Ischaemic Heart Disease- ACS

Question 1

what does Acute Coronary Syndrome compromise?

Answer 1

• Unstable angina
• STEMI
• NSTEMI

Question 2

symptoms?

Answer 2

central crushing/constricting chest pain at rest >20mins associated with:

• N&V
• sweating / clamminess
• feeling of impending doom
• SOB
• palpitations
• pain radiating down jaw /arms

Question 3

what must you be wary of?

Answer 3

elderly / diabetics may not expereince typical symptoms : “silent MI”

may manifest as syncope, delirium, post-op oliguria /hypotension

Question 4

Diagnosis?

Answer 4

ECG

• ST elevation/new LBBB–> STEMI
• No ST elevation
  
  • do trop
    
    • raised trop and/or othet features ie ST depression, pathological Q waves, T wave inversion–> NSTEMI
    • trop normal & no pathological signs on ECG–> UA or other cause ie MSK related chest pain

Question 5

Ix?

Answer 5

• Cardiac examination
• ECG
• Bloods
• CXR
• CT coronary angio
• Echo

Question 6

what bloods would you want to do?

Answer 6

• Troponin
• FBC
• UE
• Lipid profile
• Glucose & HbA1c
• clotting
• TFT

Question 7

what are troponins and when are they raised?

Answer 7

• myofibrillar proteins linking actin and myosin
• raised in myocardial ischaemia

non-specific, also raised in:

• chronic renal failure
• sepsis
• myocarditis
• aortic dissection
• PE

Question 8

how do you measure troponins?

Answer 8

require serial troponins for diagnosis of ACS

• levels rise within 3-12hrs of onset of chest pain
• do baseline + repeat at 6 and 12hrs post onset of symptoms

Question 9

how long does it take for troponin levels to return to baseline?

Answer 9

5-14days

Question 10

Rx of UA?

Answer 10

Initial Mx: BATMAN(O)

• Beta-blockers (unless C/I)
• Aspirin 300mg stat
• Ticagrelor 180mg stat
• Morphine
• Anti-coagulant: LMWH treatment dose
• Nitrates (GTN)
• Oxygen if sats<95%

Definitive: coronary angio +/- PCI

Question 11

Mx of NSTEMI?

Answer 11

Initial- BATMAN(O)

Assess for risk- GRACE score (6 month risk of death or repeat MI)

<5%= low risk

5-10%= medium risk

>10%= high risk

if medium/ high risk–> considered for early PCI

if low risk–> can discharge if 12h trop -ve

Question 12

in what order would you do said Mx for NSTEMI

Answer 12

Question 13

Mx of STEMI?

Answer 13

Initial: BATMAN(O)

Definitive:

• primary PCI if <12h
• thrombolysis if PCI not available within 12h

Question 14

in what order would you do said Mx for STEMI?

Answer 14

Question 15

contraindications to thrombolysis? mnemonic

Answer 15

AGAINST

Aortic dissection

GI bleeding

Allergic reaction previously

Iatrogenic: recent surgery

Neuro: history of CVA or cerebral neoplasm

Severe HTN

Trauma incl CPR

Question 16

complications of STEMI? mnemonic

Answer 16

Death

Rupture of heart septum or papillary muscles –> MR

Edema “heart failure”

Arrhythmia & Aneurysm

Dressler’s Syndrome

Question 17

what is dressler’s syndrome?

Answer 17

• aka post MI syndrome (usually 2-3 weeks after)
• localised immune response causes pericarditis
• presentation
  
  • pleuritic chest pain (relieved by sitting forwards)
  • pericardial rub
  • low grade fever
• can cause a pericardial effusion & rarely a pericardial tamponade

Question 18

diagnosis of dressler’s syndrome (ECG) and Mx

Answer 18

• ECG: global ST elevation, T wave inversion
• raised inflammatory markers

Mx:

NSAIDs or steroids

may need pericardiocentesis

Question 19

what else is part of Mx?

Answer 19

secondary prevention

• medical
  
  • 4A’s
    
    • aspirin + second antiplatelet
• lifestyle

Question 20

prognosis of STEMI & NSTEMI

Answer 20

NSTEMI- overall mortality 1-2%

STEMI- 30 day mortality 15%