Key 1, 10- ACS

ACS (acute coronary syndrome)

- reduced blood flow to heart muscle causing

-chest discomfort called Ischemic Chest Pain

ACS (acute coronary syndrome) includes

1. STEMI

2.NSTEMI

3. Unstable Angina

ECG changes for ACS? (Yes No)

Main Sign Symptoms of ACS

1. Chest pain

2. Dyspnea

3. Sweating

4. Nausea and vomiting

5. May appear pale and clammy

Unstable Angina

Symptom Based on

1. thrombus

2. ECG

3. Cardiac Enzyme

Symptom Based on

1. thrombus - non occlusive

2. ECG - non specific ECG

3. Cardiac Enzyme - normal

NSTEMI

Symptom Based on

1. thrombus

2. ECG

3. Cardiac Enzyme

symptom based on

1. occluding may cause tissue damage and mild necrois

2. ST depression w/wo T wave inversion

3. Elevated

STEMI

Symptom Based on

1. thrombus

2. ECG

3. Cardiac Enzyme

Symptom Based on

1. Complete occlusion

2. ST elevation/ LBBB

3. Elevated

4. More severe symptoms

How is the Chest Pain described in ACS

Heavy like elephant sitting on chest

Location: Central, left-sided, substernal, epigastric

Radiate to: Jaw, Left arm, shoulder

who may not experience Chest Pain for ACS during MI and what is it called?

SILENT MI - elderly & Diabetic

Risk Factors of IHD/ACS can be devided in to 2 groups which are - _____ and _____ factors

Unmodifiable

Age, Male Gender, Family History

Modifiable

Smoking

DM

Hypertension

Hypercholesterolaemia

Obesity

Diagnostic for IHD/ ACS/ ICP

1. ECG

2. Cardiac Markers - troponin

Type of MI/ site of MI

Inferior MI

Lateral MI

Anteroseptal MI

AnteroLateral MI

Right Coronary Artery Damage

1. Name the changes in ECG leads

2. Name of the site of MI

1. 2,3,avf

2. Inferior MI

Left Circumflex Artery

1. Name the changes in ECG leads

2. Name of the site of MI

1. 1, V5,V6, aVL

2. Lateral MI

LAD artery (Left Anterior Decending)

1. Name the changes in ECG leads

2. Name of the site of MI

1. v1-v4

2. Anterior MI/ Anteroseptal MI

LAD/ Circumflex Artery type of MI

1. Name the changes in ECG leads

2. Name of the site of MI

1. same as lateral MI just plus v4

2. AnteroLateral MI

SITE?

ST elevated Leads on ECG

Ocluded Artery?

Inferior MI

||,|||, aVF

Right Coronary

ECG:

Wide spread ST depression

ST elevation in aVR

Left Main Coronary Artery Occlusion (LMCA)

What to do? ECA Emergency coronary angiography

Chest pain + T wave inversion. what ecg condition does it mean?

What drugs should be given immediately

ECG for myocardial ischemia

ASPIRIN 300g + LMWH or FONDAPIRANUX

What to do in LMCA ?

Emergency Coronary Angiography

Inferior, Lateral, Anteroseptal, AnteroLateral

1. ST elevated Leads

2. Occluded Artery

Name each lead and artery for each site

Management of STEMI for Acute. Each in Details

1._____

2._____

3._____

1. MONA + Heparin

a) IV Morphine

b) O2

c) Nitrates

d) Aspirin 300 mg

Heparin can be either LMWH/ unfeagmented Heparin

2. PCI - Balloon Angioplasty + Stent via catheter into radial or femoral Artery

   (only if pt presents within 12 hours of the onset symptom)

3. Thrombolysis - Alteplase > Streptokinase

What should we use if PCI is not available in acute STEMI?

TA>S

Thrombolysis (Alteplase>streptokinase)

Management for Long Term STEMI (Chronic) *5 names

For life *3

For 12 months *2

For life *3

• Aspirin

• ACE inhibitor - Enalapril

• Statin - Atorvastatin 80 mg PO OD

For 12 months *2

• Beta Blockers - Bisoprolol

• clopidogrel (anti platelet)

(AASBC)

Name the STATIN(dosage and indication) for chronic STEMI management

Atorvorstatin 80mg PO OD (per so once daily)

Immediate management NSTEMI & UA

_____+____ is given as soon as possible.

Asiprin 300mg + subcutaneous LMWH(daltepain/enoxaparin)/ Fondaparinux

management of NSTMI & UA + management requirement before PCI if planned

There is 6, 3 if not plannning for CPI, 3 more planning for CPI

1. Aspirin 300mg + Antithrombin LMWH (enoxaparin/ fondaparinux) [subcutaneous] if no high risk of bleeding

2. Nitrates and morphine to relief chest pain if required

3. Second Antiplatelet - clopidogrel

4. Planning for CPI during NON STEMI/ creatine is > 265 micomol/l - unfractionated Heparin given [intravenously]

5. IV glycoprotein ||b/ |||a receptor antagonist (eptifibatide/ tirofiban)

6. Coronary Angiography

Antithrombin LMWH is given when no_____ within next____ and not high risk of_____.

no angioplasty

next 24 hours

not high risk of bleeding

Ask yourself these: is there angioplasty surgery in next 24H/ high risk bleeding?

If no - Antithrombin LMWH (enoxaparin/ fondaparinux) [subcutaneous]

If yes/ creatine is > 265 micomol/l - unfractionated Heparin given [intravenously]

_________should be given for patient with NSTEMI & UA if _____ is within next 24 hours or ______ is >______micomol/l. How is it given? subcutaneous/ IV

Unfractionated Heparin, angioplasty, creatinine, 265

Given IV

LMWH is given_____ and Unfragmented Heparin is given ______ in management for NSTEMI/UA

subcutaneously, IV

name the action needed for:

• Indicated for: Patients with intermediate or high risk of adverse CV events
  (Predicted 6-month mortality > 3.0%)

• Timing: Scheduled for angiography within 96 hours of hospital admission

IV Glycoprotein IIb/IIIa Inhibitors (e.g., Eptifibatide, Tirofiban)

action needed for pt with NSTEMI with below description:

• Consider within 96 hours of hospital admission in patients with
  predicted 6-month mortality > 3.0%

• Perform immediately in clinically unstable patients, including:
  

  • Refractory chest pain

  • Hemodynamic instability

  • Life-threatening arrhythmias

Coronary Angiography

6 weeks after MI, a patient returns with SOB when walking long distance and his ECG shows ST elevation in V1-V5 leads.

What is the likely cause?

Left ventrcular Aneurysm

(Persistent ST elevation—- think of LV Aneurysm)