Acute Coronary Syndrome Carrie Hurst FY 1 What

Acute Coronary Syndrome Carrie Hurst FY 1

What we’ll cover in next 30 mins… Ü Definitions Ü Clinical features and differentiating ACS Ü ECGs Ü Management Ü Complications Ü Some tips from a 2013 Warwick grad Ü Case study

What is Acute Coronary Syndrome? Stable Angina Unstable Angina NSTEMI

Definitions Ü Unstable angina: Ü An unprovoked or prolonged episode of chest pain raising suspicion of acute myocardial infarction (AMI) Ü Without definite ECG or laboratory evidence Ü NSTEMI: Ü Chest pain suggestive of AMI Ü Non-specific ECG changes (ST depression/T inversion/normal) Ü Laboratory tests showing release of troponins Ü STEMI: Ü Sustained chest pain suggestive of AMI Ü Acute ST elevation or new LBBB * ALS handbook 6 th Edn

Pathophys (enough to get by. . ) Atherosclerosis Ü Epithelial injury Ü Migration of monocytes/macroph ages Ü LDL lipids consumed foam cells Ü Growth factors smooth muscle, collagen, proteoglycans Ü Atheromatous plaque forms

Clinical features Ü Tachycardia or bradycardia Ü Chest pain Ü Nausea Ü Heart murmurs Ü Dyspnoea Ü Palpitations Ü Hypotension or Ü Sweaty Ü Vomiting hypertension Ü Syncope Ü Pallor Ü Asymptomatic/silent Ü Indigestion Ü Acute confusion Ü Fever

Distinguishing features Ü SA: Ü UA: plaque formation Ü Precipitated by stress or exertion Ü Lasts <20 minutes Ü Relieved by GTN or resting platelet adhesion Ü NSTEMI: platelet aggregation Ü STEMI: complete occlusion Ü At rest or minimal exertion Ü Lasts >20 minutes Ü Often accompanied by other s/s Ü Poor GTN relief

Risk Factors Modifiable Non-Modifiable Ü Smoking Ü Increasing age Ü Obesity Ü Gender (male) Ü Diet Ü Ethnicity Ü Lack of exercise Ü Family History Ü High serum cholesterol Ü ? Diabetes Ü Hypertension Ü ? 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 Normal troponin Raised troponin * ECG normal * Possible 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 >1 mm in limb leads and >2 mm in chest leads

Important ECG findings

Where is the problem? Inferior II, III, a. VF Right coronary Lateral I, a. VL (+V 5 -6) Left circumflex (or LAD) Anterior V 1 -2 septum, V 3 -4 apex, V 5 -6 ant/lat LAD Posterior ST depression in V 1 -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 Ü Morphine (5 -10 mg slow IV injection) Ü Oxygen (titrate sats to need) Ü Nitrates - GTN spray (400 mcg = 1 spray) or tablet (1 mg) Ü Aspirin (300 mg chewed) Ü Plus an antiemetic i. e. Metoclopramide 10 mg IV * BNF 64

Unstable angina & NSTEMI Ü LMWH i. e. Enoxaparin 1 mg/kg BD or Fondaparinux 2. 5 mg OD Ü Clopidogrel 300 mg loading dose Ü Beta blocker - atenolol 5 mg Ü Nitrates – usually IV Ü Consider coronary angiography within 72 hr

Scoring systems TIMI GRACE scoring Ü Predicts 6/12 mortality in Ü Risk of cardiac events in NSTEMI patients next 30 days Ü Age >65 Ü HR and systolic BP Ü Known coronary artery Ü Killip class (CCF, pulmonary oedema, shock) Ü Cardiac arrest on admission Ü Elevated cardiac markers Ü ST segment change Ü Ü Ü disease Aspirin in last 7/7 Severe angina (>2 in 24 hr) ST deviation >1 mm Elevated troponins > CAD risk factors

STEMI Ü TIME IS MUSCLE Ü Percutaneous coronary intervention (Primary PCI) Ü ‘Call to balloon time’ of 120 minutes Ü Requires clopidogrel 600 mg loading dose Ü Rescue PCI after failed thrombolysis Ü Thrombolysis Ü Streptokinase / alteplase / tenecteplase… Ü Contraindications Ü Clopidogrel 600 mg loading dose AND LMWH Ü Beta blocker i. e. Atenolol Ü ACE inhibitor i. e. Lisinopril

Longer-term management Ü Continuous ECG monitoring as inpatient/ CCU Ü Aspirin 75 mg OD (lifelong) Ü Clopidogrel 75 mg (1 year) Ü Beta blocker (1 year - lifelong) Ü ACE inhibitor Ü Statin Ü Modification of risk factors

Complications Early <72 hr Late Ü Death Ü Ventricular wall rupture Ü Cardiogenic shock Ü Valvular regurgitation Ü Heart failure Ü Ventricular aneurysms Ü Ventricular arrhythmia Ü Cardiac tamponade Ü Myocardial rupture Ü Dresslers syndrome Ü Thromboembolism

How to say the right thing in clinicals…. Ü Have a system!! Ü “I would order bedside, blood, imaging and special test…. ” Ü “ I would check that the patient is haemodynamically stable using an A-E approach” Ü “My management strategy would take into account conservative, medical and surgical…” Ü NEVER GUESS Ü You get more marks for knowing your limitations than for knowing an obscure fact. Ü They want to know you’ll be a safe F 1

Case study – Mr FB A 54 year old gentleman presents to A&E with chest pain…

What do you want to ask him? Ü 30 minute history of central ‘crushing’ chest pain radiating to his jaw and left arm, 10/10 Ü He is SOB, looks very pale, clammy and sweaty, and has vomited twice Ü PMHx of hypertension and hypercholesterolaemia Ü Takes metformin, salbutamol inhalers and citalopram Ü FHx includes father dying of MI aged 50 Ü Smoked 40 cigarettes a day for the past 35 years and drinks a bottle of whiskey a week Ü Cant exercise “because of my asthma”

What are his risk factors? Ü Smoking Ü Increasing age Ü Obesity Ü Gender (male) Ü Diet Ü Family History Ü Lack of exercise Ü High serum cholesterol Ü ? Hypertension Ü ? Diabetes

How would you Ix him?

Case study – Mr FB Ü Initial management in acute setting? Ü MONA Ü Reperfusion Ü BB and ACEi Ü Long-term management? Ü Aspirin, Clopidogrel, Statin, modification of lifestyle…. .

Summary Ü Don’t forget to learn what you think you already know! Ü ECG often Ü Structured approach Ü Know your acute management – MONA Ü Senior review is always the right answer

References Ü BNF 64 Ü Advance Life Support emodule handbook 6 th Edition Ü OHCS 7 th Edition Ü Great ECG example website: www. meds. queensu. ca/central/assets/modules/ECG/ ecg_index. html