ACS Flashcards
(25 cards)
what does acs include?
Includes unstable angina and myocardial infarctions
what is the common underlying pathology for ACS?
Plaque rupture, thrombosis and inflammation in coronary artery
–Rarely due to emboli, coronary spasm or vasculitis
what is a MI and how is it recognised?
Myocardial cell death, releasing cardiac troponin with ischaemia
–ST-segment elevation (STEMI) and non-ST-segment elevations
(NSTEMI) on 12 lead ECG
STEMI: complete obstruction; NSTEMI: incomplete obstruction
what is unstable angina?
–Similar clinical presentation as NSTEMI without significant rise in
cardiac troponin
what are modifiable risk factors for ACS?
–Smoking
–Diabetes
–Hypertension
–Dyslipidaemia
–Obesity
–Lack of exercise
–Cocaine use
what are the symptoms of ACS?
–Acute chest discomfort >15 mins/ or in past 12 hours
*Dull, central and/or crushing. Not relieved by rest. May radiate
–Associated symptoms: anxiety, nausea, pallor sweatiness, dyspnoea,
palpitations.
what are the signs of ACS?
–Associated with haemodynaic instability (systolic BP <90 mmHG)
*Tachycardia and sweating- sympathetic activation
*Bradycardia, nausea and vomiting- vagal activation
–4th heart sound, low grade fever
–Signs of heart failure (3rd heart sound, increased JVP, basal crepitations
what cardiac issues can cause chest pain?
Stable angina, dissecting thoracic aneurysm, pericarditis, cardiac tamponade, myocarditis, acute congestive cardiac failure, or
arrhythmias.
what non-cardiac issues can cause chest pain?
Respiratory (PE, pneumothorax, CAP, asthma pleural effusion)
–Other: acute pancreatitis, GORD, oesophagitis; rib fracture, spinal
disorders, cancer; psychogenic
–Non-specific chest pain (16% of people)
what is the suspected ACS initial management?
*999
*Aspirin 300mg STAT
*Pain relief:
–GTN and/ or opioid (IV diamorphine 2.5mg-5mg
over 5 minutes
*12-lead ECG (should not delay hospital
transfer)
*Oxygen: only if hypoxic
how do you diagnose ACS?
*Cardiac history (clinical skills)
*CV examination (clinical skills)
*Investigations
–12 lead ECG
*Pathological Q waves, left bundle branch block, ST changes
–Blood sample for high sensitivity troponin I or T
–BP, HR, oxygen saturation
–Chest x-ray
*Signs of HF, pulmonary causes
–Other: FBC, u+e, lipid, lft, TFT, HbA1c, CRP, ESR
nb need to learn off- what is the universal definition of MI?
Acute myocardial injury with evidence of acute myocardial ischaemia and detection of a rise of the cardiac troponin levels with at least one value above the 99th percentile and at
least one of the following:
–Symptoms of myocardial ischaemia;
–New ischaemic ECG changes;
–Development of pathological Q waves on the ECG;
–Imaging evidence of new loss of viable myocardium or new regional
wall motion abnormalities in a pattern consistent with ischaemic
aetiology;
–Identification of coronary thrombus by angiography or auto
what is PPCI?
*Angiography first
*Access via the radial or femoral artery
*X-ray guided insertion through the aorta and into the
affected coronary artery
*Insertion of a balloon which is inflated and a stent to
restore blood flow
what is dual antiplatelet therapy?
–Aspirin lifelong and P2Y12 inhibitor for 12 months
*Prasugrel or
*Clopidogrel (if high bleed risk or on anticoagulant)
what is the purpose of fibrinolytics?
–Activates plasminogen to form plasmin, degrades fibrin and breaks up thrombi
–Streptokinase, alteplase, tenecteplase
when are antithrombins used?
–Unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor. Bivalirudin
if femoral access needed
–With antiplatelet therapy
when is STEMi management not suitable?
–Not suitable for PCI or fibrinolysis
–Aspirin and ticagrelor (or clopidogrel if high bleed risk)
what is initial antithrombin therapy?
Fondaparinaux: binds antithrombin III, neutralizing factor Xa,
interrupts clotting cascade
what is DAPT?
–Aspirin +
–Prasugrel (if PCI intended) or
–Ticagrelor (no PCI) or
–Clopidogrel (high bleed risk/ anticoagulant)
what post MI assessments should be done?
*Left ventricular function assessment
–Covered in HF lecture
*Bleeding risk
what secondary prevention should be given?
ACEi/ bb/ DAPT/ statin/ aldosterone antagonist
when should ACEi be given?
as secondary prevention
–As soon as haemodynamically stable. Continue indefinitely
–Titrate upwards every 12-24 hours, complete titration within 6 weeks
to max tolerated dose.
–Monitor: renal function, U+E, BP before stating and every 2-4 weeks
when should BB be given?
as secondary prevention
–As soon as haemodynamically stable
–Titrate slowly up to max tolerated dose.
–Monitor HR and BP
–12 months all patients, lifelong if HF with reduced LVEF
what statin should be given for secondary prevention?
–Atorvastatin 80mg
–Monitor liver enzymes, cholesterol HbA1c at 3 months then annually.
CK if persistent muscle pain. TFT and Hba1c before starting
