Acute Coronary Sydrome

Question 1

Acute Coronary Syndrome definition

Answer 1

-any array of clinical symptoms resulting from underlying acute myocardial aschemia -almost always associated w/atherosclerotic plaque w/ or isolated from occlusive thrombus

Question 2

Causes of ACS (10)

Answer 2

1. Atherosclerotic plaque rupture with thrombus 2. Atherosclerotic plaque rupture with thrombus 3. Atherosclerotic plaque rupture with thrombus 4. Coronary embolism 5. Congenital anomalies 6. Coronary trauma or aneurysm 7. Severe coronary artery spasm (e.g. cocaine) 8. Increased blood viscosity 9. Spontaneous coronary dissection 10. Markedly increased myocardial 02 demand

Question 3

Epidemiology of heart disease

Answer 3

-1.7 million/year suffer

Question 4

Pathophysiology of ACS

Answer 4

⇒ Inflammation + risk factors promote atherosclerosis ⇒ Atherosclerosis promotes a dysfunctional endothelium Dysfunctional endothelium has decreased vasodilator effect and decreased antithrombotic effect compared to normal endothelium ⇒ Inflammatory mediators weaken the atherosclerotic fibrous cap; if cap bursts, thrombogenic tissue factor is released, activating the coagulation cascade and creating platelet aggregation ⇒ Dysfunctional endothelium + coagulation + platelet aggregation = Coronary thrombosis!

Question 5

Risk factors for atherosclerosis

Answer 5

-Primary risk factors include: Diabetes, hypertension, hyperlipidemia, tobacco -Other possible risk factors: poor diet, inactivity, obesity, kidney disease, family history

Question 6

Process of plaque rupture

Answer 6

1. en

Question 7

partial artery occlusion

Answer 7

-decreased blood flow in artery distal to partial occlusion –> decrease O2 to myocardium/ischemia

Question 8

complete occlusions

Answer 8

cessation of blood flow and O2 to the entire portion of myocardium supplied by that artery = ischemia

Question 9

Transmural MI vs. Subendocardial MI

Answer 9

-Transmural ischemia—spans entire thickness of myocardium; most often associated with complete coronary occlusion -Subendocardial ischemia—involves the innermost layers of myocardium; most often due to partial coronary occlusion -if ischemia is prolonged –> myocyte death and tissue necrosis

Question 10

Factors involved in diagnsosi of ACS

Answer 10

-ECG -biomarkers -clinical symptoms

Question 11

ECG changes possible in ACS

Answer 11

Question 12

ECG changes in subendocardial ischemia

Answer 12

-ST vector wards inner layer and away from leads –> -ST depression

Question 13

ECG changes in transmural ischemia

Answer 13

-ST vectors towards leads –> -ST elevation

Question 14

ECG changes in MI

Answer 14

-ST elevations = “STEMI” -no ST elevation = “NSTEMI”

Question 15

Serum markers of MI

Answer 15

-Tropinin I & Troponin T: sensitive and specific for myocardium; rise 3-4 hrs after onset of pain, peak = ___ -Creatine Kinase–MB isoenzyme: not as secific for myocardium as troponin; rises 3-8 hrs after onset of pain; peak = ____

Question 16

Clinical symptoms of MI

Answer 16

-angina=chest pain/presure/tightness -SOB -sweating -nauseau -weakness

Question 17

Angina types

Answer 17

-stabel=present when there is increased demand for myocardial O2 in a reproducible fashion -unstable=increase in duration, intensity or frequency, less provocation

Question 18

ACS summary comparison [table}

Answer 18

Question 19

Main goals of treatment of ACS

Answer 19

1. relief of ischemia: open the artery or prevent further arterial occlusion & reduce myocardial oxygen demand 2. prevent adverse outcomes

Question 20

Treatment of STEMI

Answer 20

-Artery is occluded→ Open it! - If artery can be opened within 90 minutes, go to cardiac cath lab to open mechanically (cardiac catheterization). - If cannot be opened within 90 minutes, consider fibrinolytics -If hemodynamically stable, consider oral beta blockers or nitrates to decrease myocardial oxygen demand

Question 21

Treatment of NSTEMI/unstable Angina

Answer 21

-Artery is partially occluded→halt the thrombotic process from completely occluding the artery by giving anticoagulant and antiplatelet agents -If hemodynamically stable, consider oral beta blockers or nitrates to decrease myocardial oxygen

Question 22

Anticoagulants/antiplatelets used in NSTEMI/unstable angina

Answer 22

-Anticoagulants: unfractionated heparin, low-molecular weight heparin, fondaparinux (use one -Antiplatelets: P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor), GIIb/IIIa inhibitors -PLUS Aspirin

Question 23

Common conditions included in ACS

Answer 23

-unstable angina -NSTEMI -STEMI -most often cause by plaque rupture and thrombosis

Question 24

Biomarkers in ACS: initial elevation of biomarkers, time to peak elevation, time to return to normal

Answer 24