ACS – Finals Revision
Dr Ian Hunt, FY1
Ian.Hunt@gmail.com
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
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.
ACS
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Definition and Types
Pathophysiology
Signs and Symptoms
Clinical approach to the patient
– Investigations: Bloods, ECG, Angiography, Other
– Management
• Acute
• Chronic
• Complications
• Case Discussion
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
3 is the magic number
• 3 parts:
– Unstable Angina
– NSTEMI – Non-ST Elevated MI
– STEMI – ST Elevated MI
(De-La-Soul 1989)
Pathophysiology – RF(1)
Modifiable
Non - Modifiable
• Hyperlipidaemia
• Age – Old is bad
• Smoking
• Sex – Men are bad
• Hypertension
• Family history – Genes are bad
• 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
Pathophsyiology – Plaque formation
Pathophysiology – From plaque to
ACS(1)
• Plaque can lead to ACS by
– Erosion/Fissure
– Rupture
• This leads to:
– Thrombosis (which can also embolise)
Signs and symptoms(1)
Symptoms
• Pain
– Crushing/Squeezing/
Heaviness
– Retrosternal
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Or: Epigastric, Back, Neck, Jaw,
Shoulder
– Radiation to any of the above
– With or without trigger?
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Nausea
Dizziness/Syncope
SOB
Sense of impending doom
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NOTHING!
– Diabetics/Elderly/Women
Signs
• Tachycardia/Bradycardia
• Hypotension/Syncope
• Tachypheonia
• Vomiting
• Pallor
• Signs of acute heart failure
– Crepiations, Raised JVP, Murmors
How to approach the patient
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?
Investigations
• Bloods– FBC, U+E, Coag, Trop T, Lipids, Glucose
– Other enzymes: Trop I, CK, AST, LDH
• ECG
• CXR?
• Angiography
STEMI
NSTEMI
Unstable angina
ECG
Troponin T
ST elevation
Positive
+/- ST depression
Positive
-
Negative
ECG Findings
ECGs
Sites of infarct (1,2)
ECG
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
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:
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Know some CI – Haemoragic stoke, major surgery
(recent), active bleeding, coagulation issues,
Ischemic stroke in last 6 months.
tPA or streptokinase
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
Complications(2)
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S – Sudden Death
P – Pump Failure
A – Aneurysm/Arrhythmias
R – Rupture papillary muscle/septum
E - Embolism
D – Dressler’s syndrome / Acute pericarditis
Secondary prevention
• Lifestyle advice
– Diet
– Exercise
– Smoking
• Reduce stress on heart
– ACEI
– B-blocker
– Statin
• Reduce acute events
– Aspirin
– Clopidogrel
Case Presentation (5 minutes)
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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
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.
Questions
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.
3. Unstable angina and NSTEMI, NICE quick
reference guide, March 2010.
4. Advanced Life Support (6th edition), January
2011
Pictures
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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-ina-chair-drinking-too-much-and-smoking-too-much.jpg
Kumar and clarke 8th
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-LDeprenyl-%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