IHD: Acute Coronary Syndrome Flashcards
Define Acute Coronary Syndrome
Spectrum of acute myocardial ischaemia and/or infarction including STEMI, NSTEMI and unstable angina
Aetiology/risk factors of Acute Coronary Syndrome
Atherosclerosis - Plaque rupture, thrombosis and inflammation
Emboli, coronary spasm, vasculitis
RF: Age, male, family history, smoking, HTN, DM, hyperlipid, obesity, cocaine, sedentary lifestyle
Epidemiology of Acute Coronary Syndrome
No. 1 cause of death globally for men and women
5/1000 per annum
Incidence increasing in Western countries
Average age 65 M, 72 F
Presenting symptoms of Acute Coronary Syndrome
Chest pain: acute, central, lasts >20 minutes, crushing, sense of doom, radiates to A/S/N/J, relieved by GTN SOB N+V Sweating Palpitations
May be silent -> no chest pain (diabetics, elderly) -> syncope, pulmonary oedema, epigastric pain, N+V
Presenting signs of Acute Coronary Syndrome
Anxiety + distress Pallor Tachypnoea Sweating / diaphoresis BP abnormal Signs of heart failure RF: tar staining, xanthelasma, xanthomata, acanthosis nigricans, corneus arcus
Investigations to diagnose STEMI
ECG - ST elevation, T wave inversion, LBBB, reciprocal depression
Troponin - elevated
Angiogram - Presence of thrombus with occlusion of artery
Investigations to diagnose NSTEMI
ECG - dynamic T wave inversion, reciprocal depression, NO ST elevation
Troponin - elevated
Angiogram - Presence of thrombus with occlusion of artery
Other investigations for Acute Coronary Syndrome
FBC
Electrolytes - normal
Blood glucose and lipids for risk factors
Coagulation studies for treatment
CXR - pulmonary oedema, cardiomegaly in HF, widened mediastinum
Echo - regional wall abnormalities
Management plan for STEMI (acute)
Morphine 5-10mg IV and anti-emetic e.g. Ondansetron 4-8mg IV as a single dose
Oxygen - only if sats are low
Nitrates GTN - dilate the coronary arteries 15-20 micrograms/minute IV infusion
Aspirin 300mg PO
Clopidogrel 300mg orally as loading dose, 75mg once daily thereafter
PCI within 12 hours
OR
Fibrinolysis with Tenecteplase (single IV bolus) if PCI not available (within 2 hours/120mins)
>12 hours - angiography with PCI if necessary
Follow up with ticagrelor
Management plan for NSTEMI
Aspirin 300mg
NO immediate PCI - fondaparinux
Calculate GRACE
Low risk - ticagrelor
High risk - PCI with prasugrel/ticagrelor and unfractionated heparin
Long term management for Acute Coronary Syndrome
Beta blockers e.g. bisoprolol 1.25mg orally once daily initially for 1 week, increase according to response
ACEis e.g. ramipril 2.5mg orally 2x daily for 3 days, increase according to response
Dual antiplatelet e.g. aspirin 75-100mg orally once daily + ticagrelor 90mg orally twice daily
Statins e.g. atorvastatin 40-80mg orally once daily
Control HTN and DM
Lifestyle: Stop smoking, exercise, weight loss, reduce alcohol intake
Complications of Acute Coronary Syndrome
Death Aneurysm Rupture Tamponade Heart failure Valve disease Arrhythmia Dressler's syndrome Embolism Recurrence
Prognosis for Acute Coronary Syndrome
15% cases fatal
50% deaths occur within 2 hours of symptom onset
Worse prognosis if elderly, LV failure and ST changes
