Acute Coronary syndromes presentation + management Flashcards
What is an acute coronary syndrome
Symptoms relating to problem with coronary arteries
ACS causses myocardial ischaemia
What is the differernce between stable angina and ACS
Stable angina:
Cased by stable coronary lesion
Predictable symptoms
Symptoms relieved by rest
ACS:
Unstable coonary lesion
Unpredicactale
May occur at rest
Includes MI & unstable angina
What does the history involve in someone with ACS
Ischaemic sounding chest pain
May radiate to neck/arm
Deny pain- call it discomfort
Nausea, sweating, breathlessness
What can an examination of someone with ACS look like
May look unwell if have STEMI
Or look fine
Ensure to check:
HR, BP
Listen for murmers, crackles in chest
What does complete coronary occlusion look like on the ECG
Initial ECG- ST elevation
ECG at 3 days- Q waves
WHat does partial coronary occlusion look like on ECG
Initial ECG:
ST depression
T wave inversion
or Normal
ECG at 3 days:
No Q waves
How can anterolateral ST elevation form
Acute MI due to blocked LAD
What can an Inferior ST elevation be due to
Acute MI due to blocked RCA
What will be seen in the ECG in posterior MI
Blocked LCx
Opposite changes in leads V1-V2
Summary of how to spot difference between Stable angina and ACS
WHat therapy can open blocked artery
Reperfusion therapy
Mechanical- Using Primary PCI
Pharmacological- strong blood thinner
What treatment can be given if not next to an ambulance
Thrombolysis
Strong blood thinning medication
What are the risks of thrombolysis
Bleeding
Dont give if had recent stroke
Or if had surgery and on warfarin
What is the better option Cath lab or Thrombolysis to treat STEMI
Thrombolysis only works if given early
Cath lab generally better unless too far away
What are the mangement options for ACS
Admit to hospital
ECG
Attach to a cardiac monitor
Gain iv access
Give O2 only if levels low
What are the investigations for ACS
Serial ECGs
Repeat ECG if not sure if there are any changes
Think about doing posterior leads
Don’t want to miss an evolving STEMI or a posterior STEMI
Blood tests
Check troponin
Now can do immediate “Point of Care” test
Also check Hb, kidney function, cholesterol
What are the treatment options for ACS
Glycerol trinitrate (GTN)
Vasodilator - opens up coronary arteries
Can give sub-lingual, or as intravenous infusion
Won’t help if the artery is completely blocked
Opiates (eg morphine)
Helps relieve anxiety too
Also helps venodilate which may have haemodynamic benefits
What anti-thrombotics drugs can be used
Dual anti-platelet therapy- Aspirin
+
Either Clopidogrol, Ticagrelor, prasugrel
Anti-coagulent drugs
Heparin, LMWH, Fondaparinux
What other drugs are used
Beta blockers
Statins
Ace Inhibitors
Should patients with NSTEMI have coronary angiograms
Yes ideall within 48 hrs
What are the risks of coronary angiography and PCI
Bleeding from arterial access site
Myocardial infarction
Coronary perforation
Emergency CABG
Stroke
Dye can affect kidney function (“contrast nephropathy”)
What are the mechanical complications that can occur
Myocardial rupture
Acute Septal Ventricular Defect
Mitral valve dysfunction due to papillary muscle rupture
Listen for Development of loud new murmer
What is the course in hospital after an MI
Used to be confined to bed for weeks following an MI
Now usually home within 2-3 days if uncomplicated
Ensure seen by cardiac rehabilitation nurses
Advise about lifestyle measure including smoking, driving, going back to work
Arrange follow-up as necessary
What does ACS management in hospital involve
Keep attached to cardiac monitor for first 24-48 hours
Listen for new murmurs and signs of heart failure every day
Start “secondary prevention” medications
Organise an echocardiogram (ultrasound heart scan)
What is the treatment for Acute NSTEMI
B – Beta-blockers unless contraindicated
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk)
M – Morphine titrated to control pain
A – Anticoagulant: Fondaparinux (unless high bleeding risk)
N – Nitrates (e.g. GTN) to relieve coronary artery spasm
Give oxygen only if their oxygen saturations are dropping (i.e. <95%).
What is the treatment for an Acute STEMI
Primary PCI
Thrombolysis
What is the secondary prevention medical management
Aspirin 75mg once daily
Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily)
Atenolol (or other beta blocker titrated as high as tolerated)
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
