ERC - ACS Flashcards
You suspect ACS in a patient but the ECG is normal and markers are all negative. What do you do
chest pain observation unit
multidetector computer tomographic angiography MDCTA (good detection but ++ radiation and could overdiagnose)
Echo
What is the pharmacoinvasive strategy of PCI and fibrinolysis
Fibrinolysis then PCI 3-4hrs after
What is rescue PCI
PCI following unsuccessful fibrinolysis
define unsuccessful fibrinolysis
<50% resolution of the ST elevation 90 minutes after fibrinolysis
what is facilitated PCI
PCI immediately after fibrinolysis
You get ROSC in a STEMI patient, what next
PCI and TTM
You get ROSC in a non STEMI patient, what next
very dependant on the patient: downtime, comorbidities, ECG changes, neurological status all factor in to decision if to PCI or not
Describe post ACS care in terms of long term drugs prescribe
Bblocker
ACE-i (or ARB)
statin
Where is ST elevation measured from on an ECG
J point - termination of QRS and start of ST
What is needed for the diagnosis of STEMI
clinical signs and symptoms +
0.1mv rise in 2 adjacent limb leads
0.2mv rise in 2 adjacent chest leads
new LBBB
What would make you suspect an inferior STEMI
isolated ST depression in V1-V3 (indicating posterior infarct)
ST elevation in 2,3, AVF
how would you confirm a posterior STEMI
ST elevation and Q waves in V7-V9
Which troponins are most cardiac specific
T or I
clinical signs and symptoms of ACS + non STEMI ECG changes + troponin +ve = what diagnosis
NSTEMI
clinical signs and symptoms of ACS + non STEMI ECG changes + troponin -ve = what diagnosis
unstable angina
Which non-STEMI patients are high risk
dynamic ECG changes ST-depression diabetic haemodynamically unstable use of high risk scores eg TIMI, GRACE
Describe some factors that TIMI and GRACE take into consideration
TIMI - age, CAD risk factors (diabetes, cholesterol, HTN, FH, smoker), ST changes, cardiac enzymes, angina episodes in past 24 hours
GRACE - age, HR, BP, ST changes, cardiac enzymes, Killip class, creatinine, if they’ve been in arrest
What do all ACS patients get regardless of STEMI or NSTEMI
Morhpine 3-5mg (repeat until no pain)
Nitroglycerin (GTN) sublingual 0.4mg
Aspirin 300mg chewable
What are the contraindications to giving nitroglycerin (GTN)
Systolic BP <90
bradycardia
suspected inferior MI
Which STEMI patients get PCI and which get fibrinolysis
PCI if can get there in 60-90 minutes, in cardiogenic shock, contraindication to fibrinolysis
Fibrinolysis if can’t get to PCI in time
What adjunctive treatments do you give to STEMI patients undergoing PCI or fibrinolysis
Antithrombin - heparin, enoxaparin, bivalirudin or fondaparinux
Antiplatelet - clopidogrel or ticagrelor
What is the dose of clopidogrel in ACS
300mg for STEMI patients undergoing fibrinolysis and for non STEMI patients
600mg for STEMI patients undergoing PCI
In which patients does prasugrel increase the risk of an intracranial bleed
history of stroke or TIA
>75 y/o
<60kg body weight
What adjunctive drugs are given to non-STEMI ACS patients
antithrombin - heparin or enoxaparin (or fondaparinux if high bleeding risk)
antiplatelet - clopidogrel or ticagrelor
What are the advantages of ticagrelor over clopidogrel
Reversible
faster
not reliant on genetic differences in drug metabolism
What class of drugs are clopidogrel, ticagrelor and prasugrel
Adenosine diphosphate (ADP) receptor antagonists
What is a late presenter
presenting >3 hours since symptom onset
