Acute coronary Syndrome and Myocardial infarction Flashcards Preview

Year 3 - CR > Acute coronary Syndrome and Myocardial infarction > Flashcards

Flashcards in Acute coronary Syndrome and Myocardial infarction Deck (64)
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1

What is the definition of an MI

Rise and/or fall of troponin with at least one value >99th percentile of the URL, plus at least one of the following:
- Cardiac chest pain
- ECG changes (new ST-T change or new LBBB)

2

What are the two types of AMI

- STEMI
- NSTEMI - unstable angina

3

Describe what happens in an NSTEMI

- ruptured coronary plaque with subocclusvie thrombus
- ECG non diagnostic

4

Describe what happens in a STEMI

- Ruptured coronary plaque with occlusive thrombus
- ECG diagnostic

5

What troponin is used in to see if you have an MI

Troponin I and T
- specific to the heart

6

What are the classifications of AMI

Type 1
- spontaneous AMI
- due to plaque rupture

Type 2
- ischaemic imbalance
- due to coronary spasm, embolism , dissection, hypotension

Type 3
- cardaic death
- due to presumed AMI

Type 4a
- related to PCR
- greater than 5 times URL for troponin

Type 4b
- caused by stent thrombosis
- confirmed at angiography or autopsy

Type 5
- related to CABG
- greater than 10 times URL for troponin

7

how many people die from AMI before they reach to hospital

33% of people who die from AMI do so before they reach hospital

8

who delays in calling for help with an AMI

• Older people
• Women
• Nocturnal or w/e pain
• No previous AMI
• People with diabetes

9

what are the determinants of infarct size

Anatomical
- distribution of occluded artery
- proximity of coronary occlusion
- collateralization of occluded artery

Physiological
- thrombotic response to plaque rupture
- effectiveness of endogenous thrombolysis

Therapeutic
- reperfusion therapy
- antiplatelet drugs
- drugs to protect against LV remodelling

Logistical
- time to call for help
- time to arrive at hospital
- time to delivery of reperfusion therapy

10

If the
- circumflex
- RCA
- LAD

is damaged where is the STEM on the ECG

- circumflex = lateral STEMI
- RCA = Inferior STEMI
- LAD - anterior STEMI

11

What is the pathway when a patient comes in complaining of chest pain

1. Do an ECG = if it is diagnostic then Admit
2. if ECG is non diagnostic then do a clinical assessment = if there is typical chest pain or heart failure or unstable rhythm then admit
3. if there is atypical Chest Pain and rhythmically and haemodynamically stable then look at biomarkers
4. if biomarkers are troponin positive then admit
5. if biomarkers are troponin negative then the patient is a low risk patient
- send them home and consider a further out patient investigation

12

how is troponin used to rule out AMI in A and E

1. Allows diagnostic thresholds to be set at very low levels
2. Improves diagnostic sensitivty
3. Endorsed by NICE for accelerating diagnostic pathways and reducing pressure on beds

13

How do you treat a STEMI

- Aspirin and ticagrelor (P2Y12 receptor antagonists)
- GpIIb/IIIa inhibitor
- unfractionated/LMWH
- PPCI

14

What type of drug is ticagrelor

P2Y12 receptor antagonists

15

What is the guidelines for treating a NSTEMI

Low risk
- aspirin 300mg
- fondaparinux
- ticagrelor 300mg
Then conservative management

Intermediate risk 3-6%
- aspirin 300mg
- fondaparinux
- ticagrelor 300mg
- consdier tirofiban/eptifibatide for intermiediate or high risk groups
- Coronary angiogram within 96 hours or earlier for unstable patients - PCI or CABG

High risk greater than 6%
- aspirin 300mg
- fondaparinux
- ticagrelor 300mg
- consdier tirofiban/eptifibatide for intermiediate or high risk groups
- Coronary angiogram within 96 hours or earlier for unstable patients - PCI or CABG

16

If you have a STEMI what do you get immediately

- Coronary angiography - then PCI or CABG

17

What are the two important complications in an MI (IMPORTANT - IN EXAM)

- Heart failure
- Arrhythmia

18

How do you treat heart failure

Diuretics
• IV frusemide
• Haemofiltration if
diuretic resistant

RAS Inhibition
• ACE-I or ARB
• Eplerenone

Inotropes
• Noradrenaline
• Dobutamine

LV support device
• Balloon pump?
• LVAD?

19

name the two types of Arrhythmia

Bradyarrhythmias
Tachyarrhythmias

20

Describe how an AV node block and complete AV node block

rate of depolarisation goes from fast, slower, much slower as you get down
- depending on where the conduction system is damaged it determines how serious it is
- if you have a block at the AV node that is not a DT - pacemaker in the bundle of his will take over - the patient will feel fine - usually gets better on its own

21

How do you treat intermittent AV node block and complete AV node block

- Atropine if rate slow
- pacing rarely needed
- sponteaneous recovery in less than 7 days
- prognosis is good

22

What happens if both bundle branches blocked
(intermittent block of both bundle branches and complete block of both bundle branches)

- large infarct

23

What causes blockage of the AV node

inferior MI

24

How do you treat intermittent block of both bundle branches and complete block of both bundle branches

- Pacing mandatory
- no spontaneous recovery
- prognosis poor

25

Name some types of tachyarrythmias

- atrial fibrillation
- VT, VF

26

How do you treat an atrial fibrillation

- Beta blocker
- DV cardioversion if haemodynamic compromise
- if arrhythmia persists needs anticoagulation with later consideration of rate vs rhythm control

27

What is the difference between early and late ventricular tachyarrhythmias

- ventricular tachyarrhythmias that complicate AMI usually occur in the first 12-24 hours when if corrected they have only minor prognostic impact

- but if late VT/VF after 24 hours presentation are a bad prognostic sign are predictive of sudden death in the first year

28

what treatment is for life expect

except P2Y12 receptor antagonist = ticagrelor

29

what is the prevention lifestyle

• smoking
• diet
• exercise

30

What are the prevention drugs

• aspirin 75mg and a second antiplatlet e.g. clopidogrel for at least 12 months to decrease stroke
• P2Y12 receptor antagonist
• statin
• beta-blocker - reduce myocardial oxygen demand
• ACE-I - in patients with LV dysfunction, hypertension or diabetes unless not tolerated