Acute Coronary Syndromes: Presentation & Management Flashcards
Give characteristics of coronary heart disease?
Coronary disease can be completely silent
Coronary disease can cause myocardial ischaemia (lack of an adequate blood flow to myocardium)
Prolonged myocardial ischaemia can be enough to cause cell death (myocardial infarction
Types of heart problems?
problems relating to weakness of the heart pumping
valve problems
rhythm of heart problems
coronary artery disease problems
What is acute coronary syndrome?
Recent onset of symptoms related to a problem with the coronary arteries
Differentiate stable angina from acute coronary syndromes?
stable angina
Caused by “stable” coronary lesion
Predictable symptoms due to a narrowing
Symptoms relieved by rest
Acute
Caused by “unstable” coronary lesion
Unpredictable
May occur at rest
how to classify?
myocardial cell death?
yes- MI
then new ST elevation on ECG?
ST elevation MI
non ST elevation MI
no cell death
then unstable angina-chest pain
OR
crescendo angina- angina getting worse and worse
Cardiac arrest?
Cardiac arrest is when heart not produce enough output to able to sustain life
Often due to a sudden change in heart rhythm incompatible with life
Or something else affecting heart function meaning it is not able to pump out enough blood to sustain life
Cardiac arrest can be due to Acute Coronary Syndromes, but there are other causes
What causes coronary heart disease?
atherosclerosis
build up of fat in coronary arteries and can get to certain level- which can restrict blood flow.
How to diagnose myocardial infarction ?
Detection of cardiac cell death:
+ve cardiac biomarkers
AND
symptoms of ischaemia- chest pain, tightness
new ECG changes
evidence of coronary problem on coronary angiogram or autopsy
evidence of new cardiac damage on another test
Cardiac biomarkers?
troponin- part of sarcomere and if they get released can be detected
Other causes of troponin rise?
Coronary atherosclerosis
Other coronary problems:
Coronary artery spontaneous tearing (coronary artery dissection)
Coronary artery spasm (eg after cocaine ingestion)
Myocardial inflammation
Myocarditis
Takotsubo cardiomyopathy (“broken heart syndrome”)
Other causes of “strain” on the heart
Arrhythmia
Pulmonary embolism
Biomarkers “leaking” out of myocardial cells
Sepsis
Newly defined types of MI?
Different causes of MI?
Presentation of acute coronary syndrome?
history?
Chest pain that sounds like related to myocardial ischaemia
often deny it is a “pain”, more a “discomfort” or a “weight” or “tightening”
may radiate to neck/arm
may be associated with nausea, sweating and breathlessness
Cardiac risk factors?
Male
Age
Known coronary disease
High blood pressure
High cholesterol
Diabetes
Smoker
Family history of premature heart disease
Examination of patient?
May look very unwell if having a “full blown” heart attack (STEMI)
May look completely fine if not
Often no specific examination features to find
Ensure that you check:
HR, BP (both arms – if difference ? aortic dissection- causes difference between arms )
Listen for murmurs ? significant valve problem-
Listen for crackles in chest ? heart failure
Key investigations?
prompt ECG
biomarker release
Complete coronary occlusion and partial coronary occlusion initial ECG and ECG at 3 days?
complete- initial: ST elevation at 3 days: Q waves
Give characteristics of STEMI?
“Full blown” heart attack
Likely they have a completely blocked coronary artery
Ongoing myocardial cell death
Need to get the artery opened ASAP
“Time is muscle”
STEMI treatment?
Mechanical
in cath lab with balloons and stents
= PRIMARY PCI
Pharmacological
With a very strong blood clot dissolving drug
PCI = Percutaneous Coronary Intervention = Angioplasty and stenting
What if remote?
Thrombolysis?
Very strong blood clot dissolving medication
Can be given in back of ambulance
Often will then arrange prompt transfer to a cardiac centre with a cath lab
Risks of thrombolysis?
Bleeding
Don’t give if recent stroke, or ever had a previous intracranial bleed
Caution if had recent surgery, on warfarin, severe hypertension
Anti-thrombotic drugs?
Other drugs used for coronary syndromes?
Ongoing ACS management in hospital?
Risks of coronary angiography and Percutaneous Coronary Intervention (PCI)?
Should patients with non ST elevation ACS also have a coronary angiogram?
Post MI complications?
arrythmic
mechanical
Mechanical complications?
Can have major problems relating to issues with the damaged heart muscle, esp after STEMI
Myocardial rupture - bleed into pericardium – causes cardiac tamponade
Acute Ventricular Septal Defect
Mitral valve dysfunction due to papillary muscle rupture
Always listen for the development of a NEW loud murmur
Course in hospital?
