Acute Coronary syndromes presentation + management

Question 1

What is an acute coronary syndrome

Answer 1

Symptoms relating to problem with coronary arteries
ACS causses myocardial ischaemia

Question 2

What is the differernce between stable angina and ACS

Answer 2

Stable angina:
Cased by stable coronary lesion
Predictable symptoms
Symptoms relieved by rest
ACS:
Unstable coonary lesion
Unpredicactale
May occur at rest
Includes MI & unstable angina

Question 3

What does the history involve in someone with ACS

Answer 3

Ischaemic sounding chest pain
May radiate to neck/arm
Deny pain- call it discomfort
Nausea, sweating, breathlessness

Question 4

What can an examination of someone with ACS look like

Answer 4

May look unwell if have STEMI
Or look fine
Ensure to check:
HR, BP
Listen for murmers, crackles in chest

Question 5

What does complete coronary occlusion look like on the ECG

Answer 5

Initial ECG- ST elevation
ECG at 3 days- Q waves

Question 6

WHat does partial coronary occlusion look like on ECG

Answer 6

Initial ECG:
ST depression
T wave inversion
or Normal
ECG at 3 days:
No Q waves

Question 7

How can anterolateral ST elevation form

Answer 7

Acute MI due to blocked LAD

Question 8

What can an Inferior ST elevation be due to

Answer 8

Acute MI due to blocked RCA

Question 9

What will be seen in the ECG in posterior MI

Answer 9

Blocked LCx
Opposite changes in leads V1-V2

Question 10

Summary of how to spot difference between Stable angina and ACS

Answer 10

Question 11

WHat therapy can open blocked artery

Answer 11

Reperfusion therapy
Mechanical- Using Primary PCI
Pharmacological- strong blood thinner

Question 12

What treatment can be given if not next to an ambulance

Answer 12

Thrombolysis
Strong blood thinning medication

Question 13

What are the risks of thrombolysis

Answer 13

Bleeding
Dont give if had recent stroke
Or if had surgery and on warfarin

Question 14

What is the better option Cath lab or Thrombolysis to treat STEMI

Answer 14

Thrombolysis only works if given early
Cath lab generally better unless too far away

Question 15

What are the mangement options for ACS

Answer 15

Admit to hospital
ECG
Attach to a cardiac monitor
Gain iv access
Give O2 only if levels low

Question 16

What are the investigations for ACS

Answer 16

Serial ECGs
Repeat ECG if not sure if there are any changes
Think about doing posterior leads
Don’t want to miss an evolving STEMI or a posterior STEMI

Blood tests
Check troponin
Now can do immediate “Point of Care” test
Also check Hb, kidney function, cholesterol

Question 17

What are the treatment options for ACS

Answer 17

Glycerol trinitrate (GTN)
Vasodilator - opens up coronary arteries
Can give sub-lingual, or as intravenous infusion
Won’t help if the artery is completely blocked

Opiates (eg morphine)
Helps relieve anxiety too
Also helps venodilate which may have haemodynamic benefits

Question 18

What anti-thrombotics drugs can be used

Answer 18

Dual anti-platelet therapy- Aspirin
+
Either Clopidogrol, Ticagrelor, prasugrel

Anti-coagulent drugs
Heparin, LMWH, Fondaparinux

Question 19

What other drugs are used

Answer 19

Beta blockers
Statins
Ace Inhibitors

Question 20

Should patients with NSTEMI have coronary angiograms

Answer 20

Yes ideall within 48 hrs

Question 21

What are the risks of coronary angiography and PCI

Answer 21

Bleeding from arterial access site
Myocardial infarction
Coronary perforation
Emergency CABG
Stroke
Dye can affect kidney function (“contrast nephropathy”)

Question 22

What are the mechanical complications that can occur

Answer 22

Myocardial rupture
Acute Septal Ventricular Defect
Mitral valve dysfunction due to papillary muscle rupture

Listen for Development of loud new murmer

Question 23

What is the course in hospital after an MI

Answer 23

Used to be confined to bed for weeks following an MI
Now usually home within 2-3 days if uncomplicated

Ensure seen by cardiac rehabilitation nurses
Advise about lifestyle measure including smoking, driving, going back to work

Arrange follow-up as necessary

Question 24

What does ACS management in hospital involve

Answer 24

Keep attached to cardiac monitor for first 24-48 hours
Listen for new murmurs and signs of heart failure every day
Start “secondary prevention” medications
Organise an echocardiogram (ultrasound heart scan)

Question 25

What is the treatment for Acute NSTEMI

Answer 25

B – Beta-blockers unless contraindicated

A – Aspirin 300mg stat dose

T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk)

M – Morphine titrated to control pain

A – Anticoagulant: Fondaparinux (unless high bleeding risk)

N – Nitrates (e.g. GTN) to relieve coronary artery spasm

Give oxygen only if their oxygen saturations are dropping (i.e. <95%).

Question 26

What is the treatment for an Acute STEMI

Answer 26

Primary PCI
Thrombolysis

Question 27

What is the secondary prevention medical management

Answer 27

Aspirin 75mg once daily
Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily)
Atenolol (or other beta blocker titrated as high as tolerated)
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)