chapter 4 Flashcards
what are the specific group of people that present with angina uncharacteristically ?
no chest pain just breathlessness - diabetics , females , elderly
angina usually gets misdiagnosed as what?
in digestion
what is crescendo angina ?
a form of unstable angina -
angina on exertion , occuring with increasing frequency , provoked by progressively less exertion
unstable angina characteristic ?
angina like pain occurring recurrently and unpredictably without exercise provocation
may settle spontaneously and relieved for short term by GTN sublingual
the categories of ACS?
STEMI - ST elevation or new LBBB
Non ST segment elevation ACS :
NSTEMI (High troponin)
unstable angina (no ECG CHANGES OR NO HIGH TROPONIN)
unstable angina ECG ?
normal
show evidence of acute myocardial ischemia -ST depression
non specific abnormalities - T wave inversion
in unstable angina - when there are no ecg changes and troponin levels are normal = GRACE SCORE LOW what can be done ?
further risk assessment test = exercise testing
non invasive imaging
NSTEMI angina characteristic ?
pain >20 mins
nausea and vomiting
sweating
belching
NSTEMI in vascular sense ?
partial or intermittent occlusion
treatmnet for NSTEMI and unstable angina is the same ?
yes
unlike STEMI - needing immediate reperfusion
what does the development of q waves mean in STEMI ?
damage to the myocardium in the area where the artery is occluded - causing iMPAIRED VENTRICULAR FUNCTION
during acute phase of STEMI there is substantial risk of what ?
tach and vfib
DD for angina in STEMI ?
PE and aortic dissection
suspect aortic dissection when ?
acute chest pain - radiating to the back
marked hypotension
loss of peripheral pulse
asymmetry f pulse in the upper limbs
does a single normal ECG exclude ACS?
no - should be repeated in intervals
what needs to be established if PPCI is not given within 20 mins?
fibrinolytic
symptoms of PE
sudden hypoxia
how to detect anterior or anteroseptal infraction on ECG
change in leads V1-V4
by LAD artery - left anterior descending
if V5-V6 involved , lead 1 and AVL = anterolateral
which infraction has the worst prognosis ?
anterior infract causes most damage on left ventricle function - worst prognosis
how to detect inferior infraction ?
lead 2,3 and avF
right coronary artery
how to detect lateral infraction ?
lead V5 V6
or
lead 1 and aVL
how to detect posterior infraction ?
ST segment depression V3-V4 (anterior leads)
dominant r wave in v1-v2- reflects posterior q wave development
= right coronary artery occlusion
confirmed with repeating ecg with posterior leads v7-v10
one third of patients with inferior and posterior STEMI May also have ?
right ventricular infraction
st elevation in v1
and inferior posteriori STEMI
are ST segment depression and t wave inversion in the ecg lead related to where the damage occurred in the heart ?
no
other causes pf st elevation ?
SAH
TBI
brigade syndrome - ST elevation in V1 -V2
takotsubo cardiomyopathy
pe ecg changes ?
t wave inversion v1-v4
other causes for high troponin ?
PE
aortic dissection
myocarditis
heart failure
chronic renal failure
sepsis
what is the GRACE SCORE BASED ON ?
age
troponin levels
ecg changes
signs of heart failure
HR
serum creation
BP
cardiac arrest
treatmnet for ACS
ACS protocol
cardiac monitor
loading 300mg aspirin
GTN
oxygen
pain relief - opiate analgesia - morphine
anti metic
clopidrogel - 300mg /600
prasugrel - 60mg
ticagrelor - 180mg
when does PCI not become useful ?
after 12 hour of symptom onset
however should be considered if in ecg shows ongoing ischemia
some setting PCI is used with what adjuncts ?
glycoprotein 2b/3a inhibitors
benefits of PCI to fibrinolytic ?
lower risk of bleeding into the brain and bleeding in general
contra for PCI?
previous hemorrhagic stroke
schema stroke last 6 months
recent major injury or trauma
active bleeding
non or suspected aortic dissection
known bleeding disorder
if patient getting fibrinolytic do they need additional antithmbotic therapy ?
if so what
yes
= aspirin 300mg and clop 300= if high bleeding risk
/ or ticagrelor =180mg
+
antithrombin therapy
LMWH/ UFH / fondaparinoux
indication for fibrinolytic ?
more tha 12 hr since symptom onsert and PCI not possible within 120 min
AND
ST segment elevation in 2 adjacent chest leads of 0.2mv or more
or
2 or more peripheral limb leads of 0.1mv or more
or
dominant r waves and st depression in v1-v3
or
new onset LBBB
after successful thrmbolysiswith fibrinolytic what should be considered ?
angiography with or without PCI
how do you know fibrinolytic therapy has failed ?
cardiac monitoring continuously
12 lead ecg recored 60-90 mins after fibrinlitics
failure of st elevation to depress in more than 50 percent compared to pre treatmnet ECG
or no reperfusion arrythmia - accelerated idioventriuclar rythm - NOT in all cases and might not be witnessed
symptoms unreliable guide for reperfusion
treatmnet for NSTEMI ?
immediate treatmnet object - prevent new thrombus formation , reduce myocardial oxygen demand
= further thrombus prevention
fondaparinoux
aspirin loading and daily maintenance
prasugrel 60mg (contra >75 and hx of bleeding) then 10 mg
or
clop 300mg then 75mg
or ticagrelor 180mg then 90 mg
reduce myocardial oxygen demand = beta blockers
bb contra = diltiazem
avoid DCCB such as nifedipine
consider Nitrate infusion if angina persist pr reoccurs after sublingual nitrate
consider early ACE
long term therapy for ACS?
cardiac rehab - reduce hospital admission begins from he cardiac unit tot he community
long term anticoagulant
if PCI minimum of one year
if atrial fib as complication - DOAC or warfarin
ACEI - reduce the remodelling that contributes to left ventricular dilation
reduce risk of HF and future MI
for first few days
if low LVEF (<40) - aldosterone antagonist
ECHO examination of LVF
BB - shown to reduce mortality
cardioprotective effect
prevent future arrythmia
statins - reduce risk of future coronary event
stop smoking
anti hypertensives
NSTEMI CONSIDERED cause of cardiac arrest ?
immediate coronary angiography and PCI if needed
if an arrythmia occurs within 24-48 hr after an ACS has happened what is the management ?
ICD is not indicated unless persistently severe LV function at least 4 weeks post ACS
also check for other factors that might have predisposed the arrythmia - hypokalaemia
if there is sustained ventricular arrythmia after 48 hr of ACS ?
ICD unless arrythmia associated with ischemia which can be reversed with revascularisation
who are at most risk for cardiac arrest as late complication
those who develop Vf and tach - should be seen by a cardiologist for an ICD
what indicates poor prognosis in relation to myocardial infraction and arrythmia ?
AV block - extensive myocardial injury
usually slow and hesitant to atropine
temporary cardiac pacing is usually needed
if cardiac arrest occurs in the contact of MI what should happen
if esp in cardiac lab -
mECHANICAL DECOMPRESSION - AND START PCI
or extracorporeal CPR
