Angina and acute coronary syndrome Flashcards
(35 cards)
Acute coronary syndrome
- Definition and categories
- Signs and symptoms
Set of signs and symptoms due to cardiac ischaemia.
Categories
- STEMI
- NSTE-ACS= NSTEMI, unstable angina
Signs and symptoms
- Chest pain (crushing, heavy)
- Radiation of pain: arms, jaw, abdomen, back.
- Sweaty and clammy
- SOB
- Atypical: nausea, acid reflux type pain
Risk factors for ACS
Smoking
Dyslipidemia
Hypertension
Diabetes
STEMI
- Definition
- Diagnosis
ACS characterised by ST elevation on an ECG.
Blood tests show elevated troponin.
> 1 mm in contiguous limb leads
2mm in precordial leads
Non STE ACS
Includes NSTEMI and unstable angina
NSTEMI
- No ST elevation on ECG
- May show T wave inversion or ST depression
- Will show troponin elevated
Unstable angina
- ACS symptoms occur at rest, lasts for more than 20 mins.
- No ECG changes or significantly raised troponin
Differentials for ACS
GI
- GORD
- Oesophageal rupture
Lung
- Pneumonia
- Pneumothorax
- Asthma attack
Cardiac
- aortic dissection
- Pericarditis/ pericardial effusion
Musculoskeletal
- Costochondritis
- Rib fracture
Differentiating MI from GORD
GORD
- Lasts longer
- Worse when laying down
- Relived by antacids/ PPIs
- Triggered by eating
Unstable angina management
Antiplatelet
- Prevention of build plaque
- Aspirin + clopidogrel/ ticagrelor
- Or Clopidogrel/ ticgrelor if aspirin not tolerated
Statin
- Atrovastatin/ Rosuvatatin
Beta blocker/ ACEi
- Propanolol/ metoprolol/ atenolol/ bisoprolol/ labetalol
- Perindopril/ ramipril
MI treatment
Acutely
- Morphine sulphate
- Oxygen >94%
- GTN
- Antiplatelet (aspirin, ticgrelolr, prasugrel, clopidogrel)
Subendocardial infarct
Limited to inner third or half of ventricular wall
- Gives rise to NSTEMI/ Unstable angina
- Due to generalises reduced perfusion of coronary arteries
Troponin assays
- Advantages
- Disadvantages
Adv
- Detects recent MI (within 3 hours if high sensitivity)
-
Disadv
- Specificity
- Other causes: strokes, hyperthyroid, renal disease, Subarachanoid bleed, sepsis, blood cancer, PE
GRACE risk score
Score to get risk of mortality in hospital or 6 months post discharge
> 3%= significant risk.
Posterior MI ECG changes
Inverted findings for ST elevation as electrical activity is recorded anteirorly
ST depression in V1-3
- ST elevation is deflected
Tall R wave in V1-3
- Sign of deep Q wave
Uptight t wave
- T wave inversion
Other causes of STE
Acute pericarditis
- Saddle shaped
Myocarditis
Massive PE (esp V1-2)
- Also T wave inversion
Brugada
- Inherited Na+ channel pathology
- Coved STE
Hyperkalaemia/ Calcaemia
Hypothermia
LVH ECG changes
Atypical chest pain
ST depression
T wav inversion
- In anterolateral leads
Treatment of MI
- STEMI and NSTEMI/ unstable angina
- Antiplatelet
- 300mg aspirin, then 75 mg maintenance +
- 600mg clopidogrel, 75 mg maintenance - Anticoagulant
- fondaparinux (if not undergoing PCI) - Anti-ischaemia
- Beta-blockers
- ACEi
- Nitrates
- Statins (atorvastatin)
- Eplenerone if LVEF <40%
STEMI= PCI, thrombolysis
Management of stable angina
First line
- Beta blocker/ CCB
Shorting acting nitrate
- GTN for symptomatic relief
GTN
- For before and during episodes of angina
- Can repeat after 5 mins if pain persists
- Call ambulance if 2nd dose does not work
Management of stable angina
Shorting acting nitrate
- Glyceryl trinitrate
For before and during episodes of angina
- Can repeat after 5 mins if pain persists
- Call ambulance if 2nd dose does not work
Secondary prevention options for people with stable angina
75mg aspirin OD
ACEi
- If diabetic
- If hypertensive
Start statins (atorvastatin) based on background
Assessments required before starting statins
Bloods
- Lipid profile: total cholesterol, non‑HDL cholesterol, HDL cholesterol and triglycerides
- HbA1c
- LFT = transaminase level (alanine aminotransferase or aspartate aminotransferase)
- renal function and eGFR
- thyroid‑stimulating hormone.
Smoking status
Alcohol consumption
BP
BMI )
Statin therapy is indicated for _______ and involves [insert drug name and dose]
Indicated for Qrisk2 score of 10% risk of CVD within 10 years (primary intervention)
- 20mg atorvastatin
________mg of [statin] is indicated as secondary prevention post-MI
80mg atorvastatin
Second-line treatment for stable angina (if beta-blocker/ CCB not tolerated)
Long acting nitrate (isosorbide mononitrate)
Ivabradine
Nicorandil
Coronary angiogram is indicated in stable angina when…
Symptoms are not controlled with optimal medical therapy
Indications and types of revascularisation in STEMI
When coronary angiogram shows significant stenosis
1. PCI
2. CABG
