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Acute Coronary Syndrome

Acute Coronary Syndrome. Nicholas Shaw. ACS. STEMI New onset LBBB NSTEMI Unstable angina. Risk Factors for ACS. Age Male Ethnicity Family history CKD. Smoking Obesity Dyslipidaemia Hypertension. Stable Angina. Cardiac chest pain precipitated by exercise

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Acute Coronary Syndrome

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  1. Acute Coronary Syndrome Nicholas Shaw

  2. ACS • STEMI • New onset LBBB • NSTEMI • Unstable angina

  3. Risk Factors for ACS • Age • Male • Ethnicity • Family history • CKD • Smoking • Obesity • Dyslipidaemia • Hypertension

  4. Stable Angina • Cardiac chest pain precipitated by exercise • Caused by atheroma, but also: anaemia, AS, tachyarrhythmias, HOCM • Eases with rest / GTN • 4 classes: • I: angina on strenuous exercise • II: Slight limitation of ordinary activities • III: difficulty climbing stairs • IV: unable to carry out any physical activity • Risk of progression to ACS (1% non-fatal MI/year)

  5. Angina investigations • ECG • Ecercise ECG • FBC – anaemia • Glucose – diabetes • Lipids – dyslipidaemia • TFTs - thyrotoxicosis

  6. Angina Management • Lifestyle modification • Modifying risk factors • Medication • Aspirin • Beta blockers • Calcium channel blockers • Statins • Nitrates • Surgical – PTCA, CABG

  7. Unstable Angina • Presence of angina without precipitating cause / at rest • Spectrum with stable angina and NSTEMI

  8. Presentation of ACS • Typical chest pain • Male • Left sided chest pain • Radiating to left arm • Radiating to neck Silent MI • Cool • Clammy • Nausea • Dyspnoea • Pulmonary oedema • Confusion • Palpitations • Collapse • Death • Atypical chest pain • Right sided chest pain • Abdominal pain • Female • Diabetic • Elderly

  9. Differential Diagnosis • Musculoskeletal chest pain • Pulmonary embolus • Aortic dissection • Gastric reflux

  10. Diagnostic criteria of acute MI • 2/3 of: • ECG changes • Chest pain • Rise in cardiac enzymes

  11. Investigations • ECG • Bloods • FBC • U&E • Trop T • CXR • Cardiomegaly • Pulmonary oedema • Widened mediastinum

  12. NSTEMI • Subocclusive thrombus • ECG changes: • ST depression • T wave inversion

  13. NSTEMI

  14. ECG Leads High lateral Septal Inferior Lateral Anterior

  15. Arteries Affected Location of MI Artery Lateral Left circumflex Anterior LAD Septum LAD Inferior RCA Posterior RCA Right Ventricle RCA

  16. Anterior MI • ST elevation is maximal in the anteroseptal leads (V1-4). • Q waves are present in the septal leads (V1-2). • There is also some subtle STE in I, aVL and V5, with reciprocal ST depression in lead III. • There are hyperacute (peaked ) T waves in V2-4. • These features indicate a hyperacute anteroseptal STEMI

  17. Tombstoning

  18. Posterior MI

  19. Inferior MI

  20. STEMI • - ST elevation > 1mm in two or more limb leads and/or • - ST elevation > 2mm in two or more consecutive precordial leads and/or • - Left Bundle Branch Block (LBBB) which is known or suspected to be of new onset and in the presence of cardiac symptoms

  21. Treatment of STEMI • Morphine • Antiemetics (metoclopramide) • Antiplatelets – aspirin (300mg) and ticagrelor (180mg) • IV access • Bloods • Primary Coronary Intervention • Thrombolysis (tPA / streptokinase)

  22. Further inpatient management • Education • Echocardiogram (LV function) • Clopidogrel (or ticagrelor) • Beta blockers • ACE-I • Statins • Risk factor modification

  23. Late Complications • Dresslers syndrome • Papillary muscle rupture • Fibrosis • Aneurysm • Heart failure • Death

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