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Flashcards in CBD 2: Chest pain Deck (14)
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Ischaemic heart disease: risk factors
a) FHx - cutoff
b) others

a) MI in 1st degree relative < 55 years

b) HTN, obesity, high cholesterol, diabetes, ethnicity, smoking, alcohol, stress, cocaine


ACS: differentials

Cardiac - angina, pericarditis, aortic dissection
Resp - PE, pneumothorax
GI - GORD, oesophageal spasm
MSK - costochondritis, trauma
Psych - non-cardiac chest pain


Chest pain on exertion (angina): pathophysiology

Coronary occlusion, on exertion oxygen demand increases and coronary insufficiency leads to hypoxia


a) Which one at NGH?
b) Measured when?
c) vs. CK

a) high-sensitivity Troponin T assay

b) 6h after onset of pain

c) More cardio-specific


Diagnosis of ACS: need two out of what three things?

- Symptoms consistent with ACS
- ECG changes
- Raised cardiac enzymes


ACS: investigations
a) 2 initial
b) Gold standard
c) Other

a) ECG, Troponins

b) CT angiography or invasive angiogram

c) Stress ECG, cardiac MRI, D-dimer


ACS: management
a) Initial

a) - Nitrates - GTN
- Morphine (+ metoclopramide) if still in pain
- Aspirin loading dose 300 mg
- Oxygen if SpO2 < 94%
- ECG - if ST elevation - transfer for pPCI


ECG changes of MI
a) ST elevation
b) ST depression

- anteroseptal (V1-V4),
- lateral (V5, V6, aVL, I),
- right (avR)
- inferior (II, III, avF)

b) Depression in anterior leads? - do posterior ECG to rule out posterior STEMI


PCI time window in STEMI:
a) Must be within ___ hours of onset of symptoms
b) Should be within ___ hours of when fibrinolysis could have been given
c) Target 'door to balloon' window

a) 12 hours

b) 2 hours

c) 90 mins


Indications for PCI

- Acute STEMI
- Acute NSTEMI/Unstable angina (if medium-high risk of subsequent cardiac events)
- Stable angina (if resistant to medical therapy)
- Left main artery disease (responds well to PCI, even if asymptomatic)


Contraindications to PCI

- Lack of cardiac surgical support
- Critical left main coronary stenosis without collateral flow from a native vessel or previous bypass graft to the left anterior descending artery
- Coagulopathy/ Hypercoagulable states
- Diffusely diseased vessels without focal stenoses
- Total occlusion / stenosis < 50%


PCI: adjuvant treatment
a) If cannot be offered PCI within 90 mins symptoms onset, also need to give...?
b) During/after PCI


b) - Dual antiplatelet therapy (aspirin/clopidogrel) for 1 month (basic metal stent) or 1 year (drug-eluting stent).
- Then stop clopidogrel and continue aspirin for life.
- Also - BB, ACE and statin


Alternative to PCI
a) Main one - 3 drugs that may be used. How they work. Time window?
b) If outside 12 hour window?

a) Thrombolysis - streptokinase, alteplase, reteplase.
tPA - activate plasminogen to produce plasmin and break down clots. Also need to be given within 12 hours symptom onset

b) Aspirin, clopidogrel and an antithrombin agent (heparin, enoxaparin or fondaparinux)


PCI: risks

Stent thrombosis