Angina + ACS Flashcards
What are the causes of myocardial ischaemia?
Coronary artery disease, aortic stenosis, Hypertrophic cardiomyopathy, tachyarrythmia, cocaine use, anaemia, thyrotoxicosis
What is angina?
symptom complex caused by transient myocardial ischaemia
What are the 3 characteristics of typical angina?
- constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
- precipitated by physical exertion
- relieved by rest or GTN within about 5 minutes.
What are precipitants of angina?
Cold weather, heavy metals and emotion
What are the associated symptoms of angina?
dyspnoea, nausea, sweatiness, faintness
What is stable angina?
Induced by effort, relieved by rest.
What is unstable angina?
angina of increasing frequency and severity, occurs on minimal exertion or at rest
What is decubitus angina?
angina precipitated by lying flat
What is causes prinzmetal angina?
coronary artery spasm
How is stable angina initially managed?
Blood - identify condition which exacerbates angina
Aspirin
ECG
GTN spray
What is first line diagnostic investigation for angina?
CT coronary angiography
What is exercise testing used for?
assessing the severity of coronary disease and identifying high-risk individuals
What is used in secondary prevention of CVD?
Stop smoking, exercise, dietary advice, optimise HTN, diabetes control
75mg OD Aspirin
Address hyperlipidaemia with Statins
ACE-I if diabetic
What are first line anti-anginal drug treatments?
Beta-blockers (atenolol/bisoprolol) or Calcium channel antagonists (amlodipine/diltiazem/verapamil)
What is second line treatment for angina?
Long acting Nitrate (Isosorbide mononitrate)
OR
Nicorandil
OR
Ivabradine
OR
Ranolazine
Why are ACE-I used for diabetics with stable angina?
ACE inhibitors represent a vasculoprotective and renoprotective effect for people with diabetes.
What is the MoA of nicorandil?
K+ channel activators
What is MoA of ivabradine?
If (funny) Channel Antagonist
What is initial treatment for suspected ACS?
300mg Aspirin loading dose
What is ACS?
a term that encompasses both unstable angina and myocardial infarction (MI)
What is MI?
symptoms occur at rest and there is evidence of myocardial necrosis, as demonstrated by an elevation in cardiac troponin or creatinine kinase-MB isoenzyme
What are the symptoms of ACS?
Chest pain - tightness/heaviness that radiates to jaw or arm, breathlessness, N and V, collapse
How does sudden death occur in MI?
from ventricular fibrillation or asystole
What are the signs of ACS?
distress, anxiety, pallor, sweatiness, altered pulse rate, signs of heart failure, pan-systolic murmur
What investigations are carried out in suspected ACS?
ECG, Cardiac troponin levels, echocardiogram, coronary angiography
What type of MI occurs when ST-segement elevation arises?
transmural (full-thickness) infarction due to proximal occlusion of a coronary artery
What type of infarction is non ST-elevation MI?
partial-thickness (subendocardial) MI due to is partial occlusion of a major vessel or complete occlusion of a minor vessel
How is MI diagnosed?
History, ECG and troponin measurements
What is the GRACE score?
Ischaemic risk score
What is the CRUSADE score?
Bleeding risk score
How is ACS immediately managed? (6)
Morphine + metclopramide Oxygen Nitrates (GTN Sublingual) Aspirin 300mg Clopidogrel 300mg/Ticagrelor 180mg IV beta-blockers
Who is offered PCI?
for people with acute STEMI if:
- presentation is within 12 hours of onset of symptoms and
- primary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.
When should thrombolysis be used?
people with acute STEMI presenting within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when fibrinolysis could have been give
What drug is used to thrombolyse?
Alteplase
What should offered after thrombolysis?
ECG 60-90 mins after
How is NSTEMI managed?
beta-blocker, anti-thrombotic (LWMH/fondaparinux), assess risk with GRACE score
How are high risk NSTEMI patients managed?
GPiib/iiia antagonist (eg tirofiban, abcixmab), or bivalirudin
Angiography within 96hours
Clopidogrel + Aspirin
What is use in long-term managed for ACS (10)?
Aspirin 75mg OD lifelong Clopi + Aspirin for 12 months PPI - gasto-protection Anti-coagulate - until discharge Statins Beta-blocker if LV impairment ACE-I/ARB Aldosterone antagonists – patients taking beta blockers and ACE inhibitors with LVEF <35% Enrolment in secondary prevention programme Modify risk factors
What medication can be offered to those who are to undergo PCI? (5)
ticagrelor or prasugrel or cangrelor + heparin or bilvalirudin
A 45-year-old gentleman presents to the emergency department with nausea, sweating and severe central crushing chest pain which radiates to his left arm. His ECG shows widespread ST depression with T wave inversion. His blood tests identify a haemoglobin level of 75g/L. What is used to treat his anaemia?
transfusion of packed red cells
What are the ECG criteria to diagnose STEMI?
New LBBB or >/= 1mm ST elevation in II and III
What does the cardiac rehabilitation programmed involve?
Stress management
taking into account physical demands of work when advising return
What are possible causes of myocardial ischaemia in younger patients?
Aortic Stenosis, cocaine use, HOCM, anaemia
