Acute Coronary Syndrome
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Transcript Acute Coronary Syndrome
Acute
Coronary
Syndrome
Carrie Hurst FY1
What we’ll cover in next 30 mins…
Definitions
Clinical features and differentiating ACS
ECGs
Management
Complications
Some tips from a 2013 Warwick grad
Case study
What is Acute Coronary Syndrome?
Stable Angina
Unstable Angina
NSTEMI
STEMI
Definitions
Unstable angina:
An unprovoked or prolonged episode of chest pain
raising suspicion of acute myocardial infarction (AMI)
Without definite ECG or laboratory evidence
NSTEMI:
Chest pain suggestive of AMI
Non-specific ECG changes (ST depression/T
inversion/normal)
Laboratory tests showing release of troponins
STEMI:
Sustained chest pain suggestive of AMI
Acute ST elevation or new LBBB
* ALS handbook 6th Edn
Pathophys (enough to get by..)
Atherosclerosis
Epithelial injury
Migration of
monocytes/macro
phages
LDL lipids
consumed foam
cells
Growth factors
smooth muscle,
collagen,
proteoglycans
Atheromatous
plaque forms
Clinical features
Tachycardia or
bradycardia
Chest pain
Nausea
Heart murmurs
Dyspnoea
Palpitations
Hypotension or
Sweaty
Vomiting
hypertension
Syncope
Pallor
Asymptomatic/silent
Indigestion
Acute confusion
Fever
Distinguishing features
SA:
UA:
plaque
formation
Precipitated by
stress or exertion
Lasts <20 minutes
Relieved by GTN or
resting
platelet
adhesion
NSTEMI:
STEMI:
platelet
complete
aggregation occlusion
At rest or minimal exertion
Lasts >20 minutes
Often accompanied by other s/s
Poor GTN relief
Risk Factors
Modifiable
Non-Modifiable
Smoking
Increasing age
Obesity
Gender (male)
Diet
Ethnicity
Lack of exercise
Family History
High serum cholesterol
?Diabetes
Hypertension
? Diabetes
Differential Diagnosis
Cardiac
• MI
• Angina
• Pericarditis
• Aortic dissection
Respiratory
• Pulmonary embolism
• Pneumothorax
• Pneumonia
Chest pain
GI
Musculoskeletal
• Oesophageal spasm
• GORD
• Pancreatitis
• Costochondriasis
• Trauma
Investigations
Bedside
Obs, ECG, BM
Blood
FBC, UE, LFT, lipids, cardiac enzymes, amylase,
CRP
Imaging
CXR
Special
Echo, angiography
UA
NSTEMI
STEMI
Normal troponin
Raised troponin
Raised troponin
* ECG normal
* Possible ST
depression
* ST depression
* Can be normal
* Possible T wave
inversion
* ST elevation
* Hyperacute T
waves
* New LBBB
* T inversion (hours)
* Q waves (days)
* ST elevation is >1mm in limb leads and >2mm in chest leads
Important ECG findings
Where is the problem?
Inferior
II, III, aVF
Right coronary
Lateral
I, aVL (+V5-6)
Left circumflex (or LAD)
Anterior
V1-2 septum, V3-4 apex, V5-6 ant/lat
LAD
Posterior
ST depression in V1-3
Left circumflex or right
coronary
Management
A
Patent?
B
Oxygen (aim for sats 94-98%), auscultate, RR
C
IV access (+/-fluids), HR, BP
D
GCS, pupils, cap blood glucose
E
Expose
Common ACS management
Morphine (5-10mg slow IV injection)
Oxygen (titrate sats to need)
Nitrates - GTN spray (400mcg = 1 spray) or tablet (1mg)
Aspirin (300mg chewed)
Plus an antiemetic i.e.
Metoclopramide 10mg IV
* BNF 64
Unstable angina & NSTEMI
LMWH i.e. Enoxaparin 1mg/kg BD or Fondaparinux
2.5mg OD
Clopidogrel 300mg loading dose
Beta blocker - atenolol 5mg
Nitrates – usually IV
Consider coronary angiography within 72 hr
Scoring systems
GRACE scoring
TIMI
Predicts 6/12 mortality in
Risk of cardiac events in
NSTEMI patients
next 30 days
Age
Age >65
HR and systolic BP
Known coronary artery
Killip class (CCF,
pulmonary oedema,
shock)
Cardiac arrest on
admission
Elevated cardiac
markers
ST segment change
disease
Aspirin in last 7/7
Severe angina (>2 in
24hr)
ST deviation >1mm
Elevated troponins
> CAD risk factors
STEMI
TIME IS MUSCLE
Percutaneous coronary intervention (Primary PCI)
‘Call to balloon time’ of 120 minutes
Requires clopidogrel 600mg loading dose
Rescue PCI after failed thrombolysis
Thrombolysis
Streptokinase / alteplase / tenecteplase…
Contraindications
Clopidogrel 600mg loading dose AND LMWH
Beta blocker i.e. Atenolol
ACE inhibitor i.e. Lisinopril
Longer-term management
Continuous ECG monitoring as inpatient/ CCU
Aspirin 75mg OD (lifelong)
Clopidogrel 75mg (1 year)
Beta blocker (1 year - lifelong)
ACE inhibitor
Statin
Modification of risk factors
Complications
Early <72hr
Late
Death
Ventricular wall rupture
Cardiogenic shock
Valvular regurgitation
Heart failure
Ventricular aneurysms
Ventricular arrhythmia
Cardiac tamponade
Myocardial rupture
Dresslers syndrome
Thromboembolism
Thromboembolism
How to say the right thing in
clinicals….
Have a system!!
“I would order bedside, blood, imaging and
special test….”
“ I would check that the patient is
haemodynamically stable using an A-E approach”
“My management strategy would take into
account conservative, medical and surgical…”
NEVER GUESS
You get more marks for knowing your limitations
than for knowing an obscure fact.
They want to know you’ll be a safe F1
Case study – Mr FB
A 54 year old gentleman presents to A&E with chest pain…
What do you want to ask him?
30minute history of central ‘crushing’ chest pain radiating
to his jaw and left arm, 10/10
He is SOB, looks very pale, clammy and sweaty, and has
vomited twice
PMHx of hypertension and hypercholesterolaemia
Takes metformin, salbutamol inhalers and citalopram
FHx includes father dying of MI aged 50
Smoked 40 cigarettes a day for the past 35 years and
drinks a bottle of whiskey a week
Cant exercise “because of my asthma”
What are his risk factors?
Smoking
Increasing age
Obesity
Gender (male)
Diet
Family History
Lack of exercise
High serum cholesterol
? Hypertension
?Diabetes
How would you Ix him?
Case study – Mr FB
Initial management in acute setting?
MONA
Reperfusion
BB and ACEi
Long-term management?
Aspirin, Clopidogrel, Statin, modification of
lifestyle…..
Summary
Don’t forget to learn what you think you already
know!
ECG often
Structured approach
Know your acute management – MONA
Senior review is always the right answer
References
BNF 64
Advance Life Support emodule handbook 6th
Edition
OHCS 7th Edition
Great ECG example website:
www.meds.queensu.ca/central/assets/modules/
ECG/ecg_index.html