Acute coronary syndrome ACS Dr Darren Reed FY

Acute coronary syndrome (ACS) Dr Darren Reed FY 1

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?

Atherosclerosis

ACS – umbrella term Stable Angina Unstable Angina NSTEMI ACS is a spectrum, especially between UA and NSTEMI, where the severity affects degree of cardiac insult.

Terminology

Differentiating ACS Chest pain ? ACS ECG ST-elevation No ST-elevation STEMI Troponin T Raised Not raised NSTEMI Unstable angina

STEMI NSTEMI Unstable angina ECG Troponin T ST elevation Positive +/- ST depression Positive - Negative Remember posterior infarcts can cause ST depression

Risk factors MODIFIABLE Smoking Obesity Diet No exercise Hypercholesterolaemia Hypertension Diabetes? UNMODIFIABLE Increased age Gender (male) Ethnicity Family Hx Diabetes?

Signs and symptoms Signs Pallor Tachycardia Pulmonary crepitations Raised JVP Murmurs Symptoms Pain SOB Sweating Syncope N&V

History Chest pain? Brief PMH – why? Risk factors? Allergies? Current meds?

Differential diagnosis Cardiac • • MI Angina Pericarditis Aortic dissection Respiratory • Pulmonary embolism • Pneumothorax • Pneumonia GI • Oesophageal spasm • GORD • Pancreatitis

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 raised

Management A – airway B – breathing O 2, aim sats > 95% C– circulation D – disability E – exposure Sats probe, BP, HR, IV access

ECG

MONA Morphine Oxygen Nitrates Aspirin Clopidogrel Beta blocker (not in asthma, or with heart failure) Antiemetic

Time is muscle… Percutaneous coronary intervention (angioplasty) Thrombolysis (beware CI) CABG

Subacute management Bed rest 48 hours Gradual build up in activity over 1 -2 months Thromboprophylaxis Job?

Secondary prevention MODIFIABLE Hypercholesterolaemia Hypertension Diabetes? Smoking Obesity Diet No exercise Statins ACE inhibitors Beta blocker Life style advice Aspirin/clopidogrel

UA/NSTEMI Oxygen Nitrates Clopidogrel Aspirin LMWH Risk assess (TIMI score) ? intervention

Complications Sudden death PE Rupture of ventricle Arrythmia/aneurysm Emboli Dressler’s syndrome (AI pericarditis)

ECG quiz This shows posterior infarct?

ECG quiz This only shows evidence of an old infarct?

LBBB indicating STEMI?

Anterior MI?

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?

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 2222