ACS Flashcards
Definition of ACS
Acute ischaemic chest pain either at rest or crescendo pain on minimal exertion associated with ECG changes showing ischaemia
Types of ACS
- STEMI/new onset LBBB
2. NSTEMI
What does ACS basically mean
Unstable angina and evolving MI
Pathophysiology
Gradual buildup of fatty plaque endothelium dysfunction caused by smoking hypertension and hyperglycaemia
This builds up within wall of coronary artery and narrows lumen and causes decreased oxygen supply to heart leading to angina or if no blood reaches myocardium get myocardial infarction
Modifiable risk factors
Hypertension diabetes smoking high cholesterol and obesity
Nonmodifiable risk factors
Male gender, increased Age,family history of premature CAD (male first-degree relative before 55 years old, female 1st° relative before 65 years old)
Signs and symptoms
Chest pain (central crushing pain lasting more than 20 minutes, may radiate to neck or arms, similar pain found in angina but people say that it is more severe and last longer than angina
Nausea vomiting and sweating
Distressed tachycardic cold and clammy
Variable blood pressure
Patient may be cyanosed
Mild pyrexia
Features of complications (LVF equals third heart sand, raised JVP, bibasal crepitations and dyspnoea and brackets; Papillary muscle dysfunction equals PSM)
30% have silent symptoms: syncope, delirium,stroke, hyperglycaemia
What investigations would you do
12 lead ECG, bloods, echocardiogram, chest x-ray
What ECG changes would you see for STEMI
First few hours: ST elevation and hyperacute T waves
First 24 hours:ST elevationstarting to resolve and T-wave inversion
More than 24 hours: pathological queue waves may occur within hours or 24 hours – indicating full thickness infarct
Long-term changes: persistent Q-waves (90%), persistent T-wave inversion, persistent ST elevation is rare and seen in ventricular aneurysm
What is e.g. changes would you see in NSTEMI
ST depression and T-wave inversion, no Q-waves present – indicating that the endothelial infarcts
N.b. deep and widespread ST depression is associated with hi mortality (higher than in people with unstable angina)
ECG leads and which areas and vessels of the heart the they correlate to
Inferior view: Leads two, three, avF – vessel: right coronary artery
Anterolateral view: leads one, aVL, V4 – V6: vessel is left circumflex artery
Anteroseptal view: V2-V3, LAD
Anterior view: V2– V6, L A.D
Posterior: V1, V2, V3: right coronary a
What bloods would you send for
And what other ix tests
- troponin T/I, peaks at 20 hours, ideal time to check is 6-9 hours post onset of pain and then at 12 to 24 hours (latter is optional)
- CK – MB is most specific for acute MI, peaks at 12 to 24 hours and remains high for half a day to 3 days
- LDH, high post MI and in myocarditis levels peak at 48 to 72 hours
- 🌟u &E, 🌟glucose [if >11mmol/L, call endocrinologist or diabetes nurse early], 🌟cholesterol(do within 24 hours of pain onset because it gives a reasonable indication of the values before the acute event-should be started on a statin regardless of basal lipids & assess any secondary causes of high lipids e.g.diabetes, alcohol abuse, renal disease, liver disease, badly treated hypothyroidism), 🌟FBC, 🌟🌟clotting Profile
- Echo= shows if LV damage, RV damage, cardiac rupture with the Tamponade, acute MR, ventricular septal rapture, extent of akinesis in transmural infarction
- CXR: May show heart failure (cardiomegaly, pulmonary oedema), helps exclude aortic dissection, widened mediastinum may show aortic rupture
How would you manage an acute Mi
🎀Attach ECG monitor
Record a 12 lead ECG
🎀Establish IV access and give oxygen if the levels are less than 95%/acute heart failure:aim for 94 to 98%, 88 to 92% if COPD patient
🎀Brief Assessment:
❤️history of CVD, rfs for IHD;
♥️examine:pulse, blood pressure both arms, JVP, murmurs, signs of CCF, scars from previous surgeries, chest x-ray
❤️check if contraindication to PCI/fibronolysis
🎀Aspirin 300 mg (unless already given by GP or paramedic), and Ticagrelor 180 mg PO (Superior alternative to the clopidogrel) OR Prasugrel 60 mg PO
🎀Morphine 5 to 10 mg IV, and anti-emetic with first dose of morphine (first line: metoclopramide 10 mg IV, second line cyclizine 50 mg IV)
🎀GTN is not recommended unless patient is hypertensive or in acute LVF
🎀the aim now is to restore cardiac profusion
🎀If stemi on the ECG and PCI available in two hours: yes: primary PCI -> angiographic identification of culprit blockages and revascularisation with deployment of stent, done if less than 12 hours since signs and symptoms or if patient can be transferred to a PCI Centre within 120 minutes of medical contact.
Must ensure pt is loaded with appropriate antiplatelet agent ie. aspirin & prasugrel/clop.
Must give an injectable anticoagulant (BIVALIRUDIN, a direct thrombin inhibitor) is preferred, if not present use ENOXAPARIN and or GPIIb/IIIa blocker
🎀 if primary PCI not possible, give patient Thrombolysis and transfer to PCI Centre for rescue PCI, (if residual ST elevation or angiography if successful)
🎀STEMI on ECG and PCI available in 120 minutes: no: fibrinolysis. This is systematically administered clot dissolving agent ( alteplase, reteplase,streptokinase,tenectoplase). INDICATION FOR USE IS PRESENTATION WITHIN 12 HOURS OF SYMPTOM ONSET + TYPICAL CARDIAC CHEST PAIN >30MINS. use more than 12 hours need specialist advice, it is contraindicated beyond 24 hours). DO ECG AFTER 90 MINS, SHOULD SEE >50% RESOLUTION IN ST ELEVATION.
- -> If no adequete resolution: RESCUE PCI [is superior to repeat thrombolysis]
- -> if thrombolysis is successful = PCI is still shown to be beneficial! (optimal timing of this is still being ix’d)
nb: glycemic control in pt with DM, recommendation = dose adjusted insulin infusion with regular blood glucose monitoring till <11 mmol/L
Fibrinolysis CI absolute
ANY ACTIVE BLEEDING
Prev ischemic hemorrhage Ischaemic stroke less than six months Cerebral malignancy Avm Recent major head trauma or injury less than 3weeks Gi bleeding less than 1mo Known bleeding disorders Aortic dissection Non compressible punctures eg, LP,liver biopsy
Fibrinolysis relative CI, STILL V SERIOUS
Tia less than 6mo Anticoagulant rx Preg Less than 1 week postpartum Refractory htn (>180/110) Advanced liver disease iE Active peptic ulcer Prolonged/traumatic resus
