Acute coronary Syndomre Flashcards

1
Q

Define an ACS?

A

Any sudden cardiac event suspected to be related to occlusion of the coronary arteries

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2
Q

What are the risk factors for an ACS?

A

Older Age
Male
Smoker
FH
Low Exercise/Poor diet
Hypercholesterolaemia
Hypertension
Diabetes

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3
Q

What are the symptoms of an ACS?

A

SOB
Chest Pain:
(retrosternal, radiating to arms neck/jaw) Tight band/pressure/heaviness
Cold Sweat/Nausea
Fatigue
Sense of Impending Doom
Near Syncope/dizziness
Incomplete or unchanged relief with rest & GTN

Some may also show palpitations, anxiety or a sense of impending doom

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4
Q

What is an atypical ACS presentation?

A

In people with reduced pain sensation such as the elderly, diabetics and women ACS can present as:
SOB
Signs of heart failure (i.e. pulmonary oedema, raised JVP etc)
nausea/vomiting

But without the classic chest pain

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5
Q

What causes an ACS?

A

Usually a complicated atheroma growing a thrombus and/or embolising

Also Vasospasm & vasoconstriction

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6
Q

What do we do first to investigate an ACS?

A

An ECG asap, in the ambulance if possible.
ST elevation indicates acute heart damage telling us its a STEMI

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7
Q

What do we do for a STEMI?

A

MONAC + LMWH & B-blocker
PCI in the form of angioplasty +/- stenting (within 2 hours of event or 90mins of hostpital admission)
Failing that Thrombolysis (within 90 mins of event)

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8
Q

How does thrombolysis work and what agents are used?

A

Recombinant Tissue Plasminogen Activators (rtPA) such as alteplase or bacterial enzymes such as streptokinase
Alteplase converts plasminogen -> plasmin mainly in the presence of fibrin (so is a Fibrin Specific Agent)

Streptokinase activates plasmin systemically which can lyse other plasma proteins leading to a bleeding tendency (its a non-fibrin specific thrombolytic)

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9
Q

What cant streptokinase be used more than once?

A

Its bacterial so the patient will grow immune and may even have an allergic reaction to a 2nd dose.
If treatment is needed for a 2nd MI then it will be rtPA.

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10
Q

If theres no ST elevation how do we distinguish between NSTEMI & UAP?

A

Blood Tests for biomarkers of myocardial necrosis.
The main one is cardiac troponin (cTn), specifically type I & T (type C is present in blood anyway) if present it indicates an NSTEMI & if absent its UAP.

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11
Q

How do we treat NSTEMI/UAP?

A

Analgesia: Morphine
Vasodilators: IV Nitrates (e.g. GTN or isosorbide dinitrate) + CCBs (amlodipine)
Slow Heart Rate to lower O2 demand: RL CCBs (diltiazem) and/or Beta Blocker (Atenolol)
Anti-platelets: Aspirin + Clopidogrel/Ticagrelor
Anti-coagulant: LMWH (or Fondaparinux if used quickly)
Specialist: Glycoprotein IIa/IIIb receptor blockers (GP2a/3b blockers)

Once stabilised Do a CT coronary Angiogram and possibly follow with PCI or CABG

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12
Q

What is involved in secondary prevention of ACS?

A

Lifestyle:
- Smoking Cessation
- Healthy limits for alcohol consumption
- Daily Exercise & healthier diet (with weight loss if applicable)

Medication:
- Aspirin + Clopidogrel for 1 year (dual anti-platelet therapy) then aspirin alone indefinetely
- Warfarin
- Beta-blockers to reduce average O2 demand of heart (e.g. Metopolol/Atenolol)
- Statins to lower cholesterol & so reduce risk of atheroma
- ACEI/ARB to control Blood Pressure (e.g. Ramipril/Losarten respectively)

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13
Q

When would thrombolytics be contraindicated?

A

When theres any chance of bleeding due to injury elsewhere in the body that could be ‘de-clotted’ by the thrombolytics:
Intercranial Haemorrhage - Malignant Intercranial Neoplasm - Ischaemic Stroke - Aortic Dissectoin - Bleeding diathesis (Coagulopathy)

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14
Q

How do GP2b3a receptor blockers work?

A

The GP2a3b complex is a receptor found on platelets that activates in the presence of fibrinogen.
By blocking the receptor platelets arn’t activated and so clotting doesn’t occur.

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15
Q

What is the treatment given at the door to ACS patients?

A

“MONA greets chest pain at the door”
Morphine - Oxygen - Nitroglycerin - Aspirin

Not necessarily all given or in that order.

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16
Q

What do we give following PCI?

A

Anti-platelets e.g. Aspirin and Clopidogrel for min 12 months plus GP2b3a receptor antagonist acutely (Abciximab)