normal or abnormal
Troponin not raised
Reason behind raised troponin
Myocardial cell death
Management of suspected acute coronary syndrome
Admit to hopsital
Cardiac monitor
IV access
Give oxygen if levels low
Treatment of acute coronary syndrome
Glycerol trinitrate (GTN) Opiates - morphine Anti-platelet - aspirin Anti-coagulant - heparin Beta blocker Statin ACE inhibitor
Glycerol trinitrate (GTN)
Vasodilator - opens up coronary arteries
Opiates function
Painkillers
Also relieve anxiety and help venodilate
Anti-platelet and anti-coagulant drugs function
Anti-thrombotic - stop platelets sticking together to prevent thrombosis
Beta blockers function
Reduce work heart has to do
Statin function
Lowers cholesterol levels
Ace inhibitor function
Helps heart muscle recover
Risks of coronary angiogram and PCI
Bleeding Blood vessel damage MI Coronary perforation Stroke Dye affecting kidney function
Post-operation management
Monitor heart Echocardiogram Auscultate for murmurs and signs of heart failure Start drugs Look out for complications
Mechanical complications of operation
Myocardial rupture - cardiac tamponade
Acute ventricular septal defect
Mitral valve dysfunction due to papillary muscle rupture
Cardiac tamponade
Accumulation of fluid in pericardial space
Pre-discharge management
Check medications Address risk factors Smoking cessation Arrange cardiac rehabilitation Make plans for follow-up
Longer term concerns most MI
Higher risk of bleeding and further MI/death
Cardiac failure
Late arrhythmias related to scar
