ACS – Finals Revision

ACS – Finals Revision

Dr Ian Hunt, [email protected]

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

ObjectivesBy 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

• 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 (De-La-Soul 1989)

• 3 parts:– Unstable Angina– NSTEMI – Non-ST Elevated MI– STEMI – ST Elevated MI

Pathophysiology – RF(1)Modifiable Non - 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

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

• 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

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

ECG Troponin T

STEMI ST elevation Positive

NSTEMI +/- ST depression Positive

Unstable angina - 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:– 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)

• 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)• 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 • 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-matur

e-man-sitting-in-a-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.j

pg• http://www.mindandmuscle.net/articles/wp-content/uploads/2011/09/Chemicall

y-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