Wk 12: Acute coronary syndrome Flashcards
What is acute coronary syndromes?
- Unstable angina
- MI
- Due to plaque rupture, thrombosis + inflammation in coronary artery
What is the presentation of unstable angina?
NSTEMI w/o significant rise in cardiac troponin
What are the non-modifiable risk factors of ACS?
- Age
- Male
- Fam history
- Ethnicity
What are the modifiable risk factors of ACS?
- Smoking
- Diabetes
- Hypertension
- Dyslipidemia
- Obesity
- Lack of exercise
- Cocaine use
What are the symptoms of ACS?
- Acute chest discomfort >15mins or past 12 hrs
- Dull, central and/or crushing
- Not relieved by rest
What are the associated symptoms of ACS?
- Anxiety
- Nausea
- Pallor sweating
- Palpitations
- Dyspnoea
What are the signs of ACS?
Haemodynamic instability (systolic <90)
- Tachycardia + sweating: sympathetic
- Bradycardia, nausea + vomiting: vagal
- 4th heart sound, low grade fever
What are the signs of heart failure?
- 3rd heart sound
- Inc JVP
- Basal crepitations
What are the non-cardiac causes of chest pain?
- Respiratory: PE, pneumothorax, CAP
- Other: acute pancreatitis, GORD, spinal disorder, cancer
What is the initial management of suspected ACS?
- 999
- Aspirin 300mg STAT
- Pain relief: GTN or IV diamorphine 2.5-5mg over 5 mins
- 12 lead ECG
- Oxygen: if hypoxic
How do you diagnose ACS?
- Cardiac HX
- CV examination
- 12 lead ECG
- Blood sample: High sensitivity troponin I or T
- BP, HR + O2 stats
- Chest x-ray
- FBC, U+E, Lipid, LFT, HbA1c, CRP, ESR
What is PCI?
- Angiography
- Access via radial/femoral artery
- X-ray guided insertion through aorta into affected coronary artery
- Insertion of inflated balloon + stent to restore blood flow
What happens after assessing a patient with a STEMI?
Angiography or fibrolysis
What is the dual antiplatelet therapy for PCI in a STEMI?
- Aspirin lifelong + P2Y12 inhibitor for 12 months (prasugrel)
- Clopidogrel (high risk bleed or on anticoagulant)
What antithrombotics are offered alongside antiplatelet therapy for PCI?
- Unfractionated hep w/ bailout glycoprotein IIb/IIa inhibitor
- Bivalirudin if femoral access needed
What are fibrinolytics?
Activates plasminogen: forms plasmin, degrades fibrin + breaks up thrombin
Give some examples of fibrinolytics
- Streptokinase
- Alteplase
- Tenecteplase
What is the medical management of STEMI?
Aspirin + ticagrelor (clopidogrel if high bleed risk)
What is the initial antithrombin therapy of NSTEMI/unstable angina?
Fondaparinux
How does fondaparinux work?
- Binds antithrombin III
- Neutralizing factor Xa
- Interrupts clotting cascade
What would you consider for NSTEMI/unstable angina within 72 hrs?
- Angiography + PCI
- PCI eligible: give unfractionated heparin
What are the dual antiplatelet therapy for an NSTEMI/unstable angina?
Aspirin +
- Prasugrel (if PCI)
- Ticagrelor (No PCI) or clopidogrel (high bleed risk/anticoagulant
What are the assessments post MI?
- Left ventricular function assessment
- Bleeding risk
What are the drugs used for secondary prevention?
- ACE (ARB)
- Beta blocker
- DAPT
- Statin
- Aldosterone antagonist
When are ace inhibitors started?
- Hemodynamically stable
- Titrate up every 12-24 hrs, complete w/in 6 wks
- Monitor: renal, U+E, BP before starting + every 2-4 wks
When are beta blockers started?
- Hemodynamically stable
- Titrate slowly
- Monitor HR + BO
- 12 months all patients, lifelong if HF w/ red LVEF
Which statin is used?
Atorvastatin 80 mg
What needs monitoring when on a statin?
- TFT + HbA1c before starting
- Liver enzymes, cholesterol + HbA1c at 3 months then annually
- CK if persistent muscle pain
When are aldosterone antagonists used?
- HF w/ red LVEF
- Initiate after ACE + w/in 14 days of MI
- Monitor: renal function + U+Es
What are the counselling points for ACS?
- Mediterranean diet: bread, fruit, veg + fish
- Alcohol max 14 u/wk
- 20-30 mins exercise a day to slight SOB
- Smoking cessation
- Healthy BMI
- Annual flu vaccine
