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CARDIO > old ACS > Flashcards

old ACS Flashcards

1
Q

what is the definition of ACS and what are the categories?

A

unstable angina + evolving MI

STEMI or new onset LBBB
NSTEMI

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2
Q

what is the pathophysiology of ACS?

A

plaque rupture
thrombosis
inflammation
rarely due to coronary spasm, emboli or vasculitis in normal coronary arteries

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3
Q

what is the progression of ischaemic necrosis and ST elevation?

A

first subendocardial necrosis (non ST elevation MI- which showed ST depression + t wave inversion like agina)

then transmural necrosis (ST elevation MI- which shows ST elevation + t wave inversion + pathological q waves)

endocardium is spared due to o2/nutrients of ventricular blood

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4
Q

what vessels are most commonly obstructed?

A

50% LAD
30% RCA
20% LCx

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5
Q

what are the modifiable risk factors for ACS?

A 
HTN
DM
smoking
high cholesterol
obesity
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6
Q

what are the non-modifiable risk factors for ACS?

A

age
male
FH M<55yo F<65yo

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7
Q

what can a silent MI present as?

A

syncope
delirium
post-op oliguria/hypotension

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8
Q

who might have a silent MI?

A

diabetes
post cardiac surgery
elderly

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9
Q

what are the differentials for severe chest pain?

A 
angina
peri/endo/myocarditis
dissection, Takotsubo cardiomyopathy 
PE, pnuemothorax, pneumonia
costochondritis
GI- GORD, spasm, pancreatitis
anxiety
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10
Q

what are the ECG signs for STEMI (in sequence)

A 
normal
ST elevation and tall T waves
q waves- full thickness infarct
normalisation of ST segments
T wave inversion

new onset LBBB also STEMI

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11
Q

what are the ECG signs for NSTEMI?

A

ST depression
T wave inversion

no q waves= subendocardial infarct

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12
Q

what are the leads and vessels for inferior part of heart?

A

II III aVF

RCA

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13
Q

what are the leads and vessels for anterolateral part of heart?

A

I aVL V4 V5 V6

LCx

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14
Q

what are the leads and vessels for anteroseptal part of heart?

A

V2 V3 V4

LAD

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15
Q

what are the leads and vessels for anterior part of heart

A

V2-V6

LMS

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16
Q

what are the leads and vessels for posterior part of heart?

A

V1 V2 V3 (recipe)

RCA

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17
Q

what are the complications of an inferior infarct?

A

bradyarrythmias

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18
Q

what are the complications of an anterior infarct?

A

LVF

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19
Q

what indicates a STEMI/LBBB diagnosis?

A

typical symptoms + ST elevation/LBBB

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20
Q

what indicates an NSTEMI diagnosis?

A

typical symptoms
no ST elevation
positive troponin

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21
Q

what indicates unstable angina diagnosis?

A

typical symptoms
no ST elevation
negative troponin

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22
Q

what is the prognosis of STEMI?

A

30 day mortality about 15%

varies with patient factors

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23
Q

what is the prognosis of an NSTEMI?

A

overall mortality 1-2%

varies with patient factors

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24
Q

what is the typical presentaiton of an MI?

A

severe chest pain >20 mins
sweating (increased sympathetic drive)
nausea
pallor
cold/clammy/thready pulse/peripherally shut down (hypotension)
dyspnoea/tachypnoea/increased JVP (pulmonary congestion)

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25
Q

what are the atypical presentations of an MI?

A

pain only in jaw/arm or left shoulder etc
only autonomic symptoms- sweating/vomiting
feeling unwell

arrythmia
cardiac arrest
heart failure

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26
Q

what can you find on examination in ACS?

A 
nicotine staining/rothman's sign
xanthelasma, pallor/anaemia
carotid bruit, high/low bp/HR
apex beat, murmurs
AAA, femoral bruit
glycosuria, foot pulses
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27
Q

what factors suggest high-risk ACS?

A

continuing chest pain
troponin >10x normal
impaired LV function
heart failure

abnormal ECG- previous MI, st dep/inversion, during low level exercise test

extensive risk factors:
diabetes, combination of smoking + HTN + high chol

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28
Q

what is the management of STEMI?

A 
MONA B
Morphine (analgesia + vasodilation)
oxygen 
nitrate
anticoagulant- aspirin/ticagrelor
beta blockers

PCI or thrombolysis- SK or tPA +/- CABG (within 4 hours)
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29
Q

on discharge, what medications should be started for someone who had a STEMI?

A

Ace inhibitor
beta blocker- or CCB
Statin

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30
Q

what are the contraindications for thrombolysis?

A

history of CVA
stroke <3 months
aortic dissection
active bleeding

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31
Q

what does nitrates (GTN, isosorbide mononitrate) act as anti-anginal therapy?

A

coronary vasodilation which increases cardiac perfusion

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32
Q

what does beta blockers (propanolol/metoprolol) do in management of ACS?

A

decreases heart rate + contractility whihc decreases cardiac workload

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33
Q

what do calcium channel blockers (nifedipine/verapamil) do in management of ACS?

A

decreases afterload which decreases cardiac workload

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34
Q

what is the management of NSTEMI/UA?

A 
aspirin
morphine 
beta blocker
s/c LMW heparin
clopidogrel
angiography in high risk cases 
\+/- PCI/CABG
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35
Q

what are the symptoms of ACS?

A 
acute central/left chest pain >20min
radiates to left jaw/arm
nausea, sweating
dyspnoea
palpitations
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36
Q

what are the signs of ACS?

A

anxiety
pallor/sweating
pulse high or low
bp high or low
4th heart sound
signs of LVF- basal creps, elevated jvp, 3RD HS
PSM- papillary muscle dysfunction/rupture, VSD

later- pericardial friction rub or peripheral oedema

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37
Q

what investigations for ACS?

A

bloods- FBC, UE, glucose, lipids, clotting, cardiac enzymes

serial troponin- on presentation, 6 hours, within 24hours

imaging- serial resting ECGs, CXR, ECHO
3-lead cardiac telemetry screening for arrythmias

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38
Q

what can be found on CXR for ACS?

A

cardiomegaly
pulmonary oedema
widened mediastinum- aortic rupture

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39
Q

what can be found on ECHO for ACS?

A

regional wall abnormalities

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40
Q

when is troponin elevated and when does it peak

A

elevated from 3-12h, need 12h trop to exclude MI

peak 24h
baseline from 5-14 days

41
Q

for management of ACS, how would you modify their risk factors?

A

smoking cessation
treat DM, HTN, hyperlipidaemia
diet- oily fish, fruit, veg, fibre, low saturated fats
daily exercise- cardiac rehab programme referral
mental health- dep and anx associataed with poor cvs outcomes

42
Q

how do you optimise cardioprotective medications for ACS patients?

A

1) antiplatelets: aspirin 75mg OD + 2nd antiplatelet eg ticagrelor/clopidogrel for at least 12 months. add PPI eg lansoprazole
2) anticoagulant until discharge eg fondaparinux
3) beta blocker reduces myocardial O2 demand. monitor pulse/BP. CI- use verapamil or diltiazem.
4) ACE-i in LVF, HTN, DM. CI- ARB. monitor renal fx.
5) high-dose statin eg atorvastatin 80mg
6) ECHO to assess LVF. eplerenone improves outcomes for MI with HF.

43
Q

what general advice would you give regarding work and driving for ACS?

A

work- discuss with employer + change duties. functional testing if drivers of public service or heavy goods vehicles. cannot restart post-MI if airline pilot or air traffic controllers

driving- group 1 licence (car/motorbike) after 1 week of successful angioplasty or 4 weeks after ACS unsuccessful angio. if EF>40% group 2 inform DVLA and stop driving. restart after 6 weeks after functional test results.

44
Q

what is the management of a STEMI?

A

1) 12 lead ECG
2) O2 2-4L 94-98
3) IV access- bloods FBC, UE, glucose, lipids, cardiac enzymes
4) assess- hx, risk fc, thrombolysis CI, CV exam
5) antiplatelet- aspirin 300mg PO, clopidogrel 300mg PO
6) analgesia- morphine 5-10mg IV, metoclopramide 10mg IV
7) anti-ischaemia- GTN 2 puffs or 1 tablet SL, beta blcoker atenolol 5mg IV (CI- asthma, LVF)
8) LMWH - enoxaparin IV then SC
9) admit to CCU for monitoring- arryhtmias, continue meds except CCB
10) primary PCI or thrombolysis

45
Q

what is PCI and when would you do it with STEMIs?

A

angioplasty + stenting
+ GP IIB/IIIA antagonist (tirofiban) if high risk (delayed PCI, DM, complex procedure)

treatment of choice if <12h

46
Q

what is PCI and what is the criteria for use with STEMIs?

A

angioplasty + stenting
+ GP IIB/IIIA antagonist (tirofiban) if high risk (delayed PCI, DM, complex procedure)

treatment of choice if <12h

47
Q

what are the complications of PCI?

A

bleeding
emboli
arrythmias

48
Q

what is thrombolysis and what is the criteria for use in STEMI?

A

agents- 1st: streptokinase, alteplase (rt-PA), tenecteplase

ECG criteria: 
1) ST elevation >1mm in 2+ limbs
or >2mm in 2+ chest leads 
2) new LBBB
3) posterior: deep ST depression and tall R waves in V1-V3
49
Q

what are the contraindications to thrombolysis in STEMI?

A 
CI beyond 24hrs from pain onset 
AGAINST
aortic dissection
GI bleeding
allergic reaction before
iatrogenic- recent surgery 
neuro- cerebral neoplasm or CVA history 
severe HTN 200/120
trauma in CPR
50
Q

what are the complications of thrombolysis?

A

bleeding
stroke
arrythmia
allergic reaction

51
Q

what is the continuing hterapy for STEMIs?

A

1) ACEi- start within 24hrs eg lisinopril 2.5mg
2) bb bisoprolol 10mg OD or CCB
3) cardiac rehab
4) DVT prophylaxis until fully mobile- continue for 3 months if large anterior MI
5) statin - ator 80mg
6) continue clopidogrel for 1 month, aspirin forever

52
Q

continuing therapy general advice for STEMI?

A 
stop smoking
diet- oily fish, fruit, veg, low sat fats
exercise- 30 min OD
work- return in 2 months
sex- avoid for 1 month
driving- avoid for 1 month
53
Q

what is the management of NSTEMI/UA?

A

1) 12 lead ECG + admit to CCU
2) O2- 2-4L 94-98
3) IV access- bloods FBC UE glucose lipids troponin
4) assess- hx and exam
5) antiplatelet- aspirin 300mg pO, clop 300mg PO
6) anticoagulant- fondaparinux 2.5mg SC
7) analgesia- morphine 5-10mg IV, metoclopramide 10mg IV
8) anti-ischaemia- GTN 2 puffs or 1 tablet SL, bb atenolol 50mg/24h PO. IV GTN if pain continues
9) assess CVD risk- GRACE/TIMI

54
Q

what is the management of NSTEMI/UA if intermediate-high risk on GRACE/TIMI?

A

tirofiban- gpiib/iiia antagonist
angiography +/- PCI within 96h
clopidogrel 75mg/d for 1 year

55
Q

what is intermediate-high risk for NSTEMI/UA on GRACE/TIMI?

A

persistent/recurrent ischaemia
ST depression
DM
positive troponin

56
Q

what is low risk for NSTEMI/UA on GRACE/TIMI?

A

no further pain
flat or inverted T waves
normal ECG
negative troponin

57
Q

what is the management of low risk NSTEMI/UA on GRACE/TIMI?

A

discharge fi 12h trop is negative

outpatient tests: angio, perfusion scan, stress echo

58
Q

what is the continuing therapy for NSTEMI/UA?

A

1) ACE-i eg lisinopril 2.5mg
2) bb bisoprolol 10mg OD or CCB
3) cardiac rehab
4) stop antithrombotic therapy when pain free (but give 3-5 days)
5) statin
6) continue clop for 1 year following NSTEMI, aspirin forever

59
Q

what is the pathophysiology of angina pectoris?

A

insufficient coronary perfusion relative to myocardial demand (decreased myocardial perfusion)

60
Q

what are the causes of angina?

A 
mostly ahteroma- atherosclerosis leading to myocardial ischaemia >70% occlusion
anaemia
aortic stenosis
vasospasm
embolism
ascending aortic dissection

exacerbated by- ventricular hypertrophy, tacycardia, hypoxia, coronary arteritis eg in SLE
61
Q

what are the symptoms of angina?

A

central chest tightness/heaviness
exertion, relieved by rest
radiate to one/both arms/neck/jaw/teeth
precipitants: emotion, cold weather, heavy meals

62
Q

what is decubitus angina?

A

induced by lying down

63
Q

what is prinzmetals/variant angina?

A

occurs during rest
due to coronary spasm
ST elevation during attack, resolves as pain subsides
treat wiht CCB + long-acting nitrates

64
Q

what is syndrome X angina?

A

angina pain + st elevation on exercise test but no evidence of conrary atherosclerosis
may represent small vessel disease

65
Q

what is unstable angina?

A

pre-infarction angian
due to unstable atherosclerotic plaque +/- plaque disruption and thormbus

prolonged angina at rest- either new, increased severity, increased frequency

red flag- MI may be imminent

66
Q

what are the differentials of angina/chest pain?

A

AS
aortic aneurysm
GI- GORD, spasm
MSK

67
Q

what are the investigations for angina?

A 
bloods- FBC, UE, lipids, glucose, ESR, TFTs
ECG, consider exercise ECG
stress echo
perfusion scan 
CT coronary ca2+ score 
angiography- gold standard
68
Q

what is the gold standard investigation for angina?

A

angiography

69
Q

what can be the ECG findings for angina?

A

usually normal
st depression or flat/inverted t waves during attack, should be normal between attacks
past MI

70
Q

what is the lifestyle management of angina?

A

smoking cessation
weight loss and more exercise
healthy diet- oily fish, fruit, veg, low sat fats

71
Q

what are the investigations for angina?

A

1st line- resting ECG
2nd line- cardiac stress test + ECG- suggests severity of CAD- any ST depression is positive result
3rd line- stress ECHO- assess ventricular function
4th line- coronary angiography
5th line- myocardial perfusion scans

72
Q

what are the 2 categories of medical management of angina?

A

secondary prevention- prevent cardiovascular events .

anti-anginals- prevents angina episodes

73
Q

what is the secondary prevention (medical management) of angina?

A

aspirin 75mg OD
ACE-i (esp if angina and DM)
statins- simvastatin 40mg
anti-HTN

74
Q

what is the anti-anginal management of angina?

A

statin + aspirin
1) GTN (spray or SL) and either
1st- bb eg atenolol 50-100mg OD
2nd- CCB eg verapamil 80mg TDS
2) try 1st or 2nd if symptoms not controlled
3) try bb + dihydropyridine CCB eg amlodipine MR 10mg/24h
4) still not controlled:
ISMN 20-40mg BD (8h washout at pm) OR slow release nitrate (imdur 60mg OD)
ivabradine
nicorandil 10-30mg BD
ranolazine

75
Q

what is the indication of PCI for angina?

A

poor response to medical treatment

refractory angina but not suitable for CABG

76
Q

what are the complications of PCI for angina?

A

re-stenosis at 6 months
emergency CABG
MI
death

77
Q

how do you prevent re-stonisos complication of PCI for angina?

A

clopidogrel
1 month for bare metal stent
1 year for drug-elutin eg sirolimus

78
Q

what are the indications of CABG for angina?

A

L main stem disease
triple vessel disease
refractory angina
unsuccessful angioplasty

79
Q

what are the complications of CABG for angina?

A 
MI
stroke 
pericardial tamponade or haemothorax
postperfusion syndrome
post-op AF
nonunion of sternum
graft stenosis
80
Q

what can cause trop elevation apart from ACS?

A 
chronic or acute renal dysfunction
HTN crisis
tachy or bradyarrythmias
PE
myocarditis (inflam disease) 
stroke 
severe congestive HF- acute and chronic

hypothyrodism
drug toxicity- adriamycin, 5FU herceptin, snake venoms
rhabodmyolysis
resp failure/sepsis

81
Q

what are acute complications of an MI?

A

LV failure- acute pulmonary oedema, shock (70% mortality)

lethal arrythmias- VT, VF

weakening of necrotic myocardium leads to myocardial rupture -> tamponade/acute VSD

stasis leads to mural thrombosis -> embolisation -> stroke

82
Q

what are the chronic complications of an MI?

A

ventricular aneurysm
papillary muscle rupture
mitral regurgitation, CCF

83
Q

what are the groups of MI complications

A

death- by VF, LVF, CVA
pump failure
pericarditis
rupture- myomalacia cordis
arrythmias
bradycardias
ventricular aneurysms
embolism
dressler’s syndrome- pleuro-pericarditis

84
Q

in terms of MI complications, how can pericarditis present?

A

occurs early
mild fever
central chest pain/change in pain
relieved by sitting forward
pericardial friction rub

85
Q

what are the ECG changes in pericarditis?

A

saddle-shaped ST elevation
+/- PR depression

86
Q

what is the treatment of pericarditis?

A

NSAIDs
ECHO to exclude effusion

87
Q

in terms of MI complications, what can rupture of left ventricular free wall rupture cause?

A

cardiac tamponade - beck’s triad (low bp, raised jvp, muffled heart sounds), pulsus paradoxus

88
Q

what can rupture of papillary muscles/chorae tendinae cause?

A

mitral regurgitation- pansystolic murmur, pulmonary oedema

89
Q

in terms of MI complications, how can ventricular aneurysms present?

A

4-6 weeks
LVF
angina
recurrent VT
systemic emboli
ECG- persistent ST elevation

90
Q

how does an embolism occur in MI complications?

A

arise from LV mural thrombus
consider warfarin 3 months after large anterior MI

91
Q

how can dressler’s syndrome present?

A

due to auto antibodies vs myocyte sarcolemma

2-6 weeks
recurrent pericarditis
pleural effusions
fever
anaemia
raised ESR

treat- NSAIDs, if severe- steroids

92
Q

what is the result of MI complications- give 3

A

decreased contractility
electrical instability
tissue necrosis

93
Q

after an MI what does decreased contractility cause?

A

hypotension - decreased coronary vessel perfusion - ischaemia - further decreased contractility THEREFORE cardiogenic shock

blood stasis - ventricular thrombus - emboli- stroke

94
Q

after an MI how does electrical instability occur and what happens?

A

disorganisation in ion movement in myocyte

compromised internal conduction system (SA/AV node) esp if Right Atrium effected

THEREFORE arrythmias

95
Q

after an MI what does tissue necrosis cause?

A

leads to inflammation of surrounding tissue- pericarditis

if effects septum- breaks down - VSD (hypoxaemia as L to R shunt)

if effects ventricles- ventricle rupture - blood builds up within pericardium- cardiac tamponade

if effects papillary muscles + chordae tendinae - prolapse - mitral regurgitation

96
Q

what are the immediate/hours STEMI complications?

A

ventricular arrythmias- VT/VF
atrial arrhythmias- AF
failed reperfusion

97
Q

what are the STEMI complications at hours-days?

A 
cardiac rupture 
re-infarction
heart failure 
cardioenic shock 
severe impairment of LVF
RV infarction 
mechanical catastrophe - ventricular septal rupture, papillary muscle rupture
98
Q

what are the STEMI complications days-weeks?

A

thromboembolism- CVA
chronic HF
ventricular tachycardia implies myocardial scar
dressler’s syndrome- autoimmune pericarditis after full thickness MI

99
Q

what is the progression of ischaemic necrosis and ST elevation?

A

first subendocardial necrosis (non ST elevation MI- which showed ST depression + t wave inversion like agina)

then transmural necrosis (ST elevation MI- which shows ST elevation + t wave inversion + pathological q waves)

endocardium is spared due to o2/nutrients of ventricular blood

CARDIO (10 decks)

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