ACS – Finals Revision - PowerPoint Presentation

Slide1

ACS – Finals Revision

Dr Ian Hunt, FY1Ian.Hunt@gmail.comSlide2

A few confessions

I’m working on PsychiatryI don’t have all the answers (see above)I’m quite lazyI’m a little crazy Slide3

Objectives

By the end of the session:Identify current knowledge (strengths and weaknesses) about ACSIdentify the level of knowledge required for passing finals Identify how the theory relates to how to actually be a decent junior doctor in an ACS scenario

By finals:

To have learn, retained and know how to apply the information required to pass finals that we have identified

To be competent at managing ACS in the acute setting. Slide4

ACS

Definition and TypesPathophysiologySigns and SymptomsClinical approach to the patient

Investigations: Bloods, ECG, Angiography, Other

Management

Acute

Chronic

Complications

Case Discussion Slide5

Definition

Acute: Comes on quickly Coronary: Relating to the arteries supply the heartSyndrome: Group of symptoms

A group of symptoms associated with the heart arteries which come on quickly (Roughly)

Not relieved by rest/removal of possible trigger

Lasting more than 20 minutes despite GTN Slide6

3 is the magic number

(De-La-Soul 1989)3 parts:Unstable AnginaNSTEMI – Non-ST Elevated MISTEMI – ST Elevated MISlide7

Pathophysiology – RF

(1)ModifiableNon - Modifiable

Hyperlipidaemia

Smoking

Hypertension

Diabetes mellitus

Lack of exercise

Obesity

Heavy alcohol consumption

Abnormal coagulation factors– High fibrinogen or Factor VII

Homocysteinaemia

Gout

Drugs: OCP, COX-2 inhibitors, Cocaine

Personality

CRP

Soft

waterAge – Old is badSex – Men are badFamily history – Genes are badSlide8

Pathophsyiology

– Plaque formationSlide9

Pathophysiology

– From plaque to ACS(1)Plaque can lead to ACS byErosion/FissureRuptureThis leads to:Thrombosis (which can also embolise) Slide10

Signs and symptoms

(1)SymptomsPain Crushing/Squeezing/Heaviness

Retrosternal

Or:

Epigastric

, Back, Neck, Jaw, Shoulder

Radiation to any of the above

With or without trigger?

Nausea

Dizziness/Syncope

SOB

Sense of impending doom

or

NOTHING!

Diabetics/Elderly/Women

Signs

Tachycardia/BradycardiaHypotension/SyncopeTachypheoniaVomitingPallorSigns of acute heart failureCrepiations, Raised JVP, MurmorsSlide11

How to approach the patientSlide12

Super acute management

(1,3)Reassurance MONA? – Morphine, Oxygen, Nitrates, AspirinMorphine 5-10mg IV (Metoclopramide 10mg IV)GTN spray(400mcg)/tablet(300mcg) - Sublingually (repeat up to 3 times) – BUT NOT WHEN?Aspirin 300mg stat doseOxygen should already be on!HELP?Slide13

Investigations

Bloods-FBC, U+E,

Coag

,

Trop

T, Lipids, Glucose

Other enzymes:

Trop

I, CK, AST, LDH

ECG

CXR?

Angiography

ECG

Troponin T

STEMI

ST

elevationPositiveNSTEMI+/- ST depressionPositiveUnstable angina-NegativeSlide14

ECG FindingsSlide15

ECGsSlide16

Sites of infarct

(1,2)Slide17

ECGSlide18

Unstable Angina/NSTEMI

(3)Global Registry of Acute Cardiac Events [GRACE]300mg (vs 600mg) Clopidogrel STAT – followed by 12 months course

LMWH (8days) – (If no

angio

– if

angio

unfractionated

heperin

)

Fundaparinux

– 2.5mg s/c

Enoxiparin

1mg/kg BD s/c

Consider Glycoprotein

IIb/IIIa inhibitors for high risk then angiography +/- stentSlide19

STEMI

(4)PCI – percutanous coronary intervention600mg Clopidogrel loading dose<2 hours of chest pain at presentation

Door to table <90 minutes

If your to slow:

Thrombolysis

:

Know some CI –

Haemoragic

stoke, major surgery (recent), active bleeding, coagulation issues, Ischemic stroke in last 6 months.

tPA

or streptokinaseSlide20

Finish the Job

Repeat ECGs, bloodsBed rest – 48 hoursB-blocker – atenalol 5mg IV (unless asthma/LVF)Transfer to CCU/ICUDon’t forget to call for helpSecondary preventionSlide21

Complications

(2)S – Sudden DeathP – Pump FailureA – Aneurysm/ArrhythmiasR – Rupture papillary muscle/septumE - EmbolismD – Dressler’s syndrome / Acute pericarditisSlide22

Secondary prevention

Lifestyle adviceDietExerciseSmoking

Reduce stress on heart

ACEI

B-blocker

Statin

Reduce acute events

Aspirin

ClopidogrelSlide23

Case Presentation (5 minutes)

4.45pm. Friday.Mr Geldoff, 83 yo, Male. Psychiatric inpatient Collapses to the floor clutching chest

Chest pain – Unable to communicate much more than that. Maybe a bit sharp but

achey

Obese

No previous cardiac history (you think)

DDx

Initial management and investigationSlide24

Take home points

Finals is about being safe not being a consultantABCDE approach to all acute patientsAll vaguely ACS sounding chest pain should be assumed to be an MI until you have evidence otherwiseHave a system and stick to it.Slide25

QuestionsSlide26

References

Kumar and Clark's Clinical Medicine, 8e, By Parveen Kumar and Michael Clark. Saunders Ltd. 2013Cardiology (notes)– Dr R Clarke www.askdoctorclarke.com.Unstable angina and NSTEMI, NICE quick reference guide, March 2010.

Advanced Life Support (6th edition), January 2011Slide27

Pictures

http://www.davart.net/awg/wp-content/uploads/2012/08/shockedface.jpghttp://blog.vh1.com/files/2008/08/de-la-soul.jpghttp://digitaldeconstruction.com/wp-content/uploads/2012/06/overweight-mature-man-sitting-in-a-chair-drinking-too-much-and-smoking-too-much.jpg

Kumar and

clarke

8

th

http://kingmagic.files.wordpress.com/2008/10/chest_pain.jpg

http://www.gcu.ac.uk/media/gcalwebv2/library/content/help%20button.jpg

http://www.d-tect.net/images/accident_investigations.jpg

http://www.emedu.org/ecg/images/ami1a_ia.jpg

http://www.ekginterpretation.com/wp-content/uploads/2011/05/pericarditis-ekg-ecg.png

http://farm6.staticflickr.com/5021/5794684602_9dee38f5d3_z.jpg

http://en.hdyo.org/assets/ask-question-3-049ac6f2a4e25267fa670b61ee734100.jpg

http://www.mindandmuscle.net/articles/wp-content/uploads/2011/09/Chemically-Correct-L-Deprenyl-%E2%80%93-Part-II-.jpg

http://ankitremembers.files.wordpress.com/2012/08/pass1.gif

http://www.blogging4jobs.com/wp-content/uploads/2012/07/Job-Done.jpg