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Cardiology > DIAGNOSIS & MANAGEMENT OF ACUTE CORONARY SYNDROME > Flashcards

DIAGNOSIS & MANAGEMENT OF ACUTE CORONARY SYNDROME Flashcards

1
Q

What is Acute coronary syndrome

A

It is a clinical / pathologic event associated with myocardial ischemia with evidence of myocardial injury.

There is an associated rise and/or fall in level of troponin.

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2
Q

What is the major risk factor for ACS in developing or developed countries?

A

Artherosclerosis due to hypercholesterolemia

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3
Q

There is elevated cardiac markers in unstable angina.

True or false?

A

False

Cardiac enzymes are normal.

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4
Q

There is elevated cardiac markers in NSTEMI.

True or false?

A

True

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5
Q

What are the types of MI

A

TYPE 1
MI due to atherothrombotic coronary artery dx
TYPE 2
MI due to mismatch in oxygen demand and supply
TYPE 3
Classical features of MI (ECG changes with ventricular fibrillation) but the patient dies before the blood is drawn for cardiac markers or before cardiac markers show in blood.
TYPE 4a
MI with associated percutaneous coronary intervention (PCI)
TYPE 4b
Percutaneous MI for stent
TYPE 5
CABG associated MI with elevated troponin levels

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6
Q

What are the risk factors for ACS

A

MODIFIABLE
• Older age
• Gender (male)

NON MODIFIABLE
• T2DM
• Dyslipidemia (hypercholesterolemia)
• Smoking
• HTN
• Recreational drug
• Heavy exertion or mental stress
• Anger may trigger plaque disruption causing AMI

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7
Q

What are the clinical features of ACS

A

Clinical history
• Chest pain/pressure/heaviness/tightness radiating to the jaw, left arm/back.
• Worsening of previously stable angina.
• New onset angina occurring at rest, increase in frequency and severity with little or no response to use of nitrates.
• Reduced exercise tolerance.
• Epigastric discomfort, neck, jaw, arm or ear pain
• Congestive heart failure.
• Atypical presentation : females, elderly, DM ( may be silent)

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8
Q

List the physical findings on examination

A

• Pale, anxious, diaphoretic
• Hypotension from acute LV dysfunction, RV infarction
• Cardiogenic shock
• Pulmonary oedema, crackles
• Bezold-Jarisch reflex: bradycardia & hypotension
• S3, S4
• Systolic murmur
• Shortness of breath
• Dizzy spells
• Confusion / LOC
• Levine sign: clenched fist held against sternum
• Tachycardia
• Palpitations

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9
Q

Features of Bezold-Jarisch reflex

A

Bradycardia
Hypotension

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10
Q

What is the diagnostic criteria for ACS

A

Symptoms of ischemia
+ any of the following

• ECG changes- development of Q waves, significant ST-T wave changes, or new LBBB
• Rise and fall of biochemical markers of myocardial necrosis
• Imaging evidence of new loss of viable myocardium or regional wall motion abnormality.
• Angiographic or autopsy evidence of intracoronary thrombus

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11
Q

What is the earliest sign on ECG of ACS

A

Hyper acute T wave.

You must differentiate from hyperkalemia T wave

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12
Q

List other conditions that can cause false ST elevation

A

• Hyperkalaemia
• Pulmonary embolism
• Subarachnoid haemorrhage
• Cholecystitis

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13
Q

Discuss the coronary artery anatomy with respect to ECG leads

A
  • LATERAL LEADS
    Left Anterior Descending (LAD) artery and or Left Circumflex Artery (LCx)
  • INFERIOR LEADS
    Right Coronary Artery (RCA) and or Left Circumflex Artery (LCx)
  • ANTERIOR AND SEPTAL LEADS
    Left Anterior Descending (LAD) artery
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14
Q

List the cardiac markers you know

A

1) Myoglobulin
2) CK-MB
3) Troponin
4) BNP
5) CRP

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15
Q

How many Troponin subtypes do we have and list them

A

3 subtypes
• T
• I
• C

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16
Q

List the non ACS conditions that can cause raised Troponin levels

A

• Heart failure
• Rapid atrial fibrillation
• Myocarditis
• Anthracycline cardiotoxicity
• Subendocardial wall stress
• CKD
• Myopericarditis
• Sepsis
• Acute pulmonary embolism (right heart overload)
• Aortic dissection
• Myocarditis stress-induced cardiomyopathy.

17
Q

List other investigations that might help with diagnosis of ACS

A
  • Echocardiography (resting and stress)
  • CT angiography
  • Positron Emission Tomography
  • Single Photon Emission Computed Tomography
  • Invasive coronary angiography
  • Cardiac catheterization and angiography
18
Q

What is the definitive test for diagnosing CAD

A

CARDIAC CATHETERIZATION AND ANGIOGRAPHY

19
Q

How would you treat a case of ACS

A

PREHOSPITAL
• Early recognition of symptoms and signs
• IV access, Supplemental O2 if SpO2 <90%
• Immediate administration of Aspirin 320mg or
• Dual antiplatelet: Asprin loading dose chewed 325mg + Clopidogrel 300mg stat
• Nitroglycerin for active chest pain, sublingually or spray
• ECG monitoring

AT HOSPITAL
• Relieve pain and anxiety I.V morphine + antiemetic
• Prevention and treatment of complications
• Arrhythmias: IV line for treatment lidocaine, amiodarone
• ACEI/ARBs: patients with LV EF <40%, DM, HTN
• Aldosterone antagonist: patients with LV EF <40%,
• Beta blockers proven to reduce myocardial oxygen demand and mortality in pts with HF: metoprolol, carvedilol, or bisoprolol
• Statins at high intensity/ max tolerable dose
• Anticoagulation

20
Q

What conditions do are needed to commence a patient on fibrinolytic therapy?

A

• In settings where primary PCI cannot be offered to STEMI pts within the recommended 12hrs after symptom onset.
• In pts with the highest cardiovascular risk, pts older > 75 y
• Can also be administered in patients with evidence of re-infarction.

21
Q

List the drugs that can be used in fibrinolytic therapy

A

1) Streptokinase
2) Tenecteplase
3) Reteplase
4) Alteplase

22
Q

What are the absolute contraindications for fibrinolytic therapy?

A

• Prior intracranial hemorrhage,
• Ischemic stroke in past 3 months (except acute stroke within 4.5 h)
• Known structural cerebral vascular lesion
• Known intracranial neoplasm
• Significant closed-head or facial trauma within 3 months
• Intracranial or intraspinal surgery within 2 months
• Suspected aortic dissection
• Active bleeding or bleeding diathesis

23
Q

What are the relative contraindications for fibrinolytic therapy?

A

• Chronic, severe, poorly controlled HTN SBP>180 mm Hg or DBP>110 mm Hg
• History of prior ischemic stroke >3 months
• Traumatic or prolonged CPR >10 minutes
• Recent, within 2-4 weeks internal bleeding
• Active peptic ulcer disease
• Pregnancy
• Current use of anticoagulants: higher the INR, higher risk of bleeding
• Streptokinase: prior exposure >5 days before or prior allergic reaction

24
Q

What are the complications of ACS

A

• Arrhythmias in first 24hs, risk of V Fib greatest 1st hour
• Mechanical: LV aneurysm, septal rupture, severe MR, ventricular pseudoaneurysm
• Left ventricular mural thrombus
• Free ventricular wall rupture
• Ventricular septal defect
• Pericarditis (Dressler syndrome)
• Cardiac tamponade

Cardiology (3 decks)

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