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Acute Coronary Syndrome By Ina Ko Imperial College Healthcare Trust 5 December, 6pm @BRITISHINDIANMEDICASSOCIATION @BINDIANMEDICS BRITISH INDIAN MEDICAL @BIMA ASSOCIATION BIMA Clinical SeriesSession plan ● ECG interpretation ● Introduction to acute coronary syndrome ● Stable angina ● Unstable angina ● Non-ST elevation myocardial infarction (NSTEMI) ● ST elevation myocardial infarction (STEMI)ECG interpretationECG interpretation system 1. Patient ID + if symptomatic at time of ECG 2. Heart rate 3. Rhythm 4. Cardiac axis 5. P waves 6. PR interval 7. QRS complex 8. ST segment 9. T wave 10. QTc lengthECG territories of the heart Lead I avR V1 V4 Lateral Septal Anterior Circumflex artery Left anterior descending Right coronary artery artery (LAD) Lead II aVL V2 V5 Inferior Lateral Septal Lateral Right coronary artery circumflex artery Left anterior descending circumflex artery artery (LAD) Lead III aVF V3 V6 Inferior Inferior Anterior Lateral Right coronary artery Right coronary artery Right coronary artery circumflex arteryStable anginaDiagnostic criteria of stable angina • NICE diagnostic criteria for stable angina • Clinical history in keeping with anginal chest pain • Significant coronary artery disease on CT coronary angiography or • Reversible myocardial ischaemia on non-invasive functional imaging • NICE criteria of anginal chest pain • Constricting discomfort, front of chest/neck/shoulder/jaw/arms • Precipitated by physical exertion • Relieved by rest or GTN within about 5 minutesInvestigations Specialist and Bedside Bloods Imaging scoring • Cardiac • Cardiac risk • Echo • Rapid access examination • HbA1c • CT angiogram Chest Pain • Vital signs Clinic • Lipids • Exercise ECG • Invasive • ECG • Exacerbating stress test coronary factors angiography • FBC (anaemia) • Qrisk score • TFTs • U&Es • Baseline prior to Tx • LFTs (statin)Management of stable angina - overview Conservative Medical Surgical •Health •Acute relief •CABG education •Anti-anginal •PCI •Smoking •Cardiac risk cessation management •Diet •Exercise •Normal weightManagement - medical Short term • For acute symptom relief, PRN nitrate st • verapamil)eta-blocker (e.g. bisoprolol) or calcium channel blocker (e.g. diltiazem or • 2nline – dual treatment (BB + CCB) Anti-anginal • 3 line – monotherapy with either: • Long-acting nitrate; Ivabradine; Nicorandil; Ranolazine • 4 line – triple therapy • Aspirin Secondary • ACEi • Atorvastatin prevention • HTN treatmentIntroduction to acute coronary syndromeAcute coronary syndrome ● Refers to spectrum of cardiac disease were myocardial perfusion is compromised ● Includes: ○ Unstable angina ○ Non-ST elevation MI (NSTEMI) ○ ST elevation MI (STEMI) ● Underlying pathology ○ Most commonly due to atherosclerosis ● Shared risk factors ○ Non-modifiable – age, male, FHx, ethnicity ○ Modifiable – smoking, HTN, DM, hyperlipidaemia, obesity, sedentary lifestylPresentation of ACS • Cardiac chest pain • Silent MI symptoms • Syncope • Sympathetic symptoms • Pulmonary oedema • Epigastric pain • Nausea and vomiting • Acute confusion • Sweating • Hyperglycaemic state (DM) • SOB • palpitationsCardiac chest pain • Features differentiating chest pain vs cardiac chest pain •Sudden onset severe, central, crushing chest pain • May radiate to arms, jaw or back •Constant, lasting > 15 minutes •Unstable angina – onset at rest •Worse on exertion •May have complete or partial relief with GTN/restInvestigations in the acute setting - ACS Specialist Bedside Bloods Imaging or scoring • ECG • Cardiac enzymes • CXR • Cardiac • Examine • Troponin • Echocardiogram angiography • Cardio & resp • Creatinine kinase • GRACE score • Vitals MB • FBC, U&E, lactate • RF – glucose, lipidsUnstable anginaUnstable angina ● Refers to cardiac chest pain which may occur at rest and is not relieved by rest or GTN ○ No dynamic ECG changes ○ No biochemistry in keeping with acute MI ● NICE recommends initial treatment in line with NSTEMI managementMyocardial infarctionNSTEMI vs STEMI ● Both are associated with ischaemic insult of the myocardium ● Biochemistry is expected to be positive in both ● STEMI ○ New ST elevation in consecutive leads ○ New onset LBBB ● NSTEMI ○ Any other ischaemic features on ECG ○ E.g. T wave inversion, ST depressionECG evolution in STEMI ● Hyperacute T-waves (minutes to hours) ● ST elevation (0-12 hours) ● Pathological Q waves (1-12 hours) ● ST back to baseline, T wave inversion (2-5 days) ● T wave normalisation (weeks to months) ● Pathological Q waves in the affected leads are usually permanent changes ● If anterior segment ST elevation persists, LV aneurysm should be suspected.T waves in ischaemia Hyperacute T wave Inverted T waveST segment changes in ischaemia ST elevation ST depressionPathological Q wavesLeft bundle branch blockECG 1ECG 2ECG 3Acute management – NSTEMI and unstable angina 1. Hospital, admission + A-E resuscitation 2. Oxygen if saturations < 94% 3. 300mg PO aspirin 4. GTN spray 5. IV morphine + anti-emetic 6. Anti-thrombin treatment – fondaparinux or LMWH ○ Not if for immediate PCI or very high bleeding risk 7. Second anti-platelet loading if high risk 8. Coronary angiography + PCI within 72 hours if high riskAcute management - STEMI 1. Hospital, admission + A-E resuscitation 2. Oxygen if saturations < 94% 3. 300mg PO aspirin 4. Loading with second anti-platelet ○ 180mg ticagrelor or prasugrel 60mg or 300mg clopidogrel if bleeding risk 5. GTN spray 6. IV morphine + anti-emetic 7. Treatment of MI 1. Coronary angiography + PCI ■ within 12 hours of onset of pain + 120 minutes of presentation 2. Thrombolysis – if PCI unavailable, streptokinase + fondaparinux, must be ICULong term management Cardiac rehabilitation • Physical activity • Lifestyle advice • Stress management • Health education Secondary prevention • ACEi • Dual antiplatelet therapy • Beta-blocker • High dose statin • SpironolactoneComplications of myocardial infarction Complication type Manifestation Ischaemic - Angina - Re-infarction - Infract extension Mechanical - Heart failure – acute or chronic - Mitral valve dysfunction (papillary muscle rupture/infarct) - Aneurysms (ventricular) - Cardiac rupture (ventricle free wall Arrythmia - Arrhythmia - Heart block common in inferior MI as RCA supplies SA node Embolic - Thromboembolism due to mural thrombus formation Inflammatory - Dressler’s syndrome (pericarditis)Case based discussion ● A 65 year old gentleman presents to A&E with central chest pain which he describes as someone sitting on his chest. The pain started 30 minutes ago and is spreading up his left jaw. He has vomited twice since the pain started and is feeling sweaty. He has never had this pain before. He is a smoker with a 40 year pack history. He is a type 2 diabetic on diet control, with a BMI of 32. He does not take any regular medication. No significant family history. ● On arrival to A&E his observations are: HR 120, BP 110/80, saturations 92%, temperature 37.2, RR 18Case based discussion ● What is the next most appropriate step? 1. ECG 2. Start oxygen 3. Put out an arrest call 4. Give 300mg aspirin 5. Check his blood sugarCase based discussion ● What is the next most appropriate step? 1. ECG 2. Start oxygen 3. Put out an arrest call 4. Give 300mg aspirin 5. Check his blood sugarCase based discussionCase based discussion ● What is the next most appropriate next step? 1. GTN spray 2. Loading dose of 300mg aspirin and 180mg ticagrelol 3. IV fluids 4. Fondaparinux and transfer to ICU for thrombolysis 5. TroponinCase based discussion ● What is the next most appropriate next step? 1. GTN spray 2. Loading dose of 300mg aspirin and 180mg ticagrelol 3. IV fluids 4. Fondaparinux and transfer to ICU for thrombolysis 5. TroponinCase based discussion ● The patient is admitted to hospital and treated with PCI. Prior to discharge the FY1 is asked to review the patients cardiac risk factors which are amenable to optimisation in view of reducing risk of a future cardiac event. ● Select all that apply: 1. Male 2. Smoking 3. History of paternal MI at 80 4. T2DM 5. ObesityCase based discussion ● The patient is admitted to hospital and treated with PCI. Prior to discharge the FY1 is asked to review the patients cardiac risk factors which are amenable to optimisation in view of reducing risk of a future cardiac event. ● Select all that apply: 1. Male 2. Smoking 3. History of paternal MI at 80 4. T2DM 5. ObesityCase based discussion ● After his PCI the patient is asking how long he needs to take blood thinners for? ● Select the correct answer: 1. He can stop on discharge 2. He needs both lifelong 3. He must continue both for 1 year and then take aspirin lifelong 4. On discharge he only needs to take the aspirin 5. He can stop 6 weeks after PCICase based discussion ● After his PCI the patient is asking how long he needs to take blood thinners for? ● Select the correct answer: 1. He can stop on discharge 2. He needs both lifelong 3. He must continue both for 1 year and then take aspirin lifelong 4. On discharge he only needs to take the aspirin 5. He can stop 6 weeks after PCITHANK YOU FOR LISTENING ANY QUESTIONS INSERT QR CODE FOR FEEDBACK FORM BIMA Clinical Series TEMPLATE INCOMPLETE