Acute Coronary Syndrome Carrie Hurst FY1

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

What is Acute Coronary Syndrome? Stable Angina Unstable Angina NSTEMI STEMI Some degree of plaque rupture in the ACS spectrum conditions

Definitions Unstable angina: NSTEMI: STEMI: 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

Pathophys (enough to get by..) Atherosclerosis Epithelial injury Migration of monocytes/macro phages LDL lipids consumed  foam cells Growth factors  smooth muscle, collagen, proteoglycans Atheromatous plaque forms Plaque rupture Trauma to surface of plaque Sudden plaque expansion

Clinical features Tachycardia or bradycardia Chest pain Nausea Heart murmurs Dyspnoea Palpitations Sweaty Vomiting Hypotension or hypertension Don’t forget the rest of the history : Past medical hx Family hx Drug Hx Allergies Social Systems review Pallor Syncope Asymptomatic/silent Indigestion Acute confusion Fever

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

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

Differential Diagnosis Chest pain Cardiac MI Angina Pericarditis Aortic dissection Respiratory Pulmonary embolism Pneumothorax Pneumonia GI Oesophageal spasm GORD Pancreatitis Musculoskeletal Costochondriasis Trauma Rule these out during your examination i.e. - Aortic dissection: pulseless upper limb/asymmetry of pulses – don’t fibrinolyse!! - respiratory examination ? Deviated trachea, reduced chest expansion

Investigations Bedside Obs, ECG, BM Blood FBC, UE, LFT, lipids, cardiac enzymes, amylase, CRP Imaging CXR Special Echo, angiography UA NSTEMI STEMI Normal troponin Raised troponin * ECG normal * Possible ST depression * 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 >1mm in limb leads and >2mm in chest leads

Important ECG findings

Where is the problem? Inferior II, III, aVF Right coronary Lateral I, aVL (+V5-6) Left circumflex (or LAD) Anterior V1-2 septum, V3-4 apex, V5-6 ant/lat LAD Posterior ST depression in V1-3 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 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

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

Scoring systems GRACE scoring TIMI 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 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

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 Reperfuse urgently if <12hr from onset to get blood back to myocardium that isnt yet irreversibly damaged CI include: known bleeding disorder, ischaemic stroke in last 6/12, haemorrhagic stroke ever, active bleeding, suspected aortic dissection

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

Complications Early <72hr Late Death Cardiogenic shock Heart failure Ventricular arrhythmia Myocardial rupture Thromboembolism Ventricular wall rupture Valvular regurgitation Ventricular aneurysms Cardiac tamponade Dresslers syndrome Thromboembolism SPARED: sudden death, pericarditis, aneurysm/arrhythmia, ruptured ventricualr wall, embolism, dresslers

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

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

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”

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

How would you Ix him?

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

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

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