1. ACS – Finals Revision Dr Ian Hunt, FY1 Ian.Hunt@gmail.com

2. A few confessions I’m working on Psychiatry I don’t have all the answers (see above) I’m quite lazy I’m a little crazy

3. Objectives By the end of the session: Identify current knowledge (strengths and weaknesses) about ACS Identify the level of knowledge required for passing finals Identify how the theory relates to how to actually be a decent junior doctor in an ACS scenario By finals: To have learn, retained and know how to apply the information required to pass finals that we have identified To be competent at managing ACS in the acute setting.

4. ACS Definition and Types Pathophysiology Signs and Symptoms Clinical approach to the patient – Investigations: Bloods, ECG, Angiography, Other – Management Acute Chronic Complications Case Discussion

5. Definition Acute: Comes on quickly Coronary: Relating to the arteries supply the heart Syndrome: Group of symptoms A group of symptoms associated with the heart arteries which come on quickly (Roughly) – Not relieved by rest/removal of possible trigger – Lasting more than 20 minutes despite GTN

6. 3 is the magic number (De-La-Soul 1989) 3 parts: – Unstable Angina – NSTEMI – Non-ST Elevated MI – STEMI – ST Elevated MI

7. Pathophysiology – RF (1) ModifiableNon - Modifiable Hyperlipidaemia Smoking Hypertension Diabetes mellitus Lack of exercise Obesity Heavy alcohol consumption Abnormal coagulation factors– High fibrinogen or Factor VII Homocysteinaemia Gout Drugs: OCP, COX-2 inhibitors, Cocaine Personality CRP Soft water Age – Old is bad Sex – Men are bad Family history – Genes are bad

8. Pathophsyiology – Plaque formation

9. Pathophysiology – From plaque to ACS (1) Plaque can lead to ACS by – Erosion/Fissure – Rupture This leads to: – Thrombosis (which can also embolise)

10. Signs and symptoms (1) Symptoms Pain – Crushing/Squeezing/ Heaviness – Retrosternal Or: Epigastric, Back, Neck, Jaw, Shoulder – Radiation to any of the above – With or without trigger? Nausea Dizziness/Syncope SOB Sense of impending doom or NOTHING! – Diabetics/Elderly/Women Signs Tachycardia/Bradycardia Hypotension/Syncope Tachypheonia Vomiting Pallor Signs of acute heart failure – Crepiations, Raised JVP, Murmors

11. How to approach the patient

12. Super acute management (1,3) Reassurance MONA? – Morphine, Oxygen, Nitrates, Aspirin – Morphine 5-10mg IV (Metoclopramide 10mg IV) – GTN spray(400mcg)/tablet(300mcg) - Sublingually (repeat up to 3 times) – BUT NOT WHEN? – Aspirin 300mg stat dose – Oxygen should already be on! HELP?

13. Investigations Bloods- – FBC, U+E, Coag, Trop T, Lipids, Glucose – Other enzymes: Trop I, CK, AST, LDH ECG CXR? Angiography ECGTroponin T STEMIST elevationPositive NSTEMI+/- ST depressionPositive Unstable angina-Negative

14. ECG Findings

15. ECGs

16. Sites of infarct (1,2)

17. ECG

18. Unstable Angina/NSTEMI (3) Global Registry of Acute Cardiac Events [GRACE] 300mg (vs 600mg) Clopidogrel STAT – followed by 12 months course LMWH (8days) – (If no angio – if angio unfractionated heperin) – Fundaparinux – 2.5mg s/c – Enoxiparin 1mg/kg BD s/c Consider Glycoprotein IIb/IIIa inhibitors for high risk then angiography +/- stent

19. STEMI (4) PCI – percutanous coronary intervention – 600mg Clopidogrel loading dose – <2 hours of chest pain at presentation – Door to table <90 minutes If your to slow: Thrombolysis: – Know some CI – Haemoragic stoke, major surgery (recent), active bleeding, coagulation issues, Ischemic stroke in last 6 months. – tPA or streptokinase

20. Finish the Job Repeat ECGs, bloods Bed rest – 48 hours B-blocker – atenalol 5mg IV (unless asthma/LVF) Transfer to CCU/ICU Don’t forget to call for help Secondary prevention

21. Complications (2) S – Sudden Death P – Pump Failure A – Aneurysm/Arrhythmias R – Rupture papillary muscle/septum E - Embolism D – Dressler’s syndrome / Acute pericarditis

22. Secondary prevention Lifestyle advice – Diet – Exercise – Smoking Reduce stress on heart – ACEI – B-blocker – Statin Reduce acute events – Aspirin – Clopidogrel

23. Case Presentation (5 minutes) 4.45pm. Friday. Mr Geldoff, 83 yo, Male. Psychiatric inpatient Collapses to the floor clutching chest Chest pain – Unable to communicate much more than that. Maybe a bit sharp but achey Obese No previous cardiac history (you think) DDx Initial management and investigation

24. Take home points Finals is about being safe not being a consultant ABCDE approach to all acute patients All vaguely ACS sounding chest pain should be assumed to be an MI until you have evidence otherwise Have a system and stick to it.

25. Questions

26. References 1.Kumar and Clark's Clinical Medicine, 8e, By Parveen Kumar and Michael Clark. Saunders Ltd. 2013 2.Cardiology (notes)– Dr R Clarke www.askdoctorclarke.com. www.askdoctorclarke.com 3.Unstable angina and NSTEMI, NICE quick reference guide, March 2010. 4.Advanced Life Support (6th edition), January 2011

27. Pictures http://www.davart.net/awg/wp-content/uploads/2012/08/shockedface.jpg http://blog.vh1.com/files/2008/08/de-la-soul.jpg http://digitaldeconstruction.com/wp-content/uploads/2012/06/overweight-mature-man-sitting-in- a-chair-drinking-too-much-and-smoking-too-much.jpg http://digitaldeconstruction.com/wp-content/uploads/2012/06/overweight-mature-man-sitting-in- a-chair-drinking-too-much-and-smoking-too-much.jpg Kumar and clarke 8 th http://kingmagic.files.wordpress.com/2008/10/chest_pain.jpg http://www.gcu.ac.uk/media/gcalwebv2/library/content/help%20button.jpg http://www.d-tect.net/images/accident_investigations.jpg http://www.emedu.org/ecg/images/ami1a_ia.jpg http://www.ekginterpretation.com/wp-content/uploads/2011/05/pericarditis-ekg-ecg.png http://farm6.staticflickr.com/5021/5794684602_9dee38f5d3_z.jpg http://en.hdyo.org/assets/ask-question-3-049ac6f2a4e25267fa670b61ee734100.jpg http://www.mindandmuscle.net/articles/wp-content/uploads/2011/09/Chemically-Correct-L- Deprenyl-%E2%80%93-Part-II-.jpg http://www.mindandmuscle.net/articles/wp-content/uploads/2011/09/Chemically-Correct-L- Deprenyl-%E2%80%93-Part-II-.jpg http://ankitremembers.files.wordpress.com/2012/08/pass1.gif http://www.blogging4jobs.com/wp-content/uploads/2012/07/Job-Done.jpg