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Year 3 Med 1 > Acute coronary syndromes > Flashcards

Acute coronary syndromes Flashcards

1
Q

What is an acute coronary syndrome?
Which conditions are included?

A

A range of conditions associated with a sudden, reduced blood flow to the heart.

The conditions included are:

  1. Unstable angina
  2. nSTEMI
  3. STEMI
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2
Q

Definition of unstable angina

A

o An unprovoked or prolonged episode of chest pain- raising suspicion of acute myocardial infarction
o Without definite ECG or lab evidence

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3
Q

Definition of nstemi

A

o Chest pain suggestive of AMI
o Non-specific ECG changes (ST depression/ T inversion/ normal)
o Lab tests showing release of troponins
o Not necessarily caused by stenosis/ occlusion (e.g., sepsis, hypotension)

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4
Q

Definition of STEMI

A

o Sustained chest pain suggestive of AMI
o Acute ST elevation or new LBBB

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5
Q

Pathophysiology- atherosclerosis

A
  1. Epithelial injury
  2. Migration of monocytes/ macrophages
  3. LDL lipids consumed  transition to foam cells
  4. Release of growth factors  smooth muscle changes from contractile phenotype to secretory phenotype, collagen deposition
  5. Atheromatous plaque forms within intima
  6. Plague ruptures and prothrombotic factors are released (plaque and stenosis grows or emboli forms)
    Risk factors
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6
Q

Modifiable risk factors of acute coronary syndrome

A

Smoking
Obesity
Diet
Lack of exercise
High serum cholesterol
Hypertension
Diabetes
Postcode

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7
Q

Non- modifiable risk factors of acute coronary syndrome

A

Increasing age
Gender (male)
Ethnicity
Family history
Diabetes
Pre-eclampsia

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8
Q

Cardiac differentials for ACS

A

o MI
o Angina
o Pericarditis
o Aortic dissection

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9
Q

Respiratory differentials for ACS

A

o PE
o Pneumothorax
o Pneumonia

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10
Q

GI differentials for ACS

A

o Oesophageal spasm
o GORD
o Pancreatitis

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11
Q

MSK differentials for ACS

A

o Osteochondrosis
o Trauma

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12
Q

Clinical features (SOCRATES)

A

o Site- central/ left sided
o Onset- often sudden
o Character- crushing
o Radiation- left arm, neck and jaw
o Associated symptoms- nausea, sweating, clamminess, SOB, vomiting, syncope, confusion
o Timing- constant
o Exacerbating symptoms/ relieving factors- worsened by exertion, relieved by GTN spray
o Severity- often very severe

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13
Q

Distinguishing features between stable and unstable angina

A
  • Stable angina- cardiac chest pain + abnormal/ normal ECG + normal troponin precipitated by stress or exertion+ <20 mins + relieved by GTN
  • Unstable angina- cardiac chest pain + abnormal/ normal ECG + normal troponin + occurs at rest + >20 mins + poor GTN relief
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14
Q

Distinguishing between NSTEMI and STEMI

A

NSTEMI- cardiac chest pain + abnormal/ normal ECG (but not ST elevation) + raised troponin
SETMI- cardiac chest pain + persistent ST-elevation/ new LBBB (no need for raised troponin)

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15
Q

Diagnosis criteria for NSTEMI

A

2 of the following:
• Cardiac chest pain
• Newly abnormal ECG which is NOT ST-elevation
• Raised troponin

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16
Q

Diagnosis criteria for STEMI

A

ST elevation >2mm in ADJACENT chest leads
ST elevation >1mm in adjacent limb leads
New LBBB with chest pain or suspicious MI

17
Q

Investigations for suspected MI

A
  • ECG- looking for ST elevation, LBBB or T wave inversion (most important investigation)
  • Bloods- FBC and CRP to rule out infective causes of chest pain
  • Troponin- done at least 3 hours after pain starts
  • Renal function
  • Blood glucose
  • Lipid profile
  • D-dimer may be appropriate to rule out PE
  • CXR- look for pulmonary causes of angina
18
Q

Results of troponin and ECG for unstable angina

A

Normal troponin
ECG normal
possible ST depression

19
Q

Results of troponin and ECG for NSTEMI

A

raised troponin
ST depression
can be normal ECG
possible T wave inversion

20
Q

Results of troponin and ECG for STEMI

A

raised troponin
ST elevation
hyperacute T waves
new LBBB
T inversion (hrs)
Q waves (days)

21
Q

Draw and label a normal ECG

A
22
Q

draw the ECG of a STEMI

A
23
Q

draw an ST depression

A
24
Q

draw t wave inversion

A
25
Q

What is the progression of the ECG of a STEMI?

A
26
Q

localization of an infarct

which part of the heart would an MI in lead 1 present in? which artery supplies here?

which part of the heart would an MI in lead 2 present in? which artery supplies here?

3

aVR

aVL

aVF

V1

V2

V2

V4

V5

V6

A
27
Q

From which leads would you get an inferior view of the heart? associated artery supplies inferior aspect?

lateral

anterior

posterior

A
28
Q

relevance of troponin to MIs

A

A myocardial protein released inot the bloodstream when cardiac myocytes are damaged. Serum levels raise 3 hours after Mis begin. Troponin can also be raised due to other conditions (pericarditis, arrhythmias, defibrillation, PE, CKD, sepsis)

29
Q

Common ACS management

A

MONAC

Morphine- 5/10mg slow injection

Oxygen

Nitrates- GTN spray (1 spray or tablet)

Aspirin- (loading dose 300mg chewed)

Clopidogrel-

+ an anti-emetic (e.g., metoclopramide)

30
Q

Unstable angina and NSETMI management (OSTABLN)

all patients should be referred for what kind of imaging

all patients sould b e referred to

consider what kind of treatment within 72 hrs

A
  • Oxygen
  • Statin- Atorvastatin
  • Ticagrelor 180mg loading dose
  • Aspirin + Fondaparinux
  • ACEi- Ramipril
  • Beta blocker- bisoprolol
  • LMWH i.e. fondaparinux 2mg OD
  • Nitrates- IV infusion if severe pain with hypertension

All patients should get an ECHO performed to assess systolic function

All patients should be referred to cardiac rehab

consiuder PCI/ coronary angiography

31
Q

name 2 scoring systems for ACS

A

grace scoring and TIMI

32
Q

what is the grace scoring

A

Predicts 6/12 mortality in NSTEMI patients

  • Age
  • HR and systolic BP
  • Killip class (CCF, pulmonary oedema, shock)
  • Cardiac arrest on admission
  • Elevated cardiac markers
  • ST segment change
33
Q

what is the TIMI scoring system

A

Risk of cardiac events in the next 30 days

  • Age >65
  • Known coronary heart disease
  • Aspirin in last 7/7
  • Severe angina (>2 in 24 hours)
  • ST deviation >1mm
  • Elevated troponins
  • > CAD risk factors
34
Q

STEMI treatment- PTA-B

A

time is muscle

MONAC short term

  • Percutaneous coronary intervention
    • “Diagnosis to balloon time” of 120 minutes
    • Ballion and stent
    • Treat as ACS
    • Possible PCI after failed thrombolysis
  • Thrombolysis
    • Streptokinase/ Alteplase
  • ACEi
    • E.g., ramipril
  • Beta Blocker
    • E.g., bisprolol
35
Q

Longer-term management OF acs

A

Longer-term management

  • Continuous ECG monitoring as an inpatient/ ICU
  • Aspirin
  • Ticagrelor (NOAC???)
  • Beta blocker
  • ACEi
  • Statin
  • Modification of risk factors
  • Driving??
36
Q

Complications of ACS

long term short term

A
  • Early
    • Death
    • Cardiogenic shock
    • Heart failure
    • Ventricular arrhythmia
    • Thromboembolism
    • 2nd or 3rd degree heart block
  • Late
    • Wall rupture
    • Valvular regurg
    • Cardiac tamponade
    • Dressler’s syndrome- post infarct pericarditis presenting with fever and pleuritic chest pain 2-3 weeks after MI
37
Q

typical history of someone with ACS

A

Year 3 Med 1 (10 decks)

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