Dr Darren Reed FY1 Scenario 1 58 year old man 30 minute history of severe chest pain 1010 radiating to jaw not relieved by anything associated with sweating and nausea Known angina What investigations would you like ID: 310780
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Acute coronary syndrome (ACS)
Dr Darren Reed FY1Slide2
Scenario 1
58 year old man
30 minute history of severe chest pain, 10/10, radiating to jaw, not relieved by anything, associated with sweating and nausea. Known angina.
What investigations would you like?
What do you expect to find?
What would you do next?Slide3
AtherosclerosisSlide4
ACS – umbrella term
Stable Angina
Unstable Angina
NSTEMI
STEMI
ACS
ACS is a spectrum, especially between UA and NSTEMI, where the severity
affects degree of cardiac insult.Slide5
TerminologySlide6
Differentiating ACS
ECG
No ST-elevation
ST-elevation
Troponin T
Raised
Not raised
STEMI
NSTEMI
Unstable angina
Chest pain ?ACSSlide7
ECG
Troponin T
STEMI
ST
elevation
Positive
NSTEMI
+/- ST depression
Positive
Unstable
angina
-
Negative
Remember posterior infarcts can cause ST depressionSlide8
Risk factors
Modifiable
Smoking
Obesity
Diet
No exercise
Hypercholesterolaemia
Hypertension
Diabetes?
Unmodifiable
Increased age
Gender
(male)
Ethnicity
Family
Hx
Diabetes?Slide9
Signs and symptoms
Signs
Pallor
Tachycardia
Pulmonary
crepitations
Raised JVP
Murmurs
Symptoms
Pain
SOB
Sweating
Syncope
N&VSlide10
History
Chest pain?
Brief PMH – why?
Risk factors?
Allergies?
Current meds?Slide11
Differential diagnosisSlide12
Investigations
Bedside
ECG,
obs
Blood
FBC
, U+E, clotting screen,
Trop
T, glucose, lipids
Imaging
?CXR
Special tests
Diagnosis (2/3):
- Convincing MI history
- ECG with ST changes
- Cardiac enzymes raisedSlide13
Management
A
– airway
B – breathing
O2, aim
sats
> 95%
C – circulation
Sats
probe, BP, HR, IV access
D – disability
E – exposureSlide14
ECGSlide15
MONA
Morphine
Oxygen
Nitrates
Aspirin
Clopidogrel
Beta blocker (not in asthma, or with heart failure)
Antiemetic Slide16
Time is muscle…
Percutaneous
coronary intervention (angioplasty)
Thrombolysis
(beware CI)
CABGSlide17
Subacute management
Bed rest 48 hours
Gradual build up in activity over 1-2 months
Thromboprophylaxis
Job?Slide18
Secondary prevention
Statins
ACE inhibitors
Beta blocker
Life style advice
Aspirin/
clopidogrel
Modifiable
Hypercholesterolaemia
Hypertension
Diabetes?
Smoking
Obesity
Diet
No exerciseSlide19
UA/NSTEMI
Oxygen
Nitrates
Clopidogrel
Aspirin
LMWH
Risk assess (TIMI score) ?interventionSlide20
Complications
Sudden death
PE
Rupture of ventricle
Arrythmia
/aneurysm
Emboli
Dressler’s syndrome (AI
pericarditis)Slide21
ECG quiz
This shows posterior infarct?Slide22
ECG quiz
This only shows evidence of an old infarct?Slide23
LBBB indicating STEMI?Slide24
Anterior MI?Slide25
Scenario 2
It’s 23:15, you’re on nights.
You’re about to take some bloods, for
gentamicin
levels, for a patient due to have their next dose at 24:00.
You’ve just been bleeped by a nurse because a patient on another ward has developed chest pain...
What do you do next?Slide26
Take home message
ECG as soon as possible, repeat often
ABCDE + structured approach
Know your acute management – MONA ABCE
Senior review if unsure what’s happening
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