Management of ACS Flashcards
What tests on admission for acute STEMI?
12 lead ECG U&E TRoponin Glucose Cholesterol FBC CXR
Describe the immediate management for acute STEMI
MONA
Aspirin: 300
Ticagrelor 180 or prasugrel 60 if no hx of stroke/TIA and <75 years (better than clopidogrel 300)
Morphine 5-10
+ Anti-emetic - metoclopramide or cyclizine
GTN: only if hypertensive or in acute LVF
Oxygen if SaO2 <95% or breathless or acute LVF
Reperfusion therapy: PCI or thormbolysis
What are the ECG criteria for STEMI?
ST elevation >1mm in 2 or more adjacent limb leads or >2mm in 2 or more adjacent chest leads
New LBBB
Posterior changes - deep ST depression and tall R waves in leads V1-V3
What is primary PCI?
Angiographic identification of blocked vessel and revascularisation via deployment of inflatable metal stent.
Should be offered to all patients presenting within 12h of symptom onset with STEM within 120 mins.. If this is not possible, thrombolysis and transfer to primary PCI centre for rescue PCI or angiography.
What is thrombolysis?
Use of systemically administered clot-dissolving enzymes - tissue plasminogen activator.
Target time < 30 mins from admission
Do not thrombolyse ST depression alone, T wave inversion alone or normal ECG.
What are contraindications to thrombolysis?
Previous intracranial haemorrhage ISchaemic stroke <6 months Cerebral malignancy Recent major trauma/surgery/head injury GI bleeding < 1 month Known bleeding disorder Aortic dissection
How should patients with STEMI who do not receive repercussion be treated?
Fondaparinux or enoxaparin/unfrctionated heparin.
What is the management for NSTEMI?
Morphine Oxygen if SaO2<90 Nitrates Aspirin - For those with confirmed ACS, give second anti platelet - ticagrelor/clopidogrel
Anticoagulation - fondaparninus (anti-Xa) or LMWH until discharge
Beta-blokers
ACE-i
Statin
What are higher risk groups?
60+ Previous stroke, TIA, MI, CABG Known coronary artery stenosis >50% in 2 or more vessels or carotid stenosis >50% DM Peripheral arterial disease CKD
What is the conservative management of ACS?
Modify risk factors: Stop smoking Treat DM, HTN and hyperlipidaemia Diet high in oily fish, fruit, veg and fibre and low in saturated fat Daily exercise - cardiac rehab programme Mental health - flag to GP
What are cardioprotective medications?
Dual therapy anti platelet: aspirin and prasugrel/ticagrelor/clopidogrel + PPI for gastroprotection
Anticoagulate with fondaparinux
Beta blockade reduces myocardial oxygen demand
ACE-i if LV dysfunction, HTN or DM - if not tolerated consider ARB
High dose statin
When is a CABG indicated over PCI?
Multi vessel disease
Compare PCI and CABG
CABG results in longer recovery time and length of inpatient stay.
Provides more complete long-term relief and less repeated revascularisation.
Describe a CABG
Heart is stopped and blood pumped artificially by a machine.
Patient’s saphenous vein or internal mammary artery is used as graft.
