Characterised by angina pectoris
1
2
1 vasopsastic disease
Transient vasoconstriction of coronary artery
(Transient ischaemia, attack occurs at rest, attack occurs in clusters)
2 atherosclerotic disease
Coronary artery narrows due to plaque
(Stable/unstable angina or myocardial infarction)
Acute coronary syndrome
Unstable angina
Myocardial infarction
Stable angina if
No pain at rest
Pain due o physical exercise
Unstable angina if
Present at rest Frequent Lasts longer Occurs with less extertion Prolonged ischemia
Can lead to MI I’d not managed
First 10 mins do what
ABC
Physical exam
Cardiac + 02 sats
325mg aspirin
Oxygen dats need what st each %
Lesss than 90% =supplemented oxygen
Less than 80%= supplemented 02+ assisted ventilation
Cardiac markers of myocardial damage
Tropomin T and I
Essential for diagnosis of MI
Troponin found where
In cardiomyocytes
Released into blood when damaged
Take 6 hours to be released
Negative troponins
Unstable angina
Non cardiac chest pain
Short attack of prinzmetal angina
Positive troponins
Cardiomyocyte death
MI
Questions to ask
OPQRST
ONSET PROVOCATION PALLIATION QUALITY RADIATION SITE TIME COURSE
Symptoms usually
Dyspnea palpitations
Nausea
Sweating
Who’s prone to it
Women
Older adults (atypical presentation)
Diabetes
Myocardial ischemia
Unstable angina
MI
prinzemetal angina
Treatment for myocardial ischemia
Nitrates
3 sublingual doses
0.4 mg
IV if doesn’t work
Nitrates contraindicated when
Hypotension
MI of RV
PDE-S inhibitors (sildenafil)
Can cause hypotension
Myocardial ischemia symptoms
Chest pain
Tachycardia
Hypertensive
Beta blockers given to decrease cardiac demand
Beta blockers contraindicated in
Prinzemetal angina = worsen vasoconstriction
Bradycardia
Cardiogenic shock
Acute decompressed heart failure
Cocaine related acute coronary syndrome
Patients with underlying heart failure treatment
IV loop diuretic (furosemide)
Sever + persistent chest pain treatment
IV morphine sulfate
2-4 mg every 5-10 mins
ECG on who and when
Everyone and repeat it every 5-10 mins I’d suspicion if myocardial ischemia
St on ecg?
Healthy = normal/upwards concavity
Stable angina = normal
Unstable = normal/ depressed
MI on ECG appearance
NSTEMI- non-st segment elevation myocardial
ST can be normal.ST depression can be present
Deep T wave inversions over 1mm
STEMI- ST elevation
Over 1 mm in 2 or more contiguous leads or new left bundle branch block
Occurs with full thickness involvement of myocardium
ST depression in V1/V2 means
Could be mirrored ST elevation in v7 8 and 9 which doesn’t show up on the ECG
This could be a posterior STEMI and need ps to be treated like one and not an NSTEMI
Prinzemetal angina
St elevation ?
Normal/ depressed in short attack
ST elevation in long attacks
ECG changes only seen during attack so must be on ECG 24 hours
No signs of ischemia after prinzemetal angina then you do
Further testing (stress test) Induce exercise or drugs stimulation (dobutamine) Compare coronary circulation at rest vs physical exercise
Results of additional testing in prinzemetal ischemia
Negative stress test- artery can dilate
Chest pain due to non cardiac cause
Positive test - artery can’t dilate
Chest pain from unstable angina
Managed same as NSTEMI
NSTEMI treatment?
Antithrombktic - oral antiplatelet therapy
Clopidogrel
Aspirin
Anticagulent therapy- herapin
Prevents thrombosis from embolism from ulcerated plaque
After identifying someone at high risk of NSMETI what do u do
Coronary angiography + revascularization
High risk: immediate
Low risk: within 12 hours
Repercussion therapy ?
Mechanical
Stent
Primary percutaneous
Coronary intervention
Pharmacological reperfusion- (fibrinolytic)
Dine with primary PCI can’t be done within 2 hours of arrival to emergency department
Reperfusiom should not be performed after 12 hours since symptoms onset
After reperfusiom ?
Oral antiplatelet therapy andanticoagulent therapy
