Tachycardia Broad Complex Regular Ventricular tachycardia Irregular Ventricular

Tachycardia – Broad Complex Regular • Ventricular tachycardia Irregular • Ventricular fibrillation • Polymorphic VT (Torsades de Pointes)

Ventricular Tachycardia

Ventricular Tachycardia -> VF

Ischaemic Heart Disease

Stable Angina PATH • Atherosclerosis -> coronary stenosis -> ischaemia • RF! PREC • Emotion • Cold • Heavy Meals Angina Chest Pain 1. Constricting discomfort in front of chest, neck, shoulders, jaw or arms 2. Precipitated by physical exertion 3. Relieved by rest or GTN within 5 minutes

Stable Angina INV • ECG (possibly ST depression, old infarct) • Stress Echo / Coronary Angiography / Cardiac CT calcium score / Myocardial perfusion scan with SPECT Mx • RF Mx • Aspirin, Statin, Glyceryl Trinitrate (SL) 1. BB (atenolol)/CCB (verapamil/diltiazem) 2. BB + CCB (nifedipine), OR monotherapy + long-acting nitrate/ivabradine/nicorandil /ranolazine 3. Can use BB + CCB + 3 rd Drug whilst waiting for PCI/CABG • PCI • Surgery (CABG)

Acute Coronary Syndromes PATH • Plaque Rupture = Thrombosis = Inflammation (emboli, coronary spasm, vasculitis) ACS Types • Unstable Angina • NSTEMI ~subendocardial • STEMI ~transmural PRES • Acute Central Chest Pain (>15 min) +/- N+V/ SOB/ Palpitations/ Sweating ‘silent’ in elderly/DM: Syncope/Epigastric Pain/Delirium

ECG MI Myocardial Infarction (MI) DEF: 1. Rise +/- Fall of Cardiac Troponin 2. One Troponin Measurement Above Upper Limit 3. One of: • Symptomatic • New ST-T changes, LBBB or pathological Q waves • Intracoronary thrombus (CT coronary angiography) • New loss of viable myocardium or new regional wall motion abnormality (MPS with SPECT, stress echo, stress MRI) STEMI DEF • ST Elevation - >1 mm in =>2 contiguous limb leads - >2 mm in => 2 contiguous chest leads • New LBBB

Inferior STEMI

Anterior STEMI

Lateral STEMI

Management BOTH: (STEMI and NSTEMI) • Pre-Hospital: Aspirin 300 mg and GTN • Acute (MONA) 1. ECG, Troponin, Other Bloods, CXR 2. Analgesia: GTN, Morphine (5 -10 mg) +/- Metoclopramide IV 3. Aspirin (300 mg) + Clopidogrel 4. Heparin 5. O 2 (only if hypoxic) STEMI: 1. PCI (within 12 hrs symptom onset, 90 mins after thrombolysis and ST elevation not resolved), Thrombolysis (if can’t get PCI within 2 hrs)

Management NSTEMI Assess Risk (High = Continued Pain, ST depression, DM, Raised Troponin) Intermediate/High: 1. GPIIb/IIIa Infusion (tirofiban) + Angiography (within 96 hrs of admission) 2. Optimise Drugs (+Statin, +CCB, +ACE-i) 3. (continued symptoms) PCI/CABG

Subsequent Management • • Bed Rest Daily Examination, Bloods, ECG LMWH (DVT prophylaxis) Cardiac rehab DRUGS (BACAS) • Aspirin • Clopidogrel (or other PY 12) • Beta-Blocker • ACEi • Statin

Complications (short-term) • Cardiac Arrest • Cardiogenic Shock • Acute Heart Failure • Dysrhythmias (heart block, tachyarrhythmia) • Pericarditis (<48 hrs) (long-term) • Unstable Angina • Mitral Regurgitation (papillary muscle rupture) • Chronic Heart Failure • Dresslers Syndrome (2 -6 wks) • Left Ventricular Aneurysm (persistent ST elevation + LVF)

Pericarditis