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Year 3 - TCD > Case 1 - ACS > Flashcards

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
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2
Q

What is atypical angina?

A

It has only 2 of the typical angina characteristics:

  • Pain
  • On exertion
  • Relives by rest or GTN
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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
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4
Q

What is stable angina?

A
  • Atherosclerotic plaques which restricts blood flow through coronary artery.
  • Reduces oxygenated blood supply to the heart.
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5
Q

When does coronary flow occur?

A

During diastole when myocardium is relaxed.

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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)
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7
Q

Treatment for stable angina (symptomatic relief)

- Acute episodic relief

A 
1st - Beta blockers, calcium channel blockers 
Aspirin
ACEi 
Stains 
GTN spray
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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.
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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
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10
Q

ECG changes for stable angina

A

Normal

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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
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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
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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.
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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.

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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
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16
Q

What is the gold standard investigation of ACS?

A

CT coronary angiogram

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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.
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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
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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
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20
Q

What are the most cardiospecific troponin?

A

I and T

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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?

25
Q

How soon after an MI do troponins start rising?

A

4-6 hours later

Peak 18-24 hours later

26
Q

What is the immediate management of ACS?

A
  • 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
Q

What treatment is given post MI?

A
  • 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
Q

What is the treatment for STEMI?

A

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
Q

What is the treatment for unstable angina/NSTEMI?

A
  • Dual antiplatelet therapy – ASAP
  • Anticoagulation (UFH, LMWH, fondaparinux) – Continue for the duration of hospitalisation or until PCI is performed.
  • PCI within 72 hours
30
Q

What are the contraindications for thrombolysis?

A
  • Intracranial bleeding
  • Major trauma or surgery <3 weeks ago
  • Known coagulopathy
  • GI bleed <1 month ago.
31
Q

What MI complications are most common in the first 0-24 hours?

A
  • Sudden cardiac death (Ventricular arrhythmia)
  • Arrhythmia
  • Cardiogenic shock
  • Acute heart failure
32
Q

What MI complications are most common after 1 - 3 days?

A

Early infarct associated pericarditis - can lead to tamponade

33
Q

What is cardiac tamponade?

A

Compression of the right ventricle caused by pericardial effusion (fluid around the heart)

34
Q

What MI complications are most common after 3 - 14 days?

A
  • Papillary muscle rupture
  • Ventricular septal rupture
  • LV free wall rupture
35
Q

What MI complications are most common after 2 weeks?

A
  • Atrial/ventricular aneurysms
  • Dressler syndrome
  • Arrhythmia/AV block
  • Congestive heart failure
36
Q

What is Dressler syndrome?

A

Pericarditis occurring 2-10 weeks post MI without an infective cause

37
Q

What is ventricular fibrillation?

A

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
Q

What are the symptoms of arrhythmia?

A

Chest pain, numbness, paresthesia in left arm, SoB, palpitations, fatigue, dizziness

39
Q

What is ventricular tachycardia?

A
  • Heart rate of more than 100 bpm.

- ECG: wider ORS

40
Q

What is supraventricular tachycardia?

A
  • Heart rate of more than 100 bpm.

- Starts at or above AV node

41
Q

What is atrial fibrillation?

A
  • A type of SVT
  • No organised signals across atrium leading to irregular atrial contraction.
  • ECG: Irregularly irregular
42
Q

What are AF patients prescribed to reduce risk of stroke?

43
Q

What are respiratory differentials of chest pain?

A
  • PE
  • Pneumonia
  • Pneumothorax
  • Pleurisy
  • Asthma/COPD
44
Q

What are cardiac differentials of chest pain?

A
  • Aortic dissection
  • Myocarditis/Pericarditis
  • Myocardial ischemia - due to aortic stenosis, HOCM
  • ACS
45
Q

What are GI differentials of chest pain?

A
  • Gastric/peptic ulcers
  • GORD
  • Pancreatitis
  • Acute gastritis
  • Cholelithiasis, cholecystitis, biliary colic
46
Q

What are MSK differentials of chest pain?

A
  • Costochondritis

- Herpes zoster virus

47
Q

What are the causes of myocardial ischeamia?

A
  • Cocaine use (coronary artery vasospasm)
  • Anxiety
  • Anaemia
  • HOCM
  • Aortic Stenosis
48
Q

What are the ECG criteria to diagnose a ST elevation MI?

A
  • New LBBB
  • ST elevation in leads 2+3
  • ST depression in reciprocal leads
49
Q

Why is echo done in ACS?

A
  • Wall motion abnormality

- Assess LV function

50
Q

What are the symptoms of ACS?

A
  • 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

Year 3 - TCD (17 decks)

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