Acute coronary syndrome (ACS)

Dr Darren Reed FY1

Scenario 1

58 year old man

30 minute history of severe chest pain, 10/10, radiating to jaw, not relieved by anything, associated with sweating and nausea. Known angina.

What investigations would you like?

What do you expect to find?

What would you do next?

Atherosclerosis

ACS – umbrella term

Stable Angina Unstable Angina NSTEMI STEMI

ACS

ACS is a spectrum, especially between UA and NSTEMI, where the severity affects degree of cardiac insult.

Terminology

Differentiating ACS

ECG

No ST-elevationST-elevation

Troponin T

Raised Not raised

STEMI

NSTEMI Unstable angina

Chest pain ?ACS

ECG Troponin T

STEMI ST elevation Positive

NSTEMI +/- ST depression Positive

Unstable angina - Negative

Remember posterior infarcts can cause ST depression

Risk factors

MODIFIABLE Smoking Obesity Diet No exercise Hypercholesterolaemia Hypertension Diabetes?

UNMODIFIABLE Increased age Gender (male) Ethnicity Family Hx Diabetes?

Signs and symptoms

Signs Pallor Tachycardia Pulmonary

crepitations Raised JVP Murmurs

Symptoms Pain SOB Sweating Syncope N&V

History

Chest pain?

Brief PMH – why?

Risk factors?

Allergies?

Current meds?

Differential diagnosis

Cardiac•MI•Angina•Pericarditis•Aortic dissection

Respiratory

•Pulmonary embolism•Pneumothorax•Pneumonia

GI•Oesophageal spasm•GORD•Pancreatitis

Investigations

Bedside ECG, obs

Blood FBC, U+E, clotting screen, Trop T, glucose, lipids

Imaging ?CXR

Special tests

Diagnosis (2/3):- Convincing MI history- ECG with ST changes- Cardiac enzymes raised

Management

A – airway

B – breathing

O2, aim sats > 95%

C – circulation

Sats probe, BP, HR, IV access

D – disability

E – exposure

ECG

MONA

Morphine

Oxygen

Nitrates

Aspirin

Clopidogrel

Beta blocker (not in asthma, or with heart failure)

Antiemetic

Time is muscle…

Percutaneous coronary intervention (angioplasty)

Thrombolysis (beware CI)

CABG

Subacute management

Bed rest 48 hours

Gradual build up in activity over 1-2 months

Thromboprophylaxis

Job?

Secondary prevention

Statins ACE inhibitors Beta blocker Life style advice Aspirin/clopidogrel

MODIFIABLE Hypercholesterolaemia Hypertension Diabetes? Smoking Obesity Diet No exercise

UA/NSTEMI

Oxygen

Nitrates

Clopidogrel

Aspirin

LMWH

Risk assess (TIMI score) ?intervention

Complications

Sudden death

PE

Rupture of ventricle

Arrythmia/aneurysm

Emboli

Dressler’s syndrome (AI pericarditis)

ECG quizThis shows posterior infarct?

ECG quiz

This only shows evidence of an old infarct?

LBBB indicating STEMI?

Anterior MI?

Scenario 2

It’s 23:15, you’re on nights.

You’re about to take some bloods, for gentamicin levels, for a patient due to have their next dose at 24:00.

You’ve just been bleeped by a nurse because a patient on another ward has developed chest pain...

What do you do next?

Take home message

ECG as soon as possible, repeat often

ABCDE + structured approach

Know your acute management – MONA ABCE

Senior review if unsure what’s happening

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