Cardiology: Ischaemic Heart Disease II Flashcards
What investigations should you conduct for ACS? [2]
ECG:
- STEMI
- NSTEMI
- T wave inversion
- R/LBBB
Troponin levels
Label A & B
What are the criteria or ECG changes to be classified as a STEMI [4]
Cinical symptoms consistent with ACS (generally of ≥ 20 minutes duration) with persistent (> 20 minutes) ECG features in ≥ 2 contiguous leads of:
-
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men under 40 years
or - ≥ 2.0 mm (i.e ≥ 2 small squares) ST elevation in leads V2-3 in men over 40 years
- 1.5 mm ST elevation in V2-3 in women
- 1 mm ST elevation in other leads
- new LBBB (LBBB should be considered new unless there is evidence otherwise)
USE THE J POINT TO WORK OUT IF ACS IF OCCURRING
Asides from ST elevation / ST depression (STEMI & NSTEMI), what other ECG changes may indicate ACS? [1]
How can this change help ID where ischaemia is? [1]
T wave inversion may be a feature of myocardial ischaemia, T wave inversion
T wave inversion even in the absence of ST changes.
Generally relates to the territory of the coronary artery affected by ischaemia.
What does fixed vs dynamic T wave inversion indicate in ACS? [1]
T wave inversion may be fixed, which is usually associated with a previous ischaemic event and associates with Q waves.
Alternatively, T wave inversion may be dynamic, which is associated with& acute myocardial ischaemia.
Name 5 differentials for causes of troponin rises [5]
Myo/pericariditis
CKD
PE
Cardiomyopathy
Afib / tachyarythmais
What indicates a patient is suffering unstable angina c.f STEMI or NSTEMI?
Unstable angina is diagnosed when there are symptoms suggest ACS, the troponin is normal, and either:
A normal ECG
Other ECG changes (ST depression or T wave inversion)
Describe how ST changes occur in a STEMI [3]
Firstly get tall tented / hyperacute T wave
This then moves to J point meeting the increased T wave
Then a Q wave will develop
Describe how ST changes occur in a NSTEMI [2]
In patients presenting with symptoms of acute coronary syndrome, the initial management can be remembered with the “[]” mnemonic
What is the immediate pain relief and management for ACS? [5]
“CPAIN” mnemonic:
C – Call an ambulance
P – Perform an ECG
A – Aspirin 300mg
I – Intravenous morphine for pain if required (with an antiemetic, e.g., metoclopramide)
N – Nitrate (GTN)
Oxygen should only be given if the patient has oxygen saturations < 94% in keeping with British Thoracic Society oxygen therapy guidelines
Describe the management for a STEMI
Immediately assess eligibility for coronary reperfusion therapy. There are two types:
Primary coronary intervention:
- Offered if the presentation is within 12 hours of onset of symptoms AND PCI can be delivered within 120 minutes of the time when thrombolysis could have been given
- Prior to PCI: ‘dual antiplatelet therapy’, i.e. aspirin + another drug.
if the patient is not taking an oral anticoagulant: aspirin & prasugrel;
if taking an oral anticoagulant: aspirin & clopidogrel
- During PCI: patients with radial access:
unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
- During PCI: patients with femoral access:: bivalirudin with bailout GPI
Thrombolysis:
- should be offered within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 minutes of the time when thrombolysis could have been given
- streptokinase, alteplase and tenecteplase.
How do you determine which drugs to give if prior to PCI based on their current medication? [2]
Prior to PCI: ‘dual antiplatelet therapy’, i.e. aspirin + another drug.:
If the patient is not taking an oral anticoagulant:
- prasugrel
If taking an oral anticoagulant:
- clopidogrel
How do you determine which drugs to give if during to PCI based on their access? [2]
patients with radial access:
- unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)
Patients with femoral access:
- bivalirudin with bailout GPI
What is the treatment regimen for NSTEMI? [6]
B – Base the decision about angiography and PCI on the GRACE score
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M – Morphine titrated to control pain
A – Antithrombin therapy with fondaparinux (unless high bleeding risk or immediate angiography)
N – Nitrate (GTN)
Also condiser anti-emetic such as ondansetron
Ticagrelor works by which MoA? [1]
Name two more drugs that work this way [2]
P2Y12 inhibitor: inhibit the platelet activation and aggregation by antagonizing the platelet P2Y12 receptor.
clopidogrel
prasugrel
What do you need to consider with regards to blood glucose levels with STEMI & NSTEMI? [1]
Manage hyperglycaemia by keeping blood glucose levels < 11 mmol/L
What is the medication used following NSTEMI as seconary prevention? [6]
6 As AAAAAA
- Aspirin 75mg once daily indefinitely
- Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
- Atorvastatin 80mg once daily
- ACE inhibitors (e.g. ramipril) titrated as high as tolerated
- Atenolol (or another beta blocker – usually bisoprolol) titrated as high as tolerated
- Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)
Why do you need to monitor renal function with secondary prevention of NSTEMIs? [2]
Taking ACE inhibitors and aldosterone antagonists
Both can cause hyperkalaemia (raised potassium).
What is the name of the score used to calculate risk assessment / 6 month predicted 6‑month mortality for patients with ACS? [1]
Global Registry of Acute Coronary Events (GRACE)
State the different risk stratifications based of GRACE scores [5]
How do you determine if an NSTEMI patient needs coronary angiography (with follow-on PCI if necessary):
Immediately [1]
Within 72 hours [1]
immediate:
- patient who are clinically unstable (e.g. hypotensive)
within 72 hours:
- patients with a GRACE score > 3% i.e. those at immediate, high or highest risk
coronary angiography should also be considered for patients is ischaemia is subsequently experienced after admission
What drug therapy should be given to patients with NSTEMI undergoing PCI? [2]
unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not
further antiplatelet (‘dual antiplatelet therapy’, i.e. aspirin + another drug) prior to PCI:
If the patient is not taking an oral anticoagulant:
- prasugrel or ticagrelor
if taking an oral anticoagulant:
- clopidogrel
How do you decide which PY12 inhibitor should give for conservative managament of unstable angina / NSTEMI based off their risk of bleeding? [2]
if the patient is low-risk of bleeding:
- ticagrelor
if the patient is at a high-risk of bleeding
- clopidogrel
Complications of MI:
Patients commonly enter cardiac arrest due to developing which arythmia? [1]
ventricular fibrillation
Why may bradycardia occur post MI? [1]
If AVN is damaged, get atrioventricular block.
Post inferior MI
What condition is common 48hrs post a transmural MI? [1]
How can you detect this upon examination? [1]
Pericarditis
Perfom a pericardial rub: generally heard over the left sternal border, it is often louder at inspiration but sometimes can be better heard on forced expiration while the patient bends forward
Describe what is meant by Dressler’s syndrome
Post-myocardial infarction syndrome:
It usually occurs around 2 – 3 weeks after an acute myocardial infarction
It is caused by a localised immune response that results in inflammation of the pericardium
How does Dressler’s syndrome present? [6]
2-6 weeks post-MI
combination of:
- fever
- pleuritic pain
- dysopnoea
- pericardial effusion that can lead to cardiac tamponade
- a raised ESR
- concurrent pleural effusion may be present in up to 50% of patients with Dressler’s syndrome
What ECG changes would be exhibited in Dressler’s syndrome? [2]
global ST elevation and T wave inversion
How do you treat Dressler’s Syndrome? [2]
NSAIDs (e.g., aspirin or ibuprofen)
severe cases: steroids (e.g., prednisolone
What is the difference between myocardial infarction and myocardial injury? [2]
Myocardial injury = trop > 99% percentile ULN
Acute MI = Injury +
- Symptoms
- ECG changes
- Imaging showing loss of viable myocardium
- Evidence of coronary aetiology
Implies ischaemia
Describe the 4 types of MI [4]
Type 1: Traditional MI due to an acute coronary event
Type 2: Ischaemia secondary to increased demand or reduced supply of oxygen (e.g. secondary to severe anaemia, tachycardia or hypotension)
Type 3: Sudden cardiac death or cardiac arrest suggestive of an ischaemic event
Type 4: MI associated with procedures such as PCI, coronary stenting and CABG
NB: Type 1 MI have better prognosis than Type 2 MIs
Describe what causes T ype 2 MI [1]
Give two examples of Type 2 MI [2]
Troponin leak due to ischaemia due to oxygen supply and demand imbalance.
E.g. Severe HTN & sustained tachy arythmias
Describe what causes Type 3 MI [2]
Give 2 examples [2]
Troponin rise without acute ischaemia due to acute myocardial inury
E.g. Acute heart failure or myocarditis
STEMI identified, aspirin given, having fibrinolysis. What do you give next? [1]
An antithrombin
Which complications might occur that would cause loud pan-systolic murmur? [2]
What secondary symptom might this cause? [1]
VSD
Papillary muscle rupture causing MR
Both can cause pulmonary oedema
MI complications:
What would cause persistent ST elevation without chest pain? [1]
Ventricular aneurysm
Describe what is meant by Takotsubo’s disease [1]
Which population is it most common in? [1]
AKA broken heart syndrome
Unobstructed coronaries and transient LV impairment which causes myocardial stunning
Might occur due to microvascular spasm from catecholamines [?]
Catecholamine mediated stress in post-menopausal women
