W3 Clinical management of Acute Coronary Syndrome Flashcards
What is ACS?
Acute coronary syndrome.
An umbrella term used to describe conditions that result in sudden, reduced blood flow to the heart
What are the main conditions under the ACS umbrella? (4)
- Stable angina
- Unstable angina
- Non-ST elevated myocardial infarction (NSTEMI)
- ST-elevated myocardial infarction (STEMI)
State the differences between the ACS conditions:
Unstable angina
- Partially obstructive thrombus
Ischemia WITHOUT necrosis
NSTEMI
- Partial thickness damage
- Partially obstructive thrombus
- Ischemia WITH necrosis
STEMI
- Full thickness damage of heart wall
- Complete obstruction by intracoronary thrombus
- Ischemia WITH necrosis
What are the symptoms of the ACS conditions?(8)
- Chest pain
- Pains in other parts of the body
-Jaw, neck, teeth
-Shoulder, arm
-Stomach, back - Lightheaded/dizzy
- Sweating
- Shortness of breath
- Feeling sick (nausea) or being sick (vomiting)
- Overwhelming feeling of anxiety / panic
- Coughing or wheezing
SOCRATES in ACS Conditions:
*Site: central chest pain
*Onset: brought on by physical or
emotional exertion – Predictable
*Character: crushing, squeezing,
constricting, heaviness
*Radiates: can radiate to jaw,neck, shoulder, arm or stomach
*Associated symptoms: none
*Timing: brought on by physical or emotional exertion
*Exacerbating / alleviating factors:
-Exac: worse after food, cold winds/exercise/stress
-Allev: relieved by rest / GTN
*Severity: varies from patient to patient –discomfort vs severe pain
Main differences in angina vs unstable
angina symptoms:
- Worsening of “usual” angina symptoms
- More frequent - INC in GTN use
- Brought on at rest / when doing very
little - Pain last longer
- Not relieved by GTN initially
What are the Associated symptoms of an MI?(5)
- Shortness of breath/cough/wheeze
- Pale/clammy skin
- Nausea & vomiting
- Lightheaded / dizzy = fainting
- Overwhelming feeling of anxiety/panic
What are the ACS Symptoms in Men Vs Women?
Men:
Pain radiates – jaw,neck, shoulder, arm, back
Shortness of breath
Central chest pain –crushing, heavy, constricting, pressure
Shortness of breath
Women:
Pain radiates – jaw, neck, shoulder, arm, back
**ZZZ **
Central chest pain, crushing, heavy, constricting, pressure
Shortness of breath
Sudden dizziness
Nausea and vomiting
Unusual tiredness
Heartburn-like feeling
Cold sweats
What are the Red flags for ACS? (6)
- Chest pain at rest lasting >15 – 20 mins
- Recent onset of unstable angina symptoms
- Unresponsive to GTN
- Associated with autonomic symptoms:
- Nausea and vomiting
- Sweating
=Attend A&E/999
What is the treatment for angina?
1st line?
Glycerinetrinitrate
1st line: Spray
2nd line: Tablets
Symptom Prevention:
1st line Beta Blocker or Calcium Channel Blockers
if symptoms persist, take BOTH
If C/I to Beta Blocker or CCB then
2nd line: Long-acting nitrate OR IVABRADINE OR NICORANDIL
Secondary prevention:
* Aspirin
* Statin
* ACE Inhibitor
* Hypertension treatment
* Lifestyle advice
Initial management of STEMI:
What is taken?
Aspirin 300mg STAT + Fondaparinux 2.5mg OD
a) Coronary angiography with follow-up pre-cutaneous intervention (PCI) – GOLD STANDARD TREATMENT (where possible)
b) Fibrinolysis
c) Coronary artery revascularisation – “bypass”
Confirm Diagnosis (Hx taking, ECG, Trop Y)
What is a Coronary angiography?
Coronary angiography (“angio”)
* X-ray taken of the heart after a dye has been injected into the patient
* Allows visual imaging of coronary arteries to highlight stenosis (narrowing) as the result of atherosclerotic plaques
What is Percutaneous coronary intervention? (PCI)
Percutaneous coronary intervention (PCI)
* Also known as “stenting”
* Where coronary arteries have been identified as being stenosed, a drug eluting stent is inserted to widen coronary arteries again
* Important to use a drug eluting stent – prevents body reacting to foreign object which can lead to a clot
* Patients epithelial cells will eventually grow over the stent so this risk is then minimised
* This is why dual antiplatelet is used for 12 months
What is Fibrinolysis?
What are the drugs used?
Fibrinolytic drugs are administered to break up the blood clot in the coronary arteries
* Mechanism: activates plasminogen–form plasmin –breaks down fibrin within the fibrin rich clot
1. Alteplase- given within 6 hours of symptom onset
2. Streptokinase- given within 12 hours of symptom onset
What is Coronary artery bypass?
(revascularisation)
- Involves using a healthy vein to bypass the blocked coronary artery, allowing blood flow to be regained.
- Used less commonly during initial presentation of a STEMI
- “Open heart surgery” – more invasive than PCI so not used as frequently since this procedure was developed
Post MI, what are the 5 drugs a patient should be on?
Dual antiplatelets
Aspirin + Ticragerelor (or Clopidogrel or Prasugrel)
3. ACEi (or ARB)
4. Beta Blocker
5. Statin- lifelong
Secondary prevention – What lifestyle advice can you give? (5)
- Diet
- Alcohol consumption
- Smoking cessation
- Physical activity
- Weight management
How is ACS diagnosed?
Primarily by taking a good patient history. & identification of patient risk factors, an ECG and a blood test that looks for elevated levels of a cardiac enzyme called troponin (STEMI and NSTEMI not angina)
- This is because necrosis does not occur in angina and troponin is a marker for cardiovascular death, which only occurs in MI
What are the modifiable risk factors of developing ACS? (6)
Smoking
Diabetes
Hyperlipidaemia
Hypertension
Obesity
Illicit drug use (Cocaine)
What are the non-modifiable risk factors of developing ACS?(4)
Age
Gender-male
Family hx of ACS
Ethnicity
Differences in ECG for Unstable Angina, NSTEMI, STEMI
Unstable angina & NSTEMI
* ECG can be normal
* May see ST complex depression
* May see T wave inversion
* No elevation of ST complex
STEMI
* Elevation of the ST complex
DIAGNOSIS – Blood tests
What is troponin?
Blood test for Troponin taken if suspected MI
- Biological marker of cardiac muscle death
- Released into the circulation when cardiac muscle is damaged
- High levels of troponin in the blood indicate myocardial damage/necrosis
Blood test for Troponin taken if suspected MI
* Normal level <14 ng/L
* If elevated troponin on 1st sample (>14 ng/L)=repeat blood test >3 hrs later
* Rise in troponin by >7 ng/L = likely MI
* Troponin level >100 on first reading highly suggestive of MI if accompanied by ACS symptoms
