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ACS Flashcards

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1
Q

What is acute coronary syndrome

A

Any sudden cardiac event due to problem / occlusion of coronary

  • STEMI
  • NSTEMI
  • Unstable angina
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2
Q

What causes ACS

A 
Rupture of atheroma / thrombus formation that blocks coronary artery = most common 
Coronary vasospasm - cocaine
Coronary dissection - young healthy female 
Vasculitis / inflammation 
Hyperviscosity 
RT to chest
Strangulation / trauma
Severe anaemia
Congenital
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3
Q

What is unstable angina

A

Ischaemia of myocytes (due to rupture of plaque)

No troponin released

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4
Q

What does infarction (complete occlusion) cause

A

STEMI
NSTEMI
Troponin released

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5
Q

What are the symptoms of ACS

A 
Cardiac chest pain 
Chest pain - radiating to left arm, neck, jaw
Crushing / tight 
No improvement rest or GTN
SOB - blood backs up in pulmonary 
Palpitations 
Syncope 
Confusion
N+V / weakness./ dizzy - activation of vagal 
Anxiety 
Pale 
Sweaty / clammy - decreased CO so increased sympa
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6
Q

What are signs of ACS

A 
Mild fever 
Tachycardia
Tachypnoea 
Hypotension due to vagal overactivity 
JVP / 3rd HS / Inspiratory crackles if HF develop
4th HS
Pan systolic murmur due to papillary rupture 
Pulmonary oedema
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7
Q

How can ACS present in the elderly / diabetic / F

A 
Silent MI 
Syncope
Pulmonary oedema 
Epigastric pain + vomit 
Post op hypotension or oliguria 
Confusion 
Stroke
Anxiety
N+V
Hyperglycaemia
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8
Q

What are the RF for ACS

A 
Age
Male 
FH IHD
Smoking
Hypercholesterol
Hypertension
DM
Obesity 
Alcohol 
Cocaine
Angina 
HRT 
CAD
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9
Q

What is important in the PMH

A 
Previous MI 
IHD
DM
High BP
FH
Drugs
Smoke / alcohol
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10
Q

How do you Dx ACS

A

Typical Sx + RF
Ischaemic changes on ECG - do ECG always if cardiac sounding chest pain
Troponin - Cardiac enzymes elevated
Wall abnormalities on imaging

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11
Q

What do you look for in examination

A 
Pulse
BP - both arm
JVP
Murmur - if new worry
HF
Chest wall tenderness
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12
Q

Why do you worry about new murmur

A

Rupture of myocardium

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13
Q

How do you investigate ACS

A

Hx and exam
12 lead ECG (within 15 minutes) - to decide management
Cardiac monitor for arrhythmia
Bloods - FBC for anaemia, U+E, LFT, TFT, lipid, CRP, blood glucose for DM
Cardiac enzymes - troponin

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14
Q

What do the cardiac enzymes do

A

Troponin >40 = suggestive of MI (peaks at 12 hours and elevated 10 days) - want to see rise so repeat in 12-24 hours
Repeat 12-24 hours if -ve
Myoglobin = 1st to rise

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15
Q

What are further investigations

A

CXR to look for pulmonary oedema or pneumonia
Angiogram - CT or percutaneous
ECHO - post MI before discharge to look for myocardial dysfunction

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16
Q

What do you do when someone comes in with cardiac like chest pain straight away

A

ECG
Pulse oximetry
IV cannula as might arrest
Bloods

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17
Q

When would you do Mg

A 
Arrythmia
Seizure
D+v
Weakness
NOT routine
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18
Q

When would you do clotting

A

Haemorrhage
Anti-coagulant
Evidence of disorder

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19
Q

What is the ACS protocol

A 
ABCDE
Morphine
Oxygen if sats dropping
Nitrates
- GTN
- IV if not improving 
Aspirin 300g unless CI 
2nd anti platelet - ticagrelor = 1st line 180mg if no Hx stroke or TIA, clopidogrel if there is 
BB if not CI - metoprolol IV
- Caution if HF / Brady

Work out GRACE score to see if high risk needing PCI during admission

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20
Q

How much morphine and what do you give with

A

5-10mg

Give with metaclopamide (anti-emetic)

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21
Q

When do you give oxygen

A

If sats <94% or 88-92% if COPD until blood gas available

15l non breath EVERYONE

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22
Q

What nitrates do you give

A

GTN - give before hospital if GP
IV nitrate if pain continues
Careful if ED or PPH as will be on sildenafil
Ensure you monitor BP

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23
Q

When do you give aspirin

A

Before hospital 300mg unless CI

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24
Q

What do you give as well as MONAB

A

Anti-coagulant - Fondaparinux or LMWH if renal - if no PCI / CABG / angiography within 24 hours

Management different depending on whether UAP, STEMI, NSTEMI

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25
Who gets PCI
STEMI if within 2 hours of presentation | Thrombolysis then transfer if >2 hours
26
Who gets revascularisation (CABG / PCI)
STEMI | High risk NSTEMI calculated using GRACE score
27
What is given post MI
Aspirin 75mg life long Dual anti platelet 12 months at least (Tisagrelor / Pragurel) -if no risk of stroke Anti-coagulate (Fondaparinux / LMWH) until discharge or until revascularised If long term anti-coag needed e.g. AF then must use clopidogrel post ACS BB to reduce demand- continue for 12 months or forever if HF ACEI / ARB if LV dysfunction / DM / high BP High dose statin 80mg Other Aldosterone antagonist (eplerone) if HF on ECHO Anti-arrhythmia
28
What are prognostic drugs
ACEI | BB
29
What else should patient get
ECHO as inpatient or ETT Follow up 6-8 weeks Patient education and support (lifestyle, cardiac rehab)
30
What is most important determinant in survival
Age | LV ejection fraction
31
What should you never use in ACS
CCB
32
What has poor prognosis
``` Age >65 Development of CF - oedema / shock Peripheral vascular disease Reduced systolic - SHOCK Elevated cardiac marker Elevated initial creatinine Cardiac arrest ST deviation ```
33
What is UAP
Angina with increasing severity and frequency No troponin rise Abnormal ECG
34
What is a NSTEMI
Abnormal ECG Troponin rise NO ST elevation
35
What is shown on ECG
ST depression | T wave inversion
36
What causes UAP or NSTEMI
Partial occlusion of coronary artery.
37
What puts you at higher risk
Previous Hx Previous MI Previous CABG / PCI
38
How do you Dx UAP
Same investigation as above ECG changes tend to resolve after pain If troponin -ve repeat after 3 hours If still -ve not a MI
39
What is it if increased troponin but normal ECG
NSTEMI Type 1 = partial occlusion Type 2 = secondary to insult (troponin not as high)
40
How do you classify UAP and NSTEMI into risk
Do GRACE score | Ideally angio within 48 hours
41
What do you do after initial management
``` Decide if high risk needing invasive Rx in admission or low risk GRACE score = Mx of NSTEMI - Medical - Non urgent PCI - Urgent PCI HEART score - A+E whether ACS is likely Cardiac monitor for arrhythmia ECG + troponin repeat ```
42
What are very high risk, high risk patients and low risk
Very high risk = unstable, shock, arrhythmia, arrest, mechanical complication, ongoing pain after Rx ``` High risk High GRACE HEART Score >7 Age >70 Acute HF HR and BP Raised troponin Dynamic ST or T wave changes DM CKD LVEF <40% Recent PCI / CABG ``` Low risk - No recurrence pain - No signs of HF - Normal ECG
43
What does GRACE and HEART look at and when would you not use
GRACE - BP - Creatinine - CCF HEART - History - ECG - Age - RF - Tropnoni If STEMI or unstable as require immediate PCI
44
If patient not for PCI / CABG within 24 hours what do you give
SC Fondaparinux or LMWH
45
What do you do for low risk patient / UAP
``` Medical mamnegement Outpatient follow up ECHO ETT = 1st line Myocardial perfusion scan Outpatinet angiogram if found to have ischaemia ```
46
What do you do for high risk NSTEMI or UAP
Follow ACS protocol | Early intervention with PCI./ CABG within <2 hours
47
If intermediate risk
Do within 3 days
48
What do you not give if going for angio
Anti-coagulant
49
What is a STEMI
When artery becomes completely occluded
50
Why is cardiac muscle so sensitive
High metabolic demand
51
How do you Dx STEMI
ST elevation in vascular territory = diagnostic - >1mm in limb leads - >2mm in chest leads Suggestive - BBB
52
How do you treat STEMI
ACS protocol | REFER TO CCU FOR PCI
53
When do you refer for PCI
If available within 2 hours of presentation and 12 hours of symptom onset
54
What do you give before PCI
GP IIB/IIa inhibitor (epifeitibdie)
55
When would you thrombolyse
If no PCI within 2 hours Always transfer after as risk of re-occluding Alteplase (conversion of plasminogen to plasmin in absence of fibrin) - tPA
56
What do you do after thrombolyse
Repeat ECG PCI if no resolution to ST after 90minutes don't antiocagulate if stable then do routine PCI within 24 hours
57
When do you do CABG
Three vessel disease Left main stem PCI unsuccessful Mechanical complications
58
What are CI to thrombolysis
``` Prior intracranial haemorrhage Recent trauma or surgery Coagulation / bleeding disorder Known brain tumour / CVA lesion or trauma Ischaemic stroke within 3 months Aortic dissection Active bleeding Head trauma Pregnancy ```
59
What are the SE of thrombolysis
Haemorrhage Hypotension Allergy
60
What do you do if ST elevation but arrhythmia
Treat as peri-arrest | ACS could have caused but can't treat due due to tachy
61
What is needed
DC cardioversion | Treat as whether Brady or tachy
62
What else is offered to patient
Cardiac Rehab
63
What else can raise troponin
``` Chronic renal Sepsis PE Dissection Myocarditis ```
64
What are the types of MI
``` 1 = thrombus or embolus 2 to plaque rupture 2 = ischaemia 2 to anaemia / hypoxia in sepsis / spams 3 = dead with no biomarker 4 = PCI / stent thrombosis - if don't take anti-platelet 5 = CABG ```
65
DDX of ACS
``` Aortic dissection - very unwell and tearing pain between pack / scapula PE Pericarditis - Relief forward Heartburn MSK ```

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