Case 1 - ACS Flashcards
What is typical angina?
- Discomforting chest p, neck, jaw, back or shoulder pain
- Pain precipitated by exertion
- Relieves by rest or GTN within 5 mins
What is atypical angina?
It has only 2 of the typical angina characteristics:
- Pain
- On exertion
- Relives by rest or GTN
Risk factors of CAD
- 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
What is stable angina?
- Atherosclerotic plaques which restricts blood flow through coronary artery.
- Reduces oxygenated blood supply to the heart.
When does coronary flow occur?
During diastole when myocardium is relaxed.
- What is Prinzmetal’s angina?
- When does it occur?
- Vasospastic angina which occurs due to coronary artery spasms. There is narrowing of arteries.
- Can occur at rest (classically at night)
Treatment for stable angina (symptomatic relief)
- Acute episodic relief
1st - Beta blockers, calcium channel blockers Aspirin ACEi Stains GTN spray
- Treatment for acute episode of stable angina
- Key points to remember
- 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.
Differentials for stable angina
- Aortic stenosis, thyrotoxicosis, cocaine use
- Aortic dissection, pericarditis
- GORD, biliary colic, peptic ulcer
- PE, pneumothorax, pneumonia
- HZV, costochondritis
ECG changes for stable angina
Normal
What is ACS?
- 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
What are the ECG changes in unstable angina/NSTEMI?
- Normal
- Inverted T wave
- ST depression: up slopping best type, down slopping worst type, horizontal
- Loss of R wave
- NO ST ELEVATION
- How does chest pain change in unstable angina?
- What to do when experiencing chest pain?
- 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.
What are 2 different risk scores in ACS and what do they look at?
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.
- What is silent MI?
- Who is more likely to have it?
- How is it more likely to present?
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
What is the gold standard investigation of ACS?
CT coronary angiogram
What are the cardiac marker changes in NSTEMI/STEMI?
Raised troponin (greater than 99th percentile) and CK-MB. The greater the rise, the more severe the infarct, higher risk of mortality.
What are the ECG changes in STEMI?
- ST elevation in 2 contiguous leads
- Reciprocal ST depression: confirms the diagnosis
- Hyper-acute T waves (peaked T waves)
- New LBBB
What are the ECG changes over time for STEMI?
- 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
What are the most cardiospecific troponin?
I and T
