Carrie Hurst FY1 What well 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 ID: 201435
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Slide1
Acute Coronary Syndrome
Carrie Hurst FY1Slide2
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 studySlide3
What is Acute Coronary Syndrome?
Stable Angina
Unstable Angina
NSTEMI
STEMISlide4
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 6
th
EdnSlide5
Pathophys (enough to get by..)
Atherosclerosis
Epithelial injury
Migration of
monocytes
/macrophages
LDL lipids consumed
foam cells
Growth factors smooth muscle, collagen, proteoglycans
Atheromatous plaque formsSlide6
Clinical features
Dyspnoea
Heart murmurs
Palpitations
Chest pain
Nausea
Acute confusion
Pallor
Hypotension or hypertension
Sweaty
Vomiting
Syncope
Indigestion
Tachycardia or
bradycardia
Fever
Asymptomatic/silentSlide7Slide8
Distinguishing features
UA:
platelet
adhesion
NSTEMI: platelet aggregation
STEMI: complete occlusion
SA:
plaque
formation
At rest or minimal exertion
Lasts >20 minutes
Often accompanied by other
s/s
Poor GTN relief
Pr
ecipitated
by stress or exertion
Lasts <20 minutes
Relieved by GTN or restingSlide9
Risk Factors
Modifiable
Non-Modifiable
Increasing age
Gender (male)
Ethnicity
Family History
?Diabetes
SmokingObesityDietLack of exerciseHigh serum cholesterolHypertension
? DiabetesSlide10
Differential DiagnosisSlide11
Investigations
Bedside
Obs
, ECG, BM
Blood
FBC, UE, LFT,
lipids, cardiac enzymes, amylase, CRP
Imaging
CXRSpecialEcho, angiography
UA
NSTEMISTEMINormal
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 leadsSlide12
Important ECG findingsSlide13
Where is the problem?
Inferior
II,
III,
aVF
Right coronary
Lateral
I,
aVL
(+V5-6)
Left
c
ircumflex (or
LAD)
Anterior
V1-2
septum, V3-4 apex, V5-6 ant/lat
LAD
Posterior
ST depression
in V1-3
Left
c
ircumflex
or right coronarySlide14
Management
A
Patent?
B
Oxygen
(aim for
sats
94-98%), auscultate, RRC
IV access (+/-fluids), HR, BPD
GCS, pupils, cap blood glucoseE
ExposeSlide15
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 Slide16
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 hrSlide17
Scoring systems
GRACE scoring
Predicts 6/12 mortality in NSTEMI patients
Age
HR and systolic BP
Killip class (CCF, pulmonary oedema, shock)
Cardiac arrest on admission
Elevated cardiac markersST segment change
TIMIRisk of cardiac events in next 30 days
Age >65Known coronary artery diseaseAspirin in last 7/7Severe angina (>2 in 24hr)
ST deviation >1mmElevated troponins> CAD risk factorsSlide18
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…ContraindicationsClopidogrel 600mg loading dose AND LMWH
Beta blocker i.e. AtenololACE inhibitor i.e. LisinoprilSlide19
Longer-term management
Continuous ECG monitoring as inpatient/ CCU
Aspirin 75mg OD (lifelong)
Clopidogrel
75mg (1 year)
Beta blocker (1 year - lifelong)
ACE inhibitor
StatinModification of risk factors Slide20
Complications
Early <72hr
Death
Cardiogenic shock
Heart failure
Ventricular arrhythmia
Myocardial ruptureThromboembolism
Late
Ventricular wall ruptureValvular regurgitationVentricular aneurysmsCardiac tamponadeDresslers syndrome
ThromboembolismSlide21
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 F1Slide22
Case study – Mr FB
A 54 year old gentleman presents to A&E with chest pain…Slide23
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 citalopramFHx includes father dying of MI aged 50
Smoked 40 cigarettes a day for the past 35 years and drinks a bottle of whiskey a weekCant exercise “because of my asthma”Slide24
What are his risk factors?
Increasing age
Gender (male)
Family History
Smoking
Obesity
Diet
Lack of exercise
High serum cholesterol
? Hypertension
?DiabetesSlide25
How would you Ix him?Slide26
Case study – Mr FB
Initial management in acute setting?
MONA
Reperfusion
BB and ACEi
Long-term management?
Aspirin, Clopidogrel, Statin, modification of lifestyle…..Slide27
SummaryDon’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 answerSlide28
ReferencesBNF 64
Advance Life Support emodule handbook 6
th
Edition
OHCS 7
th
EditionGreat ECG example website:www.meds.queensu.ca/central/assets/modules/ECG/ecg_index.html