Case 1 - ACS Flashcards
1
Q
What is typical angina?
A
- Discomforting chest p, neck, jaw, back or shoulder pain
- Pain precipitated by exertion
- Relieves by rest or GTN within 5 mins
2
Q
What is atypical angina?
A
It has only 2 of the typical angina characteristics:
- Pain
- On exertion
- Relives by rest or GTN
3
Q
Risk factors of CAD
A
- Age – older age
- Gender – male
- Diabetes
- Hyperlipidaemia
- Smoking
- Hypertension
- Obesity
- Concurrent diagnosis of coronary artery disease (e.g. stable angina, previous MI)
- Concurrent diagnosis of other atherosclerotic artery disease (e.g. ischaemic stroke, peripheral vascular disease, renovascular disease)
- Family history of CAD or atherosclerotic arterial disease
- Cocaine – Causes coronary artery spasm
4
Q
What is stable angina?
A
- Atherosclerotic plaques which restricts blood flow through coronary artery.
- Reduces oxygenated blood supply to the heart.
5
Q
When does coronary flow occur?
A
During diastole when myocardium is relaxed.
6
Q
- What is Prinzmetal’s angina?
- When does it occur?
A
- Vasospastic angina which occurs due to coronary artery spasms. There is narrowing of arteries.
- Can occur at rest (classically at night)
7
Q
Treatment for stable angina (symptomatic relief)
- Acute episodic relief
A
1st - Beta blockers, calcium channel blockers Aspirin ACEi Stains GTN spray
8
Q
- Treatment for acute episode of stable angina
- Key points to remember
A
- GTN sublingual spray under tongue
- Can be used prophylaxis before doing strenuous activity
- Sit down after angina pain, take 2 GTN sprays as it can cause dizziness, headaches and hypotension.
9
Q
Differentials for stable angina
A
- Aortic stenosis, thyrotoxicosis, cocaine use
- Aortic dissection, pericarditis
- GORD, biliary colic, peptic ulcer
- PE, pneumothorax, pneumonia
- HZV, costochondritis
10
Q
ECG changes for stable angina
A
Normal
11
Q
What is ACS?
A
- Unstable angina: partial occlusion of coronary vessel due to thrombus formation around plaque rupture. This leads to partial tissue ischemia.
- NSTEMI: subendocardial infarction - affects inner layer of the heart
- STEMI: transmural infarction - affects full thickness of the myocardium due to complete occlusion
12
Q
What are the ECG changes in unstable angina/NSTEMI?
A
- Normal
- Inverted T wave
- ST depression: up slopping best type, down slopping worst type, horizontal
- Loss of R wave
- NO ST ELEVATION
13
Q
- How does chest pain change in unstable angina?
- What to do when experiencing chest pain?
A
- Increase in frequency of chest pain and is not relieved by GTN spray
If experiencing chest pain: - Give 2 sprays of GTN below tongue. Wait 5 mins.
- If pain persists, then given GTN again and wait for 5 mins.
- If pain doesn’t disappear, call 999.
14
Q
What are 2 different risk scores in ACS and what do they look at?
A
1) GRACE - ischaemic risk - Inpatient and 6 month mortality risk following ACS
2) CRUSADE - bleeding risk - Predicts risk of major bleeding in patients diagnosed with ACS. especially NSTEMI, used to inform about risk of thrombolysis.
15
Q
- What is silent MI?
- Who is more likely to have it?
- How is it more likely to present?
A
Minimal to no chest pain.
- More common in elderly, diabetic (who have cardiac neuropathy) and women
- More likely to present with autonomic symptoms - nausea, diaphoresis
16
Q
What is the gold standard investigation of ACS?
A
CT coronary angiogram
17
Q
What are the cardiac marker changes in NSTEMI/STEMI?
A
Raised troponin (greater than 99th percentile) and CK-MB. The greater the rise, the more severe the infarct, higher risk of mortality.
18
Q
What are the ECG changes in STEMI?
A
- ST elevation in 2 contiguous leads
- Reciprocal ST depression: confirms the diagnosis
- Hyper-acute T waves (peaked T waves)
- New LBBB
19
Q
What are the ECG changes over time for STEMI?
A
- 1-2 days after the MI, there can be T wave inversion
- Days later, ST normalises but T wave is still inverted
- Weeks later – there is permanent scarring, ST and T is normal
- T wave inversion may also suggest previous MI
20
Q
What are the most cardiospecific troponin?
A
I and T
21
Q
What are the other causes of raised troponin?
A
- PE
- Myocarditis
- Aortic dissection
- Heart failure
- Renal failure
- Respiratory causes
22
Q
What are the cardiac marker changes in unstable angina?
A
None.
Troponin and CK-MB are normal.
23
Q
Which arteries are more likely to be occluded?
A
Most - LAD
Middle - RCA
Least - Right circumflex
24
Q
How long after MI can troponins be raised for?
A
7-10 days
25
How soon after an MI do troponins start rising?
4-6 hours later
| Peak 18-24 hours later
26
What is the immediate management of ACS?
- M: Morphine IV (10mg) and IV metoclopramide
- O: Oxygen – SpO2 < 94%-98% and < 88%-92% for COPD patients. Via 15L non rebreathe mask.
- N: Nitro-glycerine sublingual (2 sprays)
- A: Aspirin loading dose 300 mg
- C: Clopidogrel loading dose 300 mg
27
What treatment is given post MI?
- Cardiac rehabilitation should be started within 10 days post hospital
- lifestyle modifications (smoking cessation, eat more fruit and veg, regular exercise for 20-30 mins till the point of slight breathlessness)
- DAPT: aspirin for life +clopidogrel for 12 months
- Beta blockers
- High dose statins
- ACEi or ARB - improves cardiac and LV function
28
What is the treatment for STEMI?
If symptoms started >12 hours ago then give anticoagulant (UFH, LMWH, fondaparinux)
If symptoms started <12 hours ago, then:
- PCI ASAP but within 120 mins of STEMI diagnosis.
- Thrombolytic therapy – tPA (alteplase): to be performed if PCI cannot be carried out within 120 mins
- PCI should be performed even if thrombolysis is successful
- Dual antiplatelet therapy – ASAP
- Anticoagulation (UFH, LMWH, fondaparinux) - until PCI is performed
29
What is the treatment for unstable angina/NSTEMI?
- Dual antiplatelet therapy – ASAP
- Anticoagulation (UFH, LMWH, fondaparinux) – Continue for the duration of hospitalisation or until PCI is performed.
- PCI within 72 hours
30
What are the contraindications for thrombolysis?
- Intracranial bleeding
- Major trauma or surgery <3 weeks ago
- Known coagulopathy
- GI bleed <1 month ago.
31
What MI complications are most common in the first 0-24 hours?
- Sudden cardiac death (Ventricular arrhythmia)
- Arrhythmia
- Cardiogenic shock
- Acute heart failure
32
What MI complications are most common after 1 - 3 days?
Early infarct associated pericarditis - can lead to tamponade
33
What is cardiac tamponade?
Compression of the right ventricle caused by pericardial effusion (fluid around the heart)
34
What MI complications are most common after 3 - 14 days?
- Papillary muscle rupture
- Ventricular septal rupture
- LV free wall rupture
35
What MI complications are most common after 2 weeks?
- Atrial/ventricular aneurysms
- Dressler syndrome
- Arrhythmia/AV block
- Congestive heart failure
36
What is Dressler syndrome?
Pericarditis occurring 2-10 weeks post MI without an infective cause
37
What is ventricular fibrillation?
1) There are no signals in the ventricles.
2) Ventricles lose the ability to contract due to no co-ordination.
3) Ventricular wall spasms and no blood circulated through the heart.
38
What are the symptoms of arrhythmia?
Chest pain, numbness, paresthesia in left arm, SoB, palpitations, fatigue, dizziness
39
What is ventricular tachycardia?
- Heart rate of more than 100 bpm.
| - ECG: wider ORS
40
What is supraventricular tachycardia?
- Heart rate of more than 100 bpm.
| - Starts at or above AV node
41
What is atrial fibrillation?
- A type of SVT
- No organised signals across atrium leading to irregular atrial contraction.
- ECG: Irregularly irregular
42
What are AF patients prescribed to reduce risk of stroke?
DOAC/NOAC
43
What are respiratory differentials of chest pain?
- PE
- Pneumonia
- Pneumothorax
- Pleurisy
- Asthma/COPD
44
What are cardiac differentials of chest pain?
- Aortic dissection
- Myocarditis/Pericarditis
- Myocardial ischemia - due to aortic stenosis, HOCM
- ACS
45
What are GI differentials of chest pain?
- Gastric/peptic ulcers
- GORD
- Pancreatitis
- Acute gastritis
- Cholelithiasis, cholecystitis, biliary colic
46
What are MSK differentials of chest pain?
- Costochondritis
| - Herpes zoster virus
47
What are the causes of myocardial ischeamia?
- Cocaine use (coronary artery vasospasm)
- Anxiety
- Anaemia
- HOCM
- Aortic Stenosis
48
What are the ECG criteria to diagnose a ST elevation MI?
- New LBBB
- ST elevation in leads 2+3
- ST depression in reciprocal leads
49
Why is echo done in ACS?
- Wall motion abnormality
| - Assess LV function
50
What are the symptoms of ACS?
- Acute retrosternal chest pain
- Dull/squeezing pressure/tightness
- Radiates to left arm, shoulder, neck, jaw/epigastrium
- Dyspnoea
- N+V
- Diaphoresis
- Dizziness, light headedness
- Tachycardia
- Pallor
