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PMP 201 Patient-Centred Learning > Clinical Management of Acute Coronary Syndrome (ACS) > Flashcards

Clinical Management of Acute Coronary Syndrome (ACS) Flashcards

1
Q

ACS

A
  • Sudden reduced blood flow
  • Stable angina
  • Unstable angina
  • Non-ST MI
  • ST MI
  • How much occluded
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2
Q

Unstable angina

A
  • Partial transient obstructive thrombus
  • Ischemia without necrosis
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3
Q

NSTEMI

A
  • Partial transient obstructive thrombus
  • Ischemia WITH
    necrosis
  • Partial thickness
    damage on heart walls
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4
Q

STEMI

A
  • Complete obstruction by the intracoronary thrombus
  • Ischemia WITH
    necrosis
  • Full thickness
    damage on heart wall
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5
Q

Symptoms of ACS

A
  • Cheat pain
  • Pain in jaw, teeth, shoulder, arm, stomach and back
  • Light headed
  • Feeling sick
  • Shortness of breath
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6
Q

Site of ACS

A
  • Central chest pain
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7
Q

Onset of angina

A
  • Brought on by physical or
    emotional exertion
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8
Q

Character of angina

A
  • Crushing, squeezing,
    constricting, heaviness
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9
Q

Radiates of angina

A
  • Can radiate to jaw,
    neck, shoulder, arm or
    stomach
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10
Q

Timing of angina

A
  • Brought on by physical or emotional exertion
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11
Q

Exacerbating angina

A
  • Worse after food
  • Cold winds
  • Exercise
  • Stress
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12
Q

Difference between STEMI & NSTEMI

A
  • Brought on by physical or
    emotional exertion OR AT REST
  • Worse symptoms
  • More frequent GNT use
  • Bought on at rest
  • Pain lasts longer
  • Not relieved by GNT initially
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13
Q

Myocardial
Infarction site

A
  • Central chest pains
  • Rapid onset symptoms bought on by physical/ emotional exertion at rest
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14
Q

Myocardial
Infarction character

A
  • Crushing, squeezing,
    constricting, heaviness
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15
Q

Radiation of MI

A
  • Can radiate to jaw,
    neck, shoulder, arm or
    stomach
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16
Q

Timing of MI

A
  • Brought on by physical or emotional exertion or at rest
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17
Q

Exacerbating MI

A
  • Worse after cold winds and eating
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18
Q

Associated symptoms

A
  • Shortness of breath
  • cough
  • Pale & clammy skin
  • Nausea & vomiting
  • Lightheaded & dizzy
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19
Q

ACS in men

A
  • Pain radiates from jaw, neck, shoulders and arms
  • Central heart pains crushing heavy
  • Shortness of breath
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20
Q

ACS in women

A
  • Tiredness
  • Sudden dizziness
  • Shortness of breath
  • Nausea and vomiting
  • Central chest pain crushing
  • Pain neck and jaw
  • Heartburn
  • Cold sweats
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21
Q

Red flags

A
  • Chest pains lasting longer than 15 mins to 20
  • Onset angina symptoms
  • Unresponsive to GTN
  • Nausea vomiting and sweating
  • Urgent 999 call
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22
Q

Diagnosis patient history

A
  • Patient consultation
  • History taking
  • Family history
  • Social history
  • Drug history
  • System review
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23
Q

Risk factors modifiable

A
  • Smoking
  • Diabetes
  • Hypolipidemia
  • Hypertension
  • Obesity
  • illicit drugs
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24
Q

Non-modifiable risk factors

A
  • Age
  • gender
  • family history
  • ethnicity
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25
Q

Unstable angina and NSTEMI

A
  • ST complex depression
  • May have T wave inversion
  • No elevation of ST complex
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26
Q

STEMI

A
  • Elevation of ST complex
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27
Q

Blood test for troponin levels

A
  • Biological marker for cardiac death
  • Released into circulation when cardiac muscle is damaged
  • High levels of troponin in blood indicate high MI
  • Normal <14ng/L if elevated then repeat blood test 3hrs later
  • > 21ng/L most likely MI
  • Troponin >100 suggest MI with ACS
  • STEMI or NSTEMI suggest
28
Q

Differential diagnosis

A
  • Acid reflux
  • Pulmonary embolism (PE)
  • Anaemia
  • Muscoskeletal
  • Collapsing lung
  • Pericarditis
29
Q

Antianginal drugs

A
  • Prevent or minimize anginal symptoms
  • Improve long term mortality and morbidity
30
Q

Secondary prevention of angina

A
  • Minimize CV events MI/stroke
31
Q

Glycerin Trinitrate for angina

A
  • Short acting nitrate that dilates blood vessels increase oxygen supply to heart
  • Used to treat prophylaxis prior to activity bring on angina pain
32
Q

GNT sublingual spray

A
  • Prophylaxis 1 to 2 spray prior to activity under tongue
  • Repeat after 5 mins
  • Symptoms not resolved 5 mins 2nd dose and call 999
33
Q

Side effects GNT tablet and spray

A
  • Headache
  • Low blood pressure
  • Flushing
  • Nausea and vomiting
34
Q

Counselling GNT spray

A
  • Dose taken when sitting down and hold breath
  • Spray under tongue
  • Press down on button firmly
  • Close mouth immediately
  • Don’t inhale
35
Q

GNT sublingual tablet

A
  • One tablet under tongue prior to activity
  • Repeat after 5 mins
  • No resolve call 999 after 5 mins
36
Q

GNT tablet counselling

A
  • Dissolve tablet under tongue do not swallow
  • Expire 8 weeks after open
37
Q

First line treatments of angina

A
  • Beta blocker Atenolol or Bisoprolol
  • Calcium channel blocker Amlodipine, felodipine and dizalitem
38
Q

2nd line treatment Angina

NICORANDIL

A
  • 10-20mg increased to 40mg if tolerated BD
  • Side effects - dizziness, haemorrage and ulcer
  • Monitor potassium levels
  • Counselling stop taking ulcer is present
39
Q

2nd line treatment Angina

Ibavradine

A
  • 2.5mg-5mg BD increased to 7.5mg BD after 3-4 week
  • Side effects - Arrhythmias, headache and vision disorders
  • Caution AF or other Arrithmyas in elderly
  • Monitor AF on ECG heart rate for bradycardia
40
Q

2nd line treatment Angina

isosorbide mononitrate

A
  • Side effects - flushing, headache, arrhythmias
  • Counselling - Non-MR formulation must be taken at 8am and 2pm to prevent tolerance to the drug
    developing
41
Q

Secondary prevention

A
  • Aspirin
  • ACE inhibitor
  • Statin
  • Hypertention
42
Q

Life style advice

A
  • Diet
  • Alcohol consumption
  • exercise
  • Stress
  • Anxiety
  • Smoking
43
Q

Intial treatment ACS

A

-ASPIRIN 300mg antiplatelet with FONDIPARINUX 2.5mg once a day

44
Q

Low molecular weight heparin

A
  • Fondiparinux 2.5mg
  • Inject 5-8 day till
  • Anticoagulant prevent further clotting
45
Q

STEMI Initial treatment
Reperfusion therapy

A
  • Coronary angiography with follow up pre-cutaneous intervention (Gold standard)
  • Fibrinolysis
  • Coronary artery revascularisation
46
Q

Coronary angiography

A
  • Take x ray after dye injected visual image of arteries to highligh stenosis due to atherosclerotic plaques
47
Q

Percutaneous coronary intervention

A
  • Stenting where coronary arteries have been identified as stenosed
  • Stent inserted to widen coronary artery
  • Use drug eluting stent to prevent body reacting to foriegn object causing clot
  • Epithelial cells soon grow over so risk minimised
  • Use Antiplatelet 12 month after
48
Q

Coronary angiograph drug requirements

A
  • Immediately ASPIRIN 300mg as antiplatelet treatment
  • Immediately TICAGRELOR 180mg or PRASUGREL 60mg
  • With FONDIPARINUX 2.5mg once daily
49
Q

Other treatment during initial management

Oxygen therapy

A

should be administered if there is evidence of hypoxia

50
Q

Other treatment during initial management

Ischaemic pain relief

A
  • Nitrates initially sublingual but if pain doesn’t subside
  • Addition of diamorphine if pain is not relieved
51
Q

Other treatment during initial management

Hyper glycaemic management

A
  • Dose adjust infuser control blood glucose levels
  • Target of < 11mmol/L
52
Q

Fibrinolysis

A

Administered to break up the blood clot in the coronary arteries

53
Q

Fibrinolysis drug

ALTEPLASE

A
  • Given within 6 hrs of onset symptoms
  • Due to risk of bleeding
54
Q

Fibrinolysis drug

STREPTOKINASE

A
  • Given within 12 hours of symptom onset
  • Due to risk of bleeding
55
Q

Coronary artery revascularisation

A
  • Using a healthy vein to bypass the
    blocked coronary artery allowing blood flow to be regained
  • Invasive treatment
56
Q

When perfusion therapy is not indicated (medical management of STEMI)

A
  • Use CLOPIDOGREL 300mg
    STAT if bleeding risk is high with TICAGRELOR 180mg
57
Q

Initial management of NSTEMI:
GRACE scoring tool

A
  • Patients age
  • Heart rate / pulse
  • Systolic BP
  • Creatinine
58
Q

GRACE score interpretation

A
  • <0.3 risk low just use pharmacological methods
  • <0.6 and >0.3 intermmediate risk and >0.6 high risk concider coronary angiography
59
Q

SECONDARY PREVENTION

A
  • Prevent future cardiac events
  • Reduce the risk of complications post-MI
60
Q

Secondary prevention pharmacological treatment

A
  • ASPIRIN
  • TICAGRELOR
    (or Clopidogrel or Prasugrel)
  • ACE INHIBITOR
    (ARB used if ACEI not tolerated)
  • BETA BLOCKER
  • STATIN
61
Q

Dual antiplatelet: Asiprin and Ticagrelor

A
  • Aspirin life long with food and Ticagrelor up to 12 months ( monitor renal function)
  • Reduce development of clots if atherosclerotic plaque ruptures
62
Q

Statin Secondary prevention

A
  • Give 80mg Atorvastatin life long
63
Q

Secondary prevention diet

A
  • Increase bread fruit veg and fish
  • Decrease meat
  • Replace butter and cheese with plant based oil foods
64
Q

Secondary prevention alcohol

A
  • Max 14 units in the week spread across 3 days
  • More drink free days
65
Q

Secondary prevention Physical activity

A
  • 20 to 30 mins of activity a day
  • More activities and regular exercise

PMP 201 Patient-Centred Learning (51 decks)

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