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Cardiology > E: Acute Coronary Syndrome > Flashcards

E: Acute Coronary Syndrome Flashcards

1
Q

What is an acute coronary syndrome

A

Complete or Partial Occlusion of a coronary artery

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2
Q

What are the 3 types of acute coronary syndrome

A

STEMI
NSTEMI
Unstable Angina

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3
Q

What are the 2 types of myocardial infarction

A

STEMI

NSTEMI

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4
Q

What is myocardial infarction

A

Continous ischaemia that leads to the death of myocardial cells, which release troponin

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5
Q

What is a type of myocardial ischaemia

A

Unstable Angina

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6
Q

What causes myocardial ischaemia

A

Lack of blood supply to cardiac cells

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7
Q

What type of MI are ACS

A

Type I

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8
Q

What is a type I MI

A

Spontaneous MI

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9
Q

What causes a STEMI

A

Rupture of an atherosclerotic plaque

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10
Q

What causes an NSTEMI

A

Formation of a thrombus on an atherosclerotic plaque

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11
Q

What causes unstable angina

A

Progressive narrowing of coronary artery or spasm of a coronary artery disrupting blood supply

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12
Q

What are the 3 non-modifiable risk factors for ACS

A

Age
Gender
FHx

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13
Q

What is the prevalence of ACS in males compared to females

A

3 times more common in males

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14
Q

What family history increases risk of ACS

A

MI in first degree relative under the age of 55y

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15
Q

What are 7 modifiable risk factors of ACS

A 
Smoking
HTN
DM
Dyslipidaemia
Obesity
Sedentary lifestyle
Cocaine use
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16
Q

How do ACS present clinically

A

Cannot be distinguished from one another

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17
Q

What are 5 symptoms of ACS

A
  1. Chest pain >20m
  2. Dyspneoa
  3. Pale and clammy
  4. Palpitations
  5. Nausea
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18
Q

What are the possible symptoms of a silent MI

A
  • Syncope
  • Epigastric pain
  • Acute confusional state
  • Pulmonary oedema
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19
Q

Describe the pathophysiology of a STEMI

A

Complete occlusion of a coronary artery resulting in TRANS MURAL infarction

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20
Q

Describe the pathophysiology of an NSTEMI

A

Partial occlusion of a coronary artery resulting in sub-endocardial infarction

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21
Q

Describe the pathophysiology of unstable angina

A

Partial occlusion of a coronary artery causing myocardial ischaemia

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22
Q

What coronary artery is most commonly affected in ACS

A

Left anterior Descending

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23
Q

1

A

1

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24
Q

If the RCA is affected what may be an outcome

A 
Arrhythmias (SA node) 
Heart Block (AV node)
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25
Q

What are the 4 criteria to diagnose an ACS

A
  1. Symptoms of ischaemia/infarction
  2. ST elevation
  3. New onset LBBB
  4. Loss of R waves
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26
Q

What is first-line investigation for ACS

A

ECG

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27
Q

In what time frame should an ECG be performed when a patient presets with ACS

A

Within 10 minutes

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28
Q

What is the first sign of a STEMI on ECG

A

Hyperacute (peaked) T waves

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29
Q

How long will peaked T waves last on ECG

A

Minutes

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30
Q

What are two other early (within hours) changes of an MI on ECG

A

ST Elevation

LBBB

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31
Q

What are ECG changes in hours to days of a STEMI

A

T wave inversion

Pathological Q Waves

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32
Q

What happens in the first 24h of a STEMI on ECG

A

T wave inversion

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33
Q

How long do pathological Q waves persist

A

Indefinitely

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34
Q

What do pathological Q waves on ECG indicate

A

Sign of previous MI

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35
Q

What is the ECG criteria for a STEMI

A

ST elevation in two anatomically contagious leads

  1. Male >40= >2mm in V2-V3, >1mm in all other leads
  2. Male <40 = >2.5mm in V2-V3m >1mm in all other leads
  3. Female = >1.5mm in V2-V3, >1mm in all other leads
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36
Q

What does ST elevation on an ECG in a STEMI correlate to

A

The coronary artery affected

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37
Q

What artery is affected in an anterior MI

A

Left Anterior Descending

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38
Q

What leads will have ST elevation in an anterior MI

A

V1,V2,V3,V4

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39
Q

What artery is affected in a lateral MI

A

Left circumflex

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40
Q

What leads will have ST elevation in a lateral MI

A

I, aVL, V5 + V6

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41
Q

What artery is affected in an inferior MI

A

Right coronary artery

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42
Q

What leads are affected in an inferior MI

A

II, III, aVF

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43
Q

What artery is affected in a posterior MI

A

Left circumflex and Right coronary artery

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44
Q

What leads are affected in a posterior MI

A

Tall R waves and ST depression in V1 and V2

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45
Q

What are the ECG changes in NSTEMI

A

non-lead specific:
ST depression
T wave inversion
Loss of R wave

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46
Q

What are the ECG changes in unstable angina

A

Normal ECG

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47
Q

When should a troponin be measured after an ACS

A

3h and 6h

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48
Q

How long does troponin remain high for

A

10d

49
Q

How will troponin present in the following:

a. STEMI
b. NSTEMI
c. Unstable Angina

A

a. Raised
b. Raised
c. Normal

50
Q

How are the different ACS differentiated from each other

A

On ECG STEMI will have ST elevation. NSTEMI and Unstable Angina will not. Then a troponin is performed. It will be elevated in NSTEMI but not in unstable angina.

51
Q

What are two other cardiac markers

A

CK-MB

Myoglobin

52
Q

When does myoglobin increase and when does it peak

A

1h. Peaks at 4-12h

53
Q

What is the problem with myoglobin as a marker for ACS

A

Non-specific

54
Q

When does CK-MB increase

A

4-9h

55
Q

When does CK-MB peak

A

12-24h

56
Q

What other Ix may be done in ACS and why

A

Lipid profile - as individuals are often put on a statin

57
Q

In the management of all ACS what is the first step

A

Aspirin (300mg) and Ticagrelor (180mg)

58
Q

What dose of aspirin is given

A

300mg initially (loading dose) and then 75mg thereafter

59
Q

When should aspirin not be given in ACS

A

If an individual is already on aspirin. Individual has a contraindication to aspirin

60
Q

What dose of ticagrelor is given

A

180mg loading dose. Then 80mg BD

61
Q

When should ticagrelor not be given

A

History of intracranial haemorrhage

62
Q

What is step 2 in the management of ACS

A

Morphine

63
Q

What dose of morphine is given

A

2.5-5mg

64
Q

What should be given with morphine

A

Metclopramide

65
Q

What dose of metclopramide is given

A

10mg IV over 2 minutes.

66
Q

Why is metclopramide given

A

Prevent vomitting due to morphine

67
Q

When is oxygen given in ACS

A

If SpO2 <94%

68
Q

What is target saturations in ACS

A

94-99% or 88-92% if risk of type II resp failure

69
Q

Who should oxygen NOT be given to in ACS

A

SpO2 of 94-99% on room air

70
Q

What is step 4 in management of ACS

A

Fondaparinux

71
Q

What dose of fondaparinux is given

A

2.5mg SC OD

72
Q

When should fondaparinux not be given

A

If on DOAC or warfarin and INR is >2

73
Q

What are the 4 steps of initial ACS management

A
  1. Aspirin + Ticagrelor
  2. Morphine
  3. Oxygen
  4. Fondaparinux
74
Q

After initial ACS management what is done for STEMI

A

Assess whether there is ST elevation on ECG and whether PCI could be reached in 120 minutes

75
Q

If PCI is available in 120m what should be done

A

primary PCI

76
Q

If PCI is not available in 120m what should be done

A

Fibrinolysis

77
Q

Who should PCI be offered to

A
  • Those presenting within 12h of symptom onset and can reach PCI centre in 120m
78
Q

What is the time frame for fibrinolysis following STEMI

A
  • Ideally performed up to 30m after. Can be performed up to 12h after.
79
Q

What is used for fibrinolysis

A

Tissue plasminogen activation (Teneplase)

80
Q

What is the initial management for an NSTEMI

A
  1. Aspirin + Ticagrelor
  2. Oxygen
  3. Morphine
  4. Fonaparinux
81
Q

After initial management what is given in NSTEMI

A

GTN spray PRN

82
Q

What should then be done for a NSTEMI

A

GRACE score should be calculated

83
Q

What GRACE score is high risk

A

> 140

84
Q

What GRACE score is intermediate risk

A

109-140

85
Q

What GRACE score is low risk

A

<109

86
Q

How should someone with a low GRACE score be managed

A

Discharged and Outpatient Investigations (eg. stress test) organised

87
Q

How should someone with a high or intermediate GRACE score be managed

A

B blocker

88
Q

What dose of bisoprolol is given

A

2.5mg

89
Q

What should then be given if the individual has continous chest pain or pulmonary oedema

A

IV GTN

90
Q

What is the next step in management of NSTEMI

A

Arrange cardiology review for angiography

91
Q

If an individual is high risk, in what time frame should a cardiology review be sought

A

24h

92
Q

If an individual is intermediate risk, in what time frame should a cardiology review be sought

A

72h

93
Q

What is the long-term management of ACS

A
  1. B blocker
  2. Dual anti-platelet
  3. ACEi
  4. Statin
GTN
Aldosterone receptor antagonist
Smoking Cessation
Mediterranean diet
Cardiac rehabilitation
94
Q

What dose of ramipril is given

A

1.25mg

95
Q

What dose of bisoprolol is given

A

2.5mg

96
Q

What dose of atorvostatin is given

A

80mg

97
Q

When is eplerenone given

A

If LEVF is <40% on ECHO

98
Q

How soon can someone with a group I license return to driving following a ACS

A

1W post angiography

4W if no angiography

99
Q

How soon can someone with group II license return to driving following an ACS

A

Stop driving and contact DVLA

100
Q

When can an individual return to work following an ACS

A

Depends on the JOB.

Pilot, Lorry Driver, Bus driver - need to undergo functional testing.

101
Q

What is the mnemonic to remember immediate ACS management

A

MONARCH

Morphine
Oxygen
Nitrates
Aspirin 
Reperfusion
Clopidogrel - now ticagrelor 
Heparin
102
Q

What is a mnemonic to remember long-term ACS management

A

DABS

Dual antiplatelet
Aspirin
B blocker
Statin

103
Q

According to the GRACE score what are 5 poor prognostic factors of NSTEMI

A 
Age
HF
Reduced systolic BP
PVD
Killip class
Initial serum creaitnine
104
Q

What are 3 complications of MI that can occur in 0-24h

A
  1. Arrhytmias
  2. Sudden cardiac death
  3. Acute left heart failure
105
Q

When are arrhythmias more common and why

A

Inferior MI - due to affecting the SA node

106
Q

What complication may occur 1-3d post-MI

A

Pericarditis

107
Q

What 3 complications may occur 3-14d post MI

A
  1. Rupture left ventricular free wall
  2. Rupture papillary muscles
  3. Ventricular septal rupture
108
Q

What may papillary muscle rupture cause

A

Mitral regurgitation

109
Q

What typically causes VSD rupture

A

Anterior MI

110
Q

How will rupture of the VSD present

A

holosytolic murmur and onset of right heart failure symptoms

111
Q

How will rupture of the free wall of the left ventricle present

A

Cardiac tamponase

112
Q

What are the signs of cardiac tamponade

A
  1. Hypotension
  2. Raised JVP
  3. Muffled HS
113
Q

What is Becks Triad

A
  1. Hypotension
  2. Distended neck veins
  3. Muffled HS
114
Q

What 4 complications can occur 14d to months afterwards

A

Dresslers Syndrome
Congestive HF
Arterial + Ventricular Aneurysms
Arrhythmias (AV block)

115
Q

What is dresslers syndrome

A

Pericarditis - due to auto antibodies attacking the pericardium

116
Q

When is sinus bradycardia more common complication of MI

A

Inferior MI

117
Q

What is heart block more common complication of MI

A

Anterior MI

118
Q

How will Dresslers syndrome present

A

Raised ESR
Fever
Anaemia

Cardiology (13 decks)

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