Scenario 1Scenario 1  58 year old man  30 minute history of severe chest pain, 10/10, radiating to jaw, not relieved by anything, associated with sweating and nausea. Known angina.  What investigations would you like?  What do you expect to find?  What would you do next?

Atherosclerosis

ACS – umbrella termACS – umbrella term Stable AnginaUnstable AnginaNSTEMISTEMI ACS ACS is a spectrum, especially between UA and NSTEMI, where the severity affects degree of cardiac insult.

Terminology

Differentiating ACSDifferentiating ACS ECG No ST-elevationST-elevation Troponin T Raised Not raised STEMI NSTEMI Unstable angina Chest pain ?ACS

ECGTroponin T STEMIST elevationPositive NSTEMI+/- ST depressionPositive Unstable angina-Negative Remember posterior infarcts can cause ST depression

Risk factorsRisk factors M ODIFIABLE  Smoking  Obesity  Diet  No exercise  Hypercholesterolaemia  Hypertension  Diabetes? U NMODIFIABLE  Increased age  Gender (male)  Ethnicity  Family Hx  Diabetes?

Signs and symptomsSigns and symptoms  Signs  Pallor  Tachycardia  Pulmonary crepitations  Raised JVP  Murmurs  Symptoms  Pain  SOB  Sweating  Syncope  N&V

History  Chest pain?  Brief PMH – why?  Risk factors?  Allergies?  Current meds?

Differential diagnosisDifferential diagnosis Cardiac MI Angina Pericarditis Aortic dissection Respiratory Pulmonary embolism Pneumothorax Pneumonia GI Oesophageal spasm GORD Pancreatitis

Investigations Bedside ECG, obs Blood FBC, U+E, clotting screen, Trop T, glucose, lipids Imaging ?CXR Special tests Diagnosis (2/3): - Convincing MI history - ECG with ST changes - Cardiac enzymes raised

Management A – airway B – breathing O2, aim sats > 95% C – circulation Sats probe, BP, HR, IV access D – disability E – exposure

ECG

MONA  Morphine  Oxygen  Nitrates  Aspirin  Clopidogrel  Beta blocker (not in asthma, or with heart failure)  Antiemetic

Time is muscle…Time is muscle…  Percutaneous coronary intervention (angioplasty)  Thrombolysis (beware CI)  CABG

Subacute managementSubacute management  Bed rest 48 hours  Gradual build up in activity over 1-2 months  Thromboprophylaxis  Job?

Secondary preventionSecondary prevention  Statins  ACE inhibitors  Beta blocker  Life style advice  Aspirin/clopidogrel M ODIFIABLE  Hypercholesterolaemia  Hypertension  Diabetes?  Smoking  Obesity  Diet  No exercise

UA/NSTEMI  Oxygen  Nitrates  Clopidogrel  Aspirin  LMWH  Risk assess (TIMI score) ?intervention

Complications  Sudden death  PE  Rupture of ventricle  Arrythmia/aneurysm  Emboli  Dressler’s syndrome (AI pericarditis)

ECG quizECG quiz This shows posterior infarct?

ECG quizECG quiz This only shows evidence of an old infarct?

LBBB indicating STEMI?

Anterior MI?

Scenario 2Scenario 2  It’s 23:15, you’re on nights.  You’re about to take some bloods, for gentamicin levels, for a patient due to have their next dose at 24:00.  You’ve just been bleeped by a nurse because a patient on another ward has developed chest pain...  What do you do next?

Take home messageTake home message  ECG as soon as possible, repeat often  ABCDE + structured approach  Know your acute management – MONA ABCE  Senior review if unsure what’s happening  2222