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
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
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
MI complications:
What would cause persistent ST elevation without chest pain? [1]
Ventricular aneurysm
