Acute Coronary Syndromes + Aortic Dissection Flashcards by Callum Donoher

What is an acute coronary syndrome?

The rupture of an atherosclerotic plaque leads to the formation of a thrombus occluding one or more coronary arteries

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What are the 3 types of acute coronary syndrome?

Unstable angina
NSTEMI (Non ST elevation myocardial infarction)
STEMI (ST elevation Myocardial Infarction)

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What part of the heart does the right coronary artery supply?

Right atrium
SAN + AVN
Right ventricle
Inferior wall of heart (left ventricle)
Posterior septum

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What 2 arteries does the left coronary artery become?

Circumflex artery
Left anterior descending (LAD)

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What part of the Heart does the circumflex artery supply?

Left atrium
Posterior aspect of left ventricle

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What part of the heart does the left anterior descending artery supply?

Anterior aspect of the left ventricles
Anterior aspect of septum

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How does a pateint with an acute coronary syndrome typically present?

Central crushing/pressing chest pain
Pain radiates to jaw or arms
N+V
Sweating and clammy
Impending doom
Shortness of breath (pain not causes by breathing in or out)
Palpitations
Symptoms at rest (15mins or longer)

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Does a non elevated troponin rule out an acute coronary syndrome?

Justly means the ruptured plaque has not yet caused myocardial ischaemia

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What are some ECG changes that can be seen with a STEMI?

ST segment elevation
NEW LEFT BUDNLE BRANCH BLOCK.

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What ECG changes can an NSTEMI have?

ST Segment depression
T wave inversion

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What is the significance of pathological Q waves on an ECG?

Indicates full thickness/transmural infarction of the myocardium (normally shows up 6+ hrs after symptom onset)

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What ECG leads would show changes if there is an acute coronary syndrome in the right coronary artery?

Inferior wall

II, III and aVF

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What ECG leads would show changes if there is an acute coronary syndrome in the circumflex artery?

Lateral wall
I, aVL, V5 and V6

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What ECG leads would show changes if there is an acute coronary syndrome in the Left anterior descending artery?

Anterior wall
V1, V2, V3 and V4

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What other than myocardial ischaemia can cause an elevated troponin?

CKD
Sepsis
Myocarditis
Aortic. Dissection
Pulmonary embolism

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What investigations would you do if you suspect an acute coronary syndrome?

CXR
Echocardiogram
ECG

U+E
LFT
Lipids
Glucose

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What is needed to diagnose an NSTEMI?

Raised troponin with either:
-normal. ECG
-ECG changes like ST depression or T wave inversion

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How is unstable angina diagnosed?

Troponin can be normal
ECG changes like ST depression or T wave inversion

Normally done with symptoms

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What is the immediate medical treatment for a patient suffering a STEMI?

Aspirin 300mg (75mg day after for life)
Prasugrel 60mg loading (10mg daily for 12 months) or Clopidogrel 600mg loading (75mg for 12months) or Ticagrelor 180mg (90mg BD day after)
GTN
IV morphine or Diamorphine + Metoclopramide (antiemetic)
Oxygen

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What is the benefit of giving GTN and morphine to a patient suffering a STEMI?

They are both venodilators
Systemic vasodilation leads to the heart having a reduced workload so reducing its oxygen demand

If pain improves immediately shows its an ACS cause

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What is the benefit of giving oxygen to a patient suffering a STEMI despite having good oxygen sats?

Ensures working part of the heart is as well saturated as possible
Ensures if artery has some patency the blood going to the effected area is as oxygenated as possible

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What is the gold standard intervention for treating a STEMI?

Percutaneous Coronary Intervention (PCI)

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When should PCI be carried out to treat a STEMI from time of presentation?

Symptoms in last 12hrs and
PCI within 2hrs of symptoms/presentation

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What intervention should be carried out if PCI cannot be carried out within 2hrs of presentation/medical contact for the STEMI?

Thrombolysis

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What type of medication is used for thrombolysis in a patient with a STEMI? What medication is used? What other medication should be given along side it?

Tissue Plasminogen Activator Alteplase Antithrombin medication like fondaparinux

What are the contraindications to PCI?

WHEN CORONARY VESSEL OCCLUDED FOR MORE THAN 48HRS Active bleeding or bleeding disorders Moderate or worse dementia (non co-operative patient) Patient refusal Severe renal impairment (nephrotoxic contrast)

What is the favoured treatment for treating a STEMI?

PCI

Why is PCI for a coronary vessel occluded for more than 48hrs contraindicated?

Reperfusion injury will cause significantly more damage to the left ventricle

What is the immediate medical treatment for unstable angina or an NSTEMI?

Aspirin 300mg (75mg for 12months) 2nd antiplatelet Ticagrelor 180mg (90mg BD for 12months) Give Ticagrelor only if GRACE score > 3% Enoxaparin 4 doses Then immediately to the catch lab for PCI

When is Ticagrelor picked over clopidogrel when treating for an NSTEMI/unstable angina?

Patient is diabetic Heading to PCI Not a high bleed risk / younger

When is Clopidogrel given over Ticagrelor for managing an NSTEMI/unstable angina?

When patient has higher bleeding risk : -elderly -GI bleeds -previous haemorrhagic strokes -active bleeding -coagulopaties Hepatic impairment

What dosage of Enoxaparin (LMWH) should be given for the management of an NSTEMI or unstable angina?

Patients mass in kg but that in mg BD E.g: patient is 70kg they will need 70mg Enoxaparin BD for 2 days 4 doses of enoxaparin over 2days

What medications are given for secondary prevention of Acute Coronary Syndromes?

Aspirin 75mg Ticagrelor (90mg BD), clopidogrel (75mg) or Prasugrel for 1 year (depends on which one they were originally on) Atorvastatin 80mg for 1 year then reduce according to their cholesterol levels Bisoprolol Ramipril or Losartan

What are the classes of medications you give for secondary prevention of Acute Coronary Syndrome?

2 antiplatelets (Aspirin + clopidogrel, Ticagrelor or prasugrel) Anti-cholesterol B-blocker ACEi or ARB

What dose of bisoprolol is given as secondary prevention for Acute Coronary Syndromes?

1.25 - 10mg

What dose of Ramipril is given as secondary prevention for Acute Coronary Syndromes?

1.25 - 10mg

When is losartan given instead of ramipril in the secondary prevention of Acute Coronary Syndromes?

Ramipril causes the dry cough

What dose of losartan is given as secondary prevention for Acute Coronary Syndromes?

25mg - 100mg.

When is the 2nd antiplatelet clopidogrel, Ticagrelor or prasugrel discontinued following an acute coronary syndrome?

Continued for a year as secondary prevention then stopped

What other medication can be given as a form of secondary prevention for acute coronary syndrome when the patient has clinical heart failure?

Aldosterone receptor antagonists like Spironolactone

What needs to be carefully monitored in patients taking both ACEi (ramipril) and Aldosterone receptor antagonists (Spironolactone or eplerenone)?

Potassium levels Risk of HYPERKALAEMIA

What seconadary prevention for ACS would you give to a patient whose Ejection fraction is 30% or less?

Normal medications + Dapagliflozin Spironolactone Entestro = Sacubitril/valsartan (STOP RAMIPRIL or Losartan)

What are some risk factors for developing an Acute Coronary Syndrome?

HTN T2DM High cholesterol Smoke 1st degree relative died of vascular disease

What are the complications of an acute coronary syndrome?

Death Ruptured heart septum or papillary muscles Oedema/heart failure Arrhythmias Aneurysm Dresslers syndrome

What is Dressler’s syndrome?

Localised immune response leading to inflammation of the pericardium leading to pericarditis This happens 2-3weeks following an ACS

How does Dressler’s syndrome present?

Pleuritic chest pain Low grade fever Pericardial rub Pericardial effusion Pericardial tamponade

What is an aortic dissection?

The division between 2 layers of the aorta creating a false lumen

What 2 layers does blood accumulate between in an aortic dissection? What layer needs to tear for this to happen?

Between tunica intima and tunica media Tear in tunica intima

Which part of the aorta does dissection most commonly occur in?

Thoracic aorta Abdominal aorta has an aneurysmal tendency

What are the risk factors for developing an aortic dissection?

HTN = main Marfans syndrome Ehlers Danlos syndrome Aortopathy FHx

How does HTN affect the pathophysiology of an aortic dissection/ which part is more commonly affected?

Will normally affect the right side/outer edge of the aortic arch / the more superior edge on the arch then as the aorta descends will more commonly affect the left side of the descending aorta This is since this is where the blood pressure within the vessel is highest (imagine flow of river around a corner)

What is a Type A Aortic dissection?

Dissection starts anywhere from aortic arch to the Left Subclavian artery

What is the emergency treatment for a Type A aortic dissection?

Emergency surgical repair

What are some complications that can occur due to Type A aortic dissections?

Acute Aortic Regurgitation-> acute pulmonary oedema Inferior STEMI Cardiac tamponade Ischaemic strokes

What are the 2 types of Ischaemic strokes that can occur as a result of a Type A aortic dissection?

Posterior circulation stroke/vertebrobasilar Anterior circulation stroke

Why can a Type A aortic dissection cause a Posterior Circulation/vertebrobasilar stroke?

Can occlude the right subclavian artery which gives of the right vertebral arteries

What changes might be seen in a vertebrobasilar stroke due to a Type A aortic dissection?

Brainstem, cerebellum and occipital lobes may be affected Dizziness Ataxia Visual disturbances Dysphagia Brainstem/cranial nerve deficits

Why can a Type A aortic dissection cause an anterior circulation stroke?

Right common carotid artery can be occluded which gives of the internal carotid artery which supplies into the anterior circulation via the anterior cerebral artery and middle cerebral artery

What is a type B aortic dissection?

Dissection that occurs after the left subclavian artery

What must you examine and why if you think a patient has a Type B aortic dissection?

Neurovascular examination of the lower limbs Anterior spinal arteries next arteries to arise after the left subclavian artery

How do patients with type B aortic dissection often present? Why?

Very high BP Poor. Renal. Perfusion

Which kidneys typically has poor perfusion in Type B aortic dissection?

Left kidney

What is the medical management of a Type B aortic dissection?

Reduce BP to 120/80 GTN infusion (nitropruside) Labetalol

What emergency intervention must you do if you have a Type B aortic dissection with lower limb muscle weakness? Why?

Lumbar puncture to drain the CSF to reduce the pressure on the anterior spinal arteries

What other conditions do you give GTN infusion (Nitropruside) and labetalol to reduce blood pressure?

Type B aortic dissection Malignant HTN Pre-eclampsia

How do you decide between giving a patient clopidogrel or prasugrel if they are having a STEMI?

Clopidogrel to those already taking an oral anticoagulant Prasugrel to those who are NOT taking an oral anticoagulant

What is the management for angina pectoris (not an ACS)?

Sublingual GTN + Bisoprolol (B-blocker) or Verapamil/diltiazem (CCB) + Aspirin 75mg (antiplatelet therapy)

What medication should be added on if maximum beta blocker therapy is not controlling angina pectoris?

Amlodipine (not verapamil or diltiazem as risk complete heart block)

When is GTN contraindicated in treating an ACS?

Patient is hypotensive Severe aortic stenosis

What i the preferred anti-platelet given with aspirin for managing STEMI that is going to go for PCI?

Prasugrel 60mg loading (10mg daily for 12months)

What are the criteria for using Prasugrel as the first line antiplatelet when managing a STEMI?

For PCI Under 75 Not had prior stroke or TIA More than 60kg

What other antiplatelet is given to manage a STEMI if Prasugrel isn’t suitable? What dose is given? Then what is the maintenance dosing?

Clopidogrel 600mg loading dose then 75mg for 12 months

When do you give a second anti-platelet when managing an NSTEMI/unstable angina? What antiplatelet is it? What is the dosing?

When the GRACE score is >3% Ticagrelor 180mg loading (90mg BD for 12months)

What is the scoring system used for NSTEMI and unstable angina that is used to determine the risk and whether PCI/coronary angiography is needed?

GRACE score

What GRACE score indicates that PCI is required within 72hours?

Over 3%

Acute Coronary Syndromes + Aortic Dissection Flashcards

(75 cards)