Clinical Management of Acute Coronary Syndrome (ACS) Flashcards
ACS
- Sudden reduced blood flow
- Stable angina
- Unstable angina
- Non-ST MI
- ST MI
- How much occluded
Unstable angina
- Partial transient obstructive thrombus
- Ischemia without necrosis
NSTEMI
- Partial transient obstructive thrombus
- Ischemia WITH
necrosis - Partial thickness
damage on heart walls
STEMI
- Complete obstruction by the intracoronary thrombus
- Ischemia WITH
necrosis - Full thickness
damage on heart wall
Symptoms of ACS
- Cheat pain
- Pain in jaw, teeth, shoulder, arm, stomach and back
- Light headed
- Feeling sick
- Shortness of breath
Site of ACS
- Central chest pain
Onset of angina
- Brought on by physical or
emotional exertion
Character of angina
- Crushing, squeezing,
constricting, heaviness
Radiates of angina
- Can radiate to jaw,
neck, shoulder, arm or
stomach
Timing of angina
- Brought on by physical or emotional exertion
Exacerbating angina
- Worse after food
- Cold winds
- Exercise
- Stress
Difference between STEMI & NSTEMI
- 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
Myocardial
Infarction site
- Central chest pains
- Rapid onset symptoms bought on by physical/ emotional exertion at rest
Myocardial
Infarction character
- Crushing, squeezing,
constricting, heaviness
Radiation of MI
- Can radiate to jaw,
neck, shoulder, arm or
stomach
Timing of MI
- Brought on by physical or emotional exertion or at rest
Exacerbating MI
- Worse after cold winds and eating
Associated symptoms
- Shortness of breath
- cough
- Pale & clammy skin
- Nausea & vomiting
- Lightheaded & dizzy
ACS in men
- Pain radiates from jaw, neck, shoulders and arms
- Central heart pains crushing heavy
- Shortness of breath
ACS in women
- Tiredness
- Sudden dizziness
- Shortness of breath
- Nausea and vomiting
- Central chest pain crushing
- Pain neck and jaw
- Heartburn
- Cold sweats
Red flags
- Chest pains lasting longer than 15 mins to 20
- Onset angina symptoms
- Unresponsive to GTN
- Nausea vomiting and sweating
- Urgent 999 call
Diagnosis patient history
- Patient consultation
- History taking
- Family history
- Social history
- Drug history
- System review
Risk factors modifiable
- Smoking
- Diabetes
- Hypolipidemia
- Hypertension
- Obesity
- illicit drugs
Non-modifiable risk factors
- Age
- gender
- family history
- ethnicity
Unstable angina and NSTEMI
- ST complex depression
- May have T wave inversion
- No elevation of ST complex
STEMI
- Elevation of ST complex
Blood test for troponin levels
- 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
Differential diagnosis
- Acid reflux
- Pulmonary embolism (PE)
- Anaemia
- Muscoskeletal
- Collapsing lung
- Pericarditis
Antianginal drugs
- Prevent or minimize anginal symptoms
- Improve long term mortality and morbidity
Secondary prevention of angina
- Minimize CV events MI/stroke
Glycerin Trinitrate for angina
- Short acting nitrate that dilates blood vessels increase oxygen supply to heart
- Used to treat prophylaxis prior to activity bring on angina pain
GNT sublingual spray
- Prophylaxis 1 to 2 spray prior to activity under tongue
- Repeat after 5 mins
- Symptoms not resolved 5 mins 2nd dose and call 999
Side effects GNT tablet and spray
- Headache
- Low blood pressure
- Flushing
- Nausea and vomiting
Counselling GNT spray
- Dose taken when sitting down and hold breath
- Spray under tongue
- Press down on button firmly
- Close mouth immediately
- Don’t inhale
GNT sublingual tablet
- One tablet under tongue prior to activity
- Repeat after 5 mins
- No resolve call 999 after 5 mins
GNT tablet counselling
- Dissolve tablet under tongue do not swallow
- Expire 8 weeks after open
First line treatments of angina
- Beta blocker Atenolol or Bisoprolol
- Calcium channel blocker Amlodipine, felodipine and dizalitem
2nd line treatment Angina
NICORANDIL
- 10-20mg increased to 40mg if tolerated BD
- Side effects - dizziness, haemorrage and ulcer
- Monitor potassium levels
- Counselling stop taking ulcer is present
2nd line treatment Angina
Ibavradine
- 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
2nd line treatment Angina
isosorbide mononitrate
- Side effects - flushing, headache, arrhythmias
- Counselling - Non-MR formulation must be taken at 8am and 2pm to prevent tolerance to the drug
developing
Secondary prevention
- Aspirin
- ACE inhibitor
- Statin
- Hypertention
Life style advice
- Diet
- Alcohol consumption
- exercise
- Stress
- Anxiety
- Smoking
Intial treatment ACS
-ASPIRIN 300mg antiplatelet with FONDIPARINUX 2.5mg once a day
Low molecular weight heparin
- Fondiparinux 2.5mg
- Inject 5-8 day till
- Anticoagulant prevent further clotting
STEMI Initial treatment
Reperfusion therapy
- Coronary angiography with follow up pre-cutaneous intervention (Gold standard)
- Fibrinolysis
- Coronary artery revascularisation
Coronary angiography
- Take x ray after dye injected visual image of arteries to highligh stenosis due to atherosclerotic plaques
Percutaneous coronary intervention
- 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
Coronary angiograph drug requirements
- Immediately ASPIRIN 300mg as antiplatelet treatment
- Immediately TICAGRELOR 180mg or PRASUGREL 60mg
- With FONDIPARINUX 2.5mg once daily
Other treatment during initial management
Oxygen therapy
should be administered if there is evidence of hypoxia
Other treatment during initial management
Ischaemic pain relief
- Nitrates initially sublingual but if pain doesn’t subside
- Addition of diamorphine if pain is not relieved
Other treatment during initial management
Hyper glycaemic management
- Dose adjust infuser control blood glucose levels
- Target of < 11mmol/L
Fibrinolysis
Administered to break up the blood clot in the coronary arteries
Fibrinolysis drug
ALTEPLASE
- Given within 6 hrs of onset symptoms
- Due to risk of bleeding
Fibrinolysis drug
STREPTOKINASE
- Given within 12 hours of symptom onset
- Due to risk of bleeding
Coronary artery revascularisation
- Using a healthy vein to bypass the
blocked coronary artery allowing blood flow to be regained - Invasive treatment
When perfusion therapy is not indicated (medical management of STEMI)
- Use CLOPIDOGREL 300mg
STAT if bleeding risk is high with TICAGRELOR 180mg
Initial management of NSTEMI:
GRACE scoring tool
- Patients age
- Heart rate / pulse
- Systolic BP
- Creatinine
GRACE score interpretation
- <0.3 risk low just use pharmacological methods
- <0.6 and >0.3 intermmediate risk and >0.6 high risk concider coronary angiography
SECONDARY PREVENTION
- Prevent future cardiac events
- Reduce the risk of complications post-MI
Secondary prevention pharmacological treatment
- ASPIRIN
- TICAGRELOR
(or Clopidogrel or Prasugrel) - ACE INHIBITOR
(ARB used if ACEI not tolerated) - BETA BLOCKER
- STATIN
Dual antiplatelet: Asiprin and Ticagrelor
- Aspirin life long with food and Ticagrelor up to 12 months ( monitor renal function)
- Reduce development of clots if atherosclerotic plaque ruptures
Statin Secondary prevention
- Give 80mg Atorvastatin life long
Secondary prevention diet
- Increase bread fruit veg and fish
- Decrease meat
- Replace butter and cheese with plant based oil foods
Secondary prevention alcohol
- Max 14 units in the week spread across 3 days
- More drink free days
Secondary prevention Physical activity
- 20 to 30 mins of activity a day
- More activities and regular exercise
