Acute Coronary Syndrome

1. Acute Coronary Syndrome Carrie Hurst FY1

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

3. What is Acute Coronary Syndrome? Stable Angina Unstable Angina NSTEMI STEMI

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

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

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

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

9. Risk Factors Non-Modifiable Increasing age Gender (male) Ethnicity Family History ?Diabetes Smoking Obesity Diet Lack of exercise High serum cholesterol Hypertension ? Diabetes Modifiable

10. Differential Diagnosis

11. Investigations * ST elevation is >1mm in limb leads and >2mm in chest leads

12. Important ECG findings

13. Where is the problem?

14. Management

15. Common ACS management • Morphine (5-10mg slow IV injection) • Oxygen (titrate sats to need) • Nitrates - GTN spray (400mcg = 1 spray) or tablet (1mg) • Aspirin (300mg chewed) • Plus an antiemetic i.e. Metoclopramide 10mg IV * BNF 64

16. Unstable angina & NSTEMI • LMWH i.e. Enoxaparin 1mg/kg BD or Fondaparinux 2.5mg OD • Clopidogrel 300mg loading dose • Beta blocker - atenolol 5mg • Nitrates – usually IV • Consider coronary angiography within 72 hr

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

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

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

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

21. How to say the right thing in clinicals…. • Have a system!! • “I would order bedside, blood, imaging and special test….” • “ I would check that the patient is haemodynamically stable using an A-E approach” • “My management strategy would take into account conservative, medical and surgical…” • NEVER GUESS • You get more marks for knowing your limitations than for knowing an obscure fact. • They want to know you’ll be a safe F1

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

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

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

25. How would you Ix him?

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

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

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