Acute Coronary Syndrome Nicholas Shaw

ACS STEMI New onset LBBB NSTEMI Unstable angina

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

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)

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

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

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

Presentation of ACS Typical chest pain Silent MI Atypical 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

Differential Diagnosis Musculoskeletal chest pain Pulmonary embolus Aortic dissection Gastric reflux

Diagnostic criteria of acute MI ECG changes Chest pain Rise in cardiac enzymes

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

NSTEMI Subocclusive thrombus ECG changes: ST depression T wave inversion

NSTEMI

ECG Leads High lateral Septal Inferior Lateral Anterior

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

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

Tombstoning

Posterior MI

Inferior MI

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

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

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

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