Cardiology

Acute Coronary Syndrome (ACS)

  • Definition: Spectrum of acute myocardial ischemia or infarction.

    • STEMI (ST-Elevation Myocardial Infarction):

      • ECG shows ST elevation.

      • Troponin levels positive.

    • NSTEMI (Non-ST Elevation Myocardial Infarction):

      • ECG may be normal or show other changes.

      • Troponin levels positive.

    • Unstable Angina:

      • Normal ECG and normal troponin levels.

  • Symptoms/Signs:

    • Angina at rest (>20 min) not relieved by GTN.

    • Gripping/heavy pain associated with:

      • Nausea

      • Sweating

      • Dyspnea

      • Palpitations

  • Investigations:

    • ECG, ABG, laboratory tests (troponins, FBC, lipids, HbA1c, U&E, LFT, TFT), CXR, echo, blood glucose.

  • Management:

    • All patients: 300 mg Aspirin, Oxygen if saturation <94%, 1g Paracetamol PO/IV (Morphine if severe pain), 1 spray GTN (caution for hypotension), ± 4 mg IV Ondansetron.

    • Unstable Angina & Secondary Prevention (lifelong):

      • 6As: 75 mg Aspirin OD, another antiplatelet for 12 months (e.g., Clopidogrel), 80 mg Atorvastatin OD, ACEI (e.g., Ramipril), Atenolol (or Bisoprolol), Aldosterone antagonist for HF (e.g., Eplerenone).

Complications of ACS

  • Mnemonic: DREAD

    • Death

    • Rupture of myocardium

    • Edema

    • Arrhythmia and aneurysms

    • Dressler's syndrome

  • Prognosis: ~10% morbidity; risk for future events.

STEMI Diagnosis Criteria

  • Symptoms/signs: ≥20 min.

  • ECG features in ≥2 contiguous leads such as:

    • Men: 2.5 mm ST elevation in V2-3 (≤40 yo) or 2.0 mm (>40 yo).

    • Women: 1.5 mm ST elevation in V2-3.

    • 1 mm ST elevation in other leads OR new LBBB (pathological).

    • Must be within 12 hours of symptoms onset and PCI possible within 2 hours.

Intervention and Treatment for STEMI

  • Primary PCI:

    • Possible within 2 hours while considering the following: Prasugrel or Clopidogrel (if patient on PO anticoagulant), Ticagrelor (high risk bleeding).

    • Obtain radial access preferred over femoral.

    • UFH + bailout GPIIb/IIIa inhibitor.

    • PCI: Drug-eluting stent.

  • Fibrinolysis:

    • Alteplase + antithrombin, followed by Ticagrelor.

    • If no ECG resolution after 60-90 min, proceed to PCI.

NSTEMI Management

  • Risk Assessment (GRACE Score):

    • ≤3%: Low risk management (Fondaparinux & Ticagrelor).

    • 3%: Intermediate/high risk.

      • Unstable: Immediate PCI.

      • Stable: PCI within 72 hours; give Fondaparinux, Prasugrel or Ticagrelor, and UFH.

Special Considerations

  • Cocaine use: add IV benzodiazepine; avoid beta-blockers.

  • Lifestyle Recommendations: Mediterranean diet, 20-30 min exercise daily, sex can resume after 4 weeks, PDE-5 inhibitors after 6 months.

Hypertension Overview

  • Definition: Persistently raised BP due to multiple factors.

  • Classification:

    • Stage 1: Clinic BP ≥140/90 or ABPM ≥135/85

    • Stage 2: Clinic BP ≥160/100 or ABPM ≥150/95

    • Stage 3 (Hypertensive Crisis): Clinic BP ≥180/120.

Diagnosis of Hypertension

  • Measure BP twice after 5 min.

  • Use ABPM to diagnose (due to white coat syndrome).

  • Home BP monitoring: 2 readings AM/PM for 4-7 days.

Management of Hypertension

  • First-line agents include:

    • ACEI/ARB: monitor for cough, hyperkalemia, renal function.

    • CCB: Verapamil and Diltiazem for rate control; monitor for HF.

    • Thiazide-like Diuretics: Monitor electrolytes and renal function.

    • Beta-blockers for specific circumstances.

Hypertensive Retinopathy Classification

  • Grade I: Barely detectable arterial narrowing.

  • Grade II: Obvious narrowing + focal irregularities.

  • Grade III: Presence of hemorrhages and exudates.

  • Grade IV: Papilledema.

Hypertensive Emergency Management

  • Define by target organ damage or high cardiovascular risk.

  • Initial management: Aim for gradual BP lowering.

  • Medications include CCB, ACEI, and diuretics.