2. 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?

3. Atherosclerosis

4. 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.

5. Terminology

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

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

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

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

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

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

12. 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

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

14. ECG

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

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

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

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

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

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

21. ECG quizECG quiz This shows posterior infarct?

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

23. LBBB indicating STEMI?

24. Anterior MI?

25. 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?

26. 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