ACS

Question 1

What is ACS

Answer 1

Acute Coronary Syndrome

Question 2

Which conditions are included in ACS?

Answer 2

STEMI

NSTEMI

Unstable angina

Question 3

What other organ systems can cause chest pain?

Answer 3

Resp - PE, pleuritic chest pain, pleural effusion, pneumonia, pneumothorax

Gastro - GORD, oesophageal rupture

Aorta - aortic dissection

Intrabdominal - pancreatitis, cholecystitis

Derm - skin

Question 4

Why is ACS important?

Answer 4

750-1250 STEMIs/million per year

5% inpatient mortality

Question 5

How does ACS present?

Answer 5

Pain
- acute onset
- central, crushing, severe, radiates to left arm or jaw/throat
- associated with autonomic symptoms, nausea and diaphoresis

Cardiac arrest/Arrythmia
- VT/VF (or rarely CHB - complete heart block)

Question 6

What investigations would you do

Answer 6

Take Hx

Serial ECGs (this is key as waiting for blood tests may be too late)
- 60mins into symptoms = 50% of ischaemic myocardium lost
- 180mins into symptoms = 66% of ischaemic myocardium lost

Troponin

Question 7

What are the ECG finding for a STEMI?

Answer 7

ST elevation
- 2mm in contiguous chest leads
- 1mm in contiguous limb leads
- new LBBB

Question 8

What are the ECG finding for a NSTEMI?

Answer 8

ST depression

T-wave inversion

Exclusion of STEMI features

Question 9

What are the ECG finding for an unstable angina?

Answer 9

May have no clear ECG findings

Question 10

What is the ACS protocol?

Answer 10

Symptom relief/supportive
- Morphine
- O2
- Antiemetic

Modify pathophysiology
- Nitrates
- Dual antiplatelets (Aspirin 300mg + one of: Clopidogrel 600mg, Ticagrelor 180mg, Prasugrel 60mg)
- LMWH e.g., Fondaparinux 2.5mg S/C OD
- Atorvastatin 80mg

Senior review and cardio opinion

Question 11

For the ACS protocol what drugs would you prescribe on the Once Only and Pre-anaesthetic medication part?

Answer 11

STAT Aspirin PO 300mg

STAT Clopidogel PO 600mg

Question 12

For the ACS protocol what drugs would you prescribe on the Chemical Thromboprophylaxis part?

Answer 12

Fondaparinux SC 2.5mg

Question 13

For the ACS protocol what drugs would you prescribe on the Regular Medicines part?

Answer 13

Aspirin 75mg PO OD

Clopidogrel 75mg PO OD

Lansoprazole 30mg PO OD

Atorvastatin 80mg PO OD

Bisoprolol 2.5mg PO OD

Ramipril 2.5mg PO OD

Question 13

For the ACS protocol what drugs would you prescribe on the As Required part?

Answer 13

Paracetamol 1g PO/IV QDS (max dose = 4mg)

Morphine 5-10mg PO 4 hourly

GTN /\ S/L (sublingual) PRN

Question 14

For STEMI, what are the criteria for offering coronary angiography with follow up primary PCI if indicated?

Answer 14

Presentation within 12 hours of Sx onset

Primary PCI can be given within 120 minutes of the time when fibrinolysis could have been given

Question 15

For people with STEMI that present 12 hours after their Sx onset what Tx should you give/consider?

Answer 15

Consider coronary angiography, with follow‑on primary PCI if indicated

Question 16

If someone with STEMI presents within 12 hours of Sx but primary PCI cannot be given within 120 minutes, what Tx should they be given?

Answer 16

Fibrinolysis

Give an antithrombin at the same time

Offer an electrocardiogram (ECG) to people with acute STEMI treated with fibrinolysis, 60 to 90 minutes after administration

Question 17

If after given fibrinolysis the patient has residual ST‑segment what does this suggest and what Tx should be given?

Answer 17

Failed coronary perfusion

Offer immediate coronary angiography, with follow‑on PCI if indicated

Do not repeat fibrinolytic therapy

Question 18

If a person has recurrent myocardial ischaemia after fibrinolysis what should you do?

Answer 18

Seek immediate cardiology advice

if appropriate, offer coronary angiography, with follow‑on PCI if indicated

Question 19

What is the Mx for people with STEMI not being treated with PCI?

Answer 19

Offer ticagrelor, as part of dual antiplatelet therapy with aspirin, unless they have a high bleeding risk

Consider clopidogrel, as part of dual antiplatelet therapy with aspirin, or aspirin alone, if they have a high bleeding risk

Offer medical management to people with acute STEMI who are ineligible for any reperfusion therapy

Question 20

What should be assessed in all patient with a STEMI and NSTEMI before discharge? Why?

Answer 20

Left ventricular function

Some people have heart failure because of damage to heart muscle and impaired contraction of the left ventricle.

This is known as left ventricular systolic dysfunction (LVSD). The effectiveness of drug treatment with ACEis, ARBs, aldosterone antagonists and beta‑blockers depends on LV function.

Question 21

What are the different post MI complications?

Answer 21

<3 days (often within hours). Arrythmias, heart block, stroke

<7 days. Free wall rupture, VSD, papillary muscle rupture

> 14 days. Dresslers syndrome

Question 22

What is Dressler’s syndrome?

Answer 22

Inflammation of the sac surrounding the heart (pericarditis).

Believed to occur as the result of the immune system responding to damage to heart tissue or damage to the sac around the heart (pericardium)

Question 23

What scoring system is used to predict 6-month mortality for unstable angina or NSTEMI?

Answer 23

Global Registry of Acute Cardiac Events (GRACE)

Question 24

What should be included in a formal risk assessment for unstable angina or NSTEMI?

Answer 24

a full clinical history (including age, previous myocardial infarction [MI] and previous PCI or coronary artery bypass grafting [CABG])

A physical examination (including measurement of blood pressure and heart rate)

A resting 12‑lead ECG, looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia

Blood tests (such as troponin I or T, creatinine, glucose and haemoglobin)

Question 25

When should immediate coronary angiography be offered to people with unstable angina or NSTEMI?

Answer 25

If their medical condition is unstable

Question 26

What drugs should be used in the Mx of NSTEMI?

Answer 26

BATMAN

Betablockers (e.g., bisoprolol)
Apsirin 300mg
Ticagrelor 180mg
Morphine
Anticoagulant (LMWH) - Fondaparinux
Nitrates

Do not offer dual antiplatelet therapy to people with chest pain before a diagnosis of unstable angina or NSTEMI is made.

Question 27

When would you consider PCI in patients with NSTEMI or unstable angina? Within what timeframe would you do the PCI?

Answer 27

If they have an intermediate or high risk of adverse cardiovascular events (according to GRACE or TIMI) - i.e., their predicted 6-month mortality is above 3.0%

PCI within 72 hours

N.B. Be aware that some younger people with low risk scores for mortality at 6 months may still be at high risk of adverse cardiovascular events and may benefit from early angiography

Question 28

What are the contraindications to thrombolysis?

Answer 28

Bleeding disorder

High INR

Recent surgery

Pregnant

Stroke in last 6m

Known GI bleed

Question 29

Sources

Answer 29

https://www.nice.org.uk/guidance/ng185/resources/visual-summary-stemi-pdf-8900623405

https://www.nice.org.uk/guidance/qs99/chapter/quality-statement-1-assessment-of-left-ventricular-function

https://www.nice.org.uk/guidance/qs68/chapter/quality-statement-6-primary-pci-for-acute-stemi#:~:text=Adults%20with%20acute%20ST%2Dsegment,fibrinolysis%20could%20have%20been%20given.

https://www.nice.org.uk/guidance/ng185/chapter/Recommendations#stemi-early-management

Question 30

How does Dressler’s syndrome typically present?

Answer 30

1-6 weeks after the initial MI

Pain + fever that may suggest further infarction

Pain - often in left shoulder + often pleuritic and worse on lying down

May be malaise, fever and dyspnoea

Could cause a cardiac tamponade or acute pneumonitis = rare

Pericardial friction rub may be hear (typically described as being like the sound of boots walking over fresh snow)