Acute Coronary Syndrome: Presentation and Management

Question 1

What is an acute coronary syndrome?

Answer 1

Recent onset of symptoms related to a problem with coronary arteries

Question 2

Explain Stable Angina

Answer 2

Stable angina is caused by the hardening of the arteries. They will have a restriction of the blood flow. They get predictable symptoms due to that. Symptoms are usually relieved by rest.

Question 3

Acute Coronary Syndromes

Answer 3

Causes by “unstable” coronary legions. These are unpredictable. It may occur at rest.

Question 4

What is cardiac arrest?

Answer 4

Cardiac arrest is when the heart is not making enough output to be able to sustain life. It is often due to a sudden change in rythm incompatible with life or something else affecting heart function, meaning it is not able to pump out enough blood to sustain life.

Question 5

How is cardiac arrest caused?

Answer 5

Cardiac arrest can be due to acute coronary syndrome and other causes.

Question 6

How do you diagnose myocardial infarction?

Answer 6

If the heart muscle has died, biomarker will be released. You need one more thing alongside this and it can be:
- Symptoms of ischaemia
- New change in ECG
- Evidence of coronary problem on coronary angiogram or autopsy
- Evidence of new cardiac damage on another test

Question 7

How can cardiac arrest be detected ?

Answer 7

Simple blood test can recognise troponin for MI and can be detected in the blood stream roughly an hour after acute coronary syndrome has occured.

Question 8

What may be included in the history of acute coronary syndrome?

Answer 8

• Patient often denys it is a pain and more a weight on the chest or discomfort/tightness in the chest
• It may radiate to neck/arm
• May be associated nausea, sweating and breathlessness.

Question 9

What are cardiac risk factors?

Answer 9

• Male
• High blood pressure
• Age
• Diabetes
• Smoking
• Family history of premature heart disease
• High cholesterol.
• Known coronary disease

Question 10

What is seen on examination of coronary acute coronary syndrome?

Answer 10

• Some may look really unwell if having a “full blown” heart attack
• Others may look fine
• Often there is nothing specific to look for on examination
• Important to ensure to check for:
• Heart rate

   - Blood pressure 
  
    - Listen for murmurs 
  
   - Listen for crackles in chest

Question 11

What are the key investigations carried out for acute coronary syndrome?

Answer 11

ECG and blood tests for biomarker release.
In ECG look for ischemia (infarction)

Question 12

What is STMI - ST elevation myocardial infarction ?

Answer 12

• This is a “full blown” heart attack.
• It is likey they will have a completely blocked coronary artery
• There will be ongoing myocardial cell death as there is no blood getting down the artery
• The longer it is left the more muscle will get damaged. You need to open the artery asap.

Question 13

What is the treatment of STEMI?

Answer 13

immediatiate reprefusion (re-establishing blood flow down the artery) therapy

Question 14

How is immediate reprefusion therapy given?

Answer 14

• Can be given mechanically
• Can be given pharmacologically

Question 15

What is the pharmalogical treatment ?

Answer 15

Thrombolysis - A very strong blood clot dissolving medication, it can be given anywhere and the individual will be arranged a prompt transfer to the cardiac centre with a cath lab incase of any complications.

Question 16

What are the risks of thrombolysis?

Answer 16

• There may be bleeding
• Dont give if someone has recently had a stroke or every had previous intracranial bleed.
• Stay cautious if they have had a recent surgery.

Question 17

What is the management of non ST elevation ACS/non stemi ?

Answer 17

• Admit to hospital
• Attach to cardiac monitor
• Gain IV access
• Give oxygen if levels are low

Question 18

What are the investigations of non ST elevation ACS?

Answer 18

• Serial ECG - You can repeat ECG if you are unsure if there is any changes, think about posterior leads as you do not want to miss an evolving STEMI or a posterior STEMI
• Blood test - Check troponin (biomarker)

Question 19

How is the non ST elevated ACS treated?

Answer 19

• GTN (glycerol trinitrate) - If patients have chest pain. Vasodilator spray and it opens up the arteries. Can also be given intravaneuosly if ongoing chest pain but won’t help if the artery is blocked but will help if there is a tight narrowing.
• Aspirin can be given as a blood thinner.

Question 20

What are the risks of coronary angiography and percutaneous coronary intervention?

Answer 20

• A dye is used which can affect the kidney function. Don’t use this if someone has a bad kidney.
• Stroke
• Bleeding from arterial access site.

Question 21

What are the post-MI complications?

Answer 21

• Mechanical complications - Something physical happening to the heart muscle result in the patients being really unwell or death. LISTEN FOR MURMUR
• Arrhythmic - rythm problems