ISCHAEMIC HEART DISEASE = ACUTE CORONARY
SYNDROME, CARDIORESPIRATORY ARREST, ANGINA
Acute Coronary Syndrome
ACS = MI & Unstable angina
ACS is usually the result of a thrombus from an atherosclerotic plaque blocking
a coronary artery (mainly formed from platelets, hence antiplatelet
medications (aspirin, clopidogrel, ticagrelor) are mainstay of treatment).
STEMI ECG = ST-elevation
NSTEMI ECG = normal or ST depression
UNSTABLE ANGINA ECG = normal or ST depression
Symptoms:
- Chest pain
- Radiating to arms/shoulders/neck/jaw/back/epigastric
- SOB
, - Clammy/sweaty, nauseous, lightheaded
- Diabetics (silent MI) and females known to present atypically
Risk factors:
- Modifiable = hyperlipidaemia/dyslipidaemia (high LDL and VLDL, low
HDL), HTN, smoking, T2DM
- Non-modifiable = age (strongest RF), gender (pre menopausal women =
decreased risk), family history (specifically under age of 65)
Types of MI:
- Type 1 = traditional MI due to acute coronary event
- Type 2 = ischaemia secondary to increased demand or reduced supply of
oxygen (e.g., secondary to anaemia, tachycardia or hypotension)
- Type 3 = sudden cardiac death or cardiac arrest suggestive of an
ischaemic event
- Type 4 = MI associated with procedures e.g., PCI, coronary stenting and
CABG
Investigations:
- ABCDE approach, senior review, assess if patient is haemodynamically
stable (using full history, exam, and obs)
- Bedside: obs, ECG, BM, ABG
- Cardioresp exam
- Multiple ECG repeats
- Bloods: FBC, coagulation studies, U&Es, LFTs, troponin (very sensitive but
not very specific), pro-ntBNP
- CXR (to look for signs of HF, pulmonary oedema and rule out respiratory
causes)
- Echo (regional wall motion abnormalities and impaired left ventricular
function)
,GRACE SCORE:
- Risk of death or future MI for the patient based on their clinical features
of presentation of MI
TREATMENT:
1. Aspirin 300mg loading dose followed by 75mg OD (dual antiplatelet)
2. Tricagrelor 180mg followed by 90mg BD (dual antiplatelet), if the patient
has a comorbid bleeding disorder then give clopidogrel instead
3. Morphine (for pain & to reduce HR) with anti-emetic
4. Oxygen if patient is hypoxic (sats <90%)
5. Nitrates to dilate coronary arteries which can be GTN spray or infusion
(be careful of hypotension)
6. Fondaparinux (anti-thrombotic) 2.5mg OD offers anti-thrombin therapy
(unfractioned heparin given during PCI therapy)
7. Other medications include beta-blockers, ACEi/ARB, statin, PPI, +/-
diuretic
8. Angiography/stenting
9. Long-term lifestyle & therapies:
, - 20-30 mins daily physical activity
- Smoking cessation
- Mediterranean diet
- Cardiac rehab
- Medication: aspirin, beta blocker, ACEi, statin
- Eplerenone for patients with comorbid HF with EF <40%
ANGIOGRAPHY/STENTING:
- STEMI = complete occlusion of blood flow with no collateral blood supply
and so irreversible myocardial necrosis can occur within 20-40 mins
Post-MI Complications: DARTH VADER
- Death
- Arrhythmia (VT & Vfib most dangerous)
- Ruptures e.g., ventricular wall, septal, papillary muscle
- Tamponade (linked to rupture)
- HF (Acute or chronic pulmonary oedema)
- Valvular disease e.g., papillary muscle rupture (mitral regurgitation),
septal rupture/ventricular septal defect
- Aneurysm
- Dressler’s syndrome (pericarditis due to autoantibodies)
- Embolism (LV mural thrombosis can lead to stroke)
- Recurrence (most likely based on diabetes, age, and eGFR)
SYNDROME, CARDIORESPIRATORY ARREST, ANGINA
Acute Coronary Syndrome
ACS = MI & Unstable angina
ACS is usually the result of a thrombus from an atherosclerotic plaque blocking
a coronary artery (mainly formed from platelets, hence antiplatelet
medications (aspirin, clopidogrel, ticagrelor) are mainstay of treatment).
STEMI ECG = ST-elevation
NSTEMI ECG = normal or ST depression
UNSTABLE ANGINA ECG = normal or ST depression
Symptoms:
- Chest pain
- Radiating to arms/shoulders/neck/jaw/back/epigastric
- SOB
, - Clammy/sweaty, nauseous, lightheaded
- Diabetics (silent MI) and females known to present atypically
Risk factors:
- Modifiable = hyperlipidaemia/dyslipidaemia (high LDL and VLDL, low
HDL), HTN, smoking, T2DM
- Non-modifiable = age (strongest RF), gender (pre menopausal women =
decreased risk), family history (specifically under age of 65)
Types of MI:
- Type 1 = traditional MI due to acute coronary event
- Type 2 = ischaemia secondary to increased demand or reduced supply of
oxygen (e.g., secondary to anaemia, tachycardia or hypotension)
- Type 3 = sudden cardiac death or cardiac arrest suggestive of an
ischaemic event
- Type 4 = MI associated with procedures e.g., PCI, coronary stenting and
CABG
Investigations:
- ABCDE approach, senior review, assess if patient is haemodynamically
stable (using full history, exam, and obs)
- Bedside: obs, ECG, BM, ABG
- Cardioresp exam
- Multiple ECG repeats
- Bloods: FBC, coagulation studies, U&Es, LFTs, troponin (very sensitive but
not very specific), pro-ntBNP
- CXR (to look for signs of HF, pulmonary oedema and rule out respiratory
causes)
- Echo (regional wall motion abnormalities and impaired left ventricular
function)
,GRACE SCORE:
- Risk of death or future MI for the patient based on their clinical features
of presentation of MI
TREATMENT:
1. Aspirin 300mg loading dose followed by 75mg OD (dual antiplatelet)
2. Tricagrelor 180mg followed by 90mg BD (dual antiplatelet), if the patient
has a comorbid bleeding disorder then give clopidogrel instead
3. Morphine (for pain & to reduce HR) with anti-emetic
4. Oxygen if patient is hypoxic (sats <90%)
5. Nitrates to dilate coronary arteries which can be GTN spray or infusion
(be careful of hypotension)
6. Fondaparinux (anti-thrombotic) 2.5mg OD offers anti-thrombin therapy
(unfractioned heparin given during PCI therapy)
7. Other medications include beta-blockers, ACEi/ARB, statin, PPI, +/-
diuretic
8. Angiography/stenting
9. Long-term lifestyle & therapies:
, - 20-30 mins daily physical activity
- Smoking cessation
- Mediterranean diet
- Cardiac rehab
- Medication: aspirin, beta blocker, ACEi, statin
- Eplerenone for patients with comorbid HF with EF <40%
ANGIOGRAPHY/STENTING:
- STEMI = complete occlusion of blood flow with no collateral blood supply
and so irreversible myocardial necrosis can occur within 20-40 mins
Post-MI Complications: DARTH VADER
- Death
- Arrhythmia (VT & Vfib most dangerous)
- Ruptures e.g., ventricular wall, septal, papillary muscle
- Tamponade (linked to rupture)
- HF (Acute or chronic pulmonary oedema)
- Valvular disease e.g., papillary muscle rupture (mitral regurgitation),
septal rupture/ventricular septal defect
- Aneurysm
- Dressler’s syndrome (pericarditis due to autoantibodies)
- Embolism (LV mural thrombosis can lead to stroke)
- Recurrence (most likely based on diabetes, age, and eGFR)
