Angina + ACS Flashcards
Why are the 3 main ‘typical’ features of angina chest pain?
- constricting discomfort in front of chest, neck, shoulders, jaw or arms
- precipitated by exertion
- relieved by rest or GTN within about 5 minutes
What is the difference between stable and unstable angina?
Stable angina is induced by effort and relieved by rest
Unstable angina is of increasing frequency or severity and occurs on minimal exertion or at rest
Which investigations should be done for suspected angina?
12 lead ECG Bloods to exclude precipitating factors Exercise tolerance test (ECG) CT coronary angiogram Non-invasive functional imaging e.g. myocardial perfusion scan?
What might been seen on an ECG in suspected angina?
Usually normal
May be signs of previous MI
- ST depression
- flat/inverted T waves
Which angina precipitating factors are you looking for in blood tests?
Anaemia Diabetes Hyperlipidaemia Thyrotoxicosis Temporal arteritis
Which investigation is best for assessing risk in suspected angina?
Exercise tolerance test
Which investigation is best for guiding management of angina?
CT coronary angiogram
When should revascularisation be considered for angina?
Severe symptoms
High risk
Symptoms not controlled by medications
What are the main steps in management of angina?
- lifestyle advice
- GTN
- beta blocker e.g. atenolol
- CCB e.g. amlodipine, nifedipine
What are the side effects of GTN?
Flushing
Headache
Light headedness
What advice should be given to a patient about use of GTN?
- use immediately before exercise or at onset of pain
- repeat dose after 5 minutes if pain not gone
- call ambulance if pain not gone 5 mins after taking second dose
What are some contraindications to beta blockers?
Asthma COPD LVF Bradycardia Coronary artery spasm
What is the next step in management of angina if symptoms not controlled with beta-blocker + CCB?
Consider mono therapy with:
- ISMN
- Ivabradine
- Nicorandil
- Ranolazine
What should be given for secondary prevention of CVD after diagnosis of angina?
Aspirin 75mg daily Atorvastatin 80mg daily BP control ACE inhibitor if angina + diabetes Consider rivaroxaban in addition to aspirin if high risk of ischaemic event
What are the typical features of an MI?
Severe crushing central chest pain Radiating to jaw/arms etc Longer and more severe than angina pain Not relieved by GTN Associated sweating, nausea and vomiting
What are the possible ECG changes seen in a STEMI?
- ST elevation (first few hours)
- T wave inversion
- Q waves
What are the 3 criteria for diagnosis of a STEMI on an ECG?
- 1mm or more ST elevation in 2 adjacent limb leads
- 2mm or more ST elevation in at least 2 contiguous precordial leads
- new onset bundle branch block
Which leads would likely be affected in an inferior MI?
II, III and AVF
Which leads would likely be affected in an anterior MI?
V1 - V6
Which leads would likely be affected in a lateral MI?
I and AVL
Which artery is likely occluded in an inferior MI?
Right coronary artery
Which artery is likely occluded in an anterior MI?
Left anterior descending
Which artery is likely occluded in a lateral MI?
Circumflex
What pattern does serum troponin follow after myocardial ischaemia?
Increase within 3-12 hours from onset of chest pain
Peak at 24-48 hours
Return to baseline over 5-14 days
When should troponin be checked?
Immediately on arrival in A&E
3 hours later
12 hours after symptoms onset to establish diagnosis
What is the diagnostic criteria for an MI?
Rise in troponin + at least one of:
- symptoms of ischaemia
- new ST/T wave changes or new LBBB
- pathological Q waves
- new loss of viable myocardium or new regional wall motion abnormality on imaging
- identification of intracoronary thrombus on angiography
What is the acute management of suspected ACS?
- ABCDE
- ECG
- Troponin level
- Morphine/diamorphine IV + antiemetic
- Oxygen if hypoxic
- GTN (if BP > 90)
- Aspirin 300mg
- Ticagrelor 180mg PO
Which intervention is first line for treatment of STEMI?
PCI
What is the time cut off for PCI?
Within 2 hours of diagnosis
What should be done if PCI is not rapidly available for STEMI?
Thrombolysis IV
+ fondaparinux
How should an NSTEMI be managed?
- fondaparinux or LMWH
- IV nitrates
- calculate GRACE score
- -> coronary angiography if med/high risk
Which medications should a patient be on post MI?
Dual anti platelet - aspirin and ticagrelor
Statin
Beta blocker
ACE inhibitor/ARB
How long should a patient be on dual anti platelet therapy post MI?
Aspirin –> indefinitely
Additional anti platelet e.g. ticagrelor –> at least 12 months
Which drug should you consider adding post MI if the patient has evidence of HF?
Spironolactone
What needs to be monitored before and during treatment with spironolactone?
Renal function
K+
What is Dressler’s syndrome?
Pericarditis, pleural effusions, fever, anaemia + increased ESR
1 - 3 weeks post MI
In cardiac arrest, which rhythms are shockable?
VF
Pulseless VT
Which rhythms are non-shockable?
Asystole
Pulseless electrical activity (PEA)
During ALS, when should adrenaline be given?
If shockable rhythm:
- After 3rd shock
- Then after alternative shocks (every 3-5 mins)
If unshockable:
- asap
Which drug, apart from adrenaline, can be given in ALS and when?
Amiodarone 300mg
After 3rd shock
Name the reversible causes of cardiac arrest
Hypoxia
Hypovolaemia
Hypo/hyperkalaemia
Hypothermia
Thrombosis - coronary or pulmonary
Tension pneumothorax
Tamponade
Toxins
How much adrenaline is given in ALS?
1mg IV
