Acute Coronary syndromes presentation + management Flashcards

1
Q

What is an acute coronary syndrome

A

Symptoms relating to problem with coronary arteries
ACS causses myocardial ischaemia

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2
Q

What is the differernce between stable angina and ACS

A

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

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3
Q

What does the history involve in someone with ACS

A

Ischaemic sounding chest pain
May radiate to neck/arm
Deny pain- call it discomfort
Nausea, sweating, breathlessness

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4
Q

What can an examination of someone with ACS look like

A

May look unwell if have STEMI
Or look fine
Ensure to check:
HR, BP
Listen for murmers, crackles in chest

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5
Q

What does complete coronary occlusion look like on the ECG

A

Initial ECG- ST elevation
ECG at 3 days- Q waves

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6
Q

WHat does partial coronary occlusion look like on ECG

A

Initial ECG:
ST depression
T wave inversion
or Normal
ECG at 3 days:
No Q waves

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7
Q

How can anterolateral ST elevation form

A

Acute MI due to blocked LAD

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8
Q

What can an Inferior ST elevation be due to

A

Acute MI due to blocked RCA

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9
Q

What will be seen in the ECG in posterior MI

A

Blocked LCx
Opposite changes in leads V1-V2

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10
Q

Summary of how to spot difference between Stable angina and ACS

A
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11
Q

WHat therapy can open blocked artery

A

Reperfusion therapy
Mechanical- Using Primary PCI
Pharmacological- strong blood thinner

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12
Q

What treatment can be given if not next to an ambulance

A

Thrombolysis
Strong blood thinning medication

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13
Q

What are the risks of thrombolysis

A

Bleeding
Dont give if had recent stroke
Or if had surgery and on warfarin

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14
Q

What is the better option Cath lab or Thrombolysis to treat STEMI

A

Thrombolysis only works if given early
Cath lab generally better unless too far away

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15
Q

What are the mangement options for ACS

A

Admit to hospital
ECG
Attach to a cardiac monitor
Gain iv access
Give O2 only if levels low

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16
Q

What are the investigations for ACS

A

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

17
Q

What are the treatment options for ACS

A

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

18
Q

What anti-thrombotics drugs can be used

A

Dual anti-platelet therapy- Aspirin
+
Either Clopidogrol, Ticagrelor, prasugrel

Anti-coagulent drugs
Heparin, LMWH, Fondaparinux

19
Q

What other drugs are used

A

Beta blockers
Statins
Ace Inhibitors

20
Q

Should patients with NSTEMI have coronary angiograms

A

Yes ideall within 48 hrs

21
Q

What are the risks of coronary angiography and PCI

A

Bleeding from arterial access site
Myocardial infarction
Coronary perforation
Emergency CABG
Stroke
Dye can affect kidney function (“contrast nephropathy”)

22
Q

What are the mechanical complications that can occur

A

Myocardial rupture
Acute Septal Ventricular Defect
Mitral valve dysfunction due to papillary muscle rupture

Listen for Development of loud new murmer

23
Q

What is the course in hospital after an MI

A

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

24
Q

What does ACS management in hospital involve

A

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)

25
Q

What is the treatment for Acute NSTEMI

A

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%).

26
Q

What is the treatment for an Acute STEMI

A

Primary PCI
Thrombolysis

27
Q

What is the secondary prevention medical management

A

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)