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ACS – Finals Revision Dr Ian Hunt, FY1

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1 ACS – Finals Revision Dr Ian Hunt, FY1

2 A few confessions I’m working on Psychiatry I don’t have all the answers (see above) I’m quite lazy I’m a little crazy

3 Objectives By the end of the session: Identify current knowledge (strengths and weaknesses) about ACS Identify the level of knowledge required for passing finals Identify how the theory relates to how to actually be a decent junior doctor in an ACS scenario By finals: To have learn, retained and know how to apply the information required to pass finals that we have identified To be competent at managing ACS in the acute setting.

4 ACS Definition and Types Pathophysiology Signs and Symptoms Clinical approach to the patient – Investigations: Bloods, ECG, Angiography, Other – Management Acute Chronic Complications Case Discussion

5 Definition Acute: Comes on quickly Coronary: Relating to the arteries supply the heart Syndrome: Group of symptoms A group of symptoms associated with the heart arteries which come on quickly (Roughly) – Not relieved by rest/removal of possible trigger – Lasting more than 20 minutes despite GTN

6 3 is the magic number (De-La-Soul 1989) 3 parts: – Unstable Angina – NSTEMI – Non-ST Elevated MI – STEMI – ST Elevated MI

7 Pathophysiology – RF (1) ModifiableNon - Modifiable Hyperlipidaemia Smoking Hypertension Diabetes mellitus Lack of exercise Obesity Heavy alcohol consumption Abnormal coagulation factors– High fibrinogen or Factor VII Homocysteinaemia Gout Drugs: OCP, COX-2 inhibitors, Cocaine Personality CRP Soft water Age – Old is bad Sex – Men are bad Family history – Genes are bad

8 Pathophsyiology – Plaque formation

9 Pathophysiology – From plaque to ACS (1) Plaque can lead to ACS by – Erosion/Fissure – Rupture This leads to: – Thrombosis (which can also embolise)

10 Signs and symptoms (1) Symptoms Pain – Crushing/Squeezing/ Heaviness – Retrosternal Or: Epigastric, Back, Neck, Jaw, Shoulder – Radiation to any of the above – With or without trigger? Nausea Dizziness/Syncope SOB Sense of impending doom or NOTHING! – Diabetics/Elderly/Women Signs Tachycardia/Bradycardia Hypotension/Syncope Tachypheonia Vomiting Pallor Signs of acute heart failure – Crepiations, Raised JVP, Murmors

11 How to approach the patient

12 Super acute management (1,3) Reassurance MONA? – Morphine, Oxygen, Nitrates, Aspirin – Morphine 5-10mg IV (Metoclopramide 10mg IV) – GTN spray(400mcg)/tablet(300mcg) - Sublingually (repeat up to 3 times) – BUT NOT WHEN? – Aspirin 300mg stat dose – Oxygen should already be on! HELP?

13 Investigations Bloods- – FBC, U+E, Coag, Trop T, Lipids, Glucose – Other enzymes: Trop I, CK, AST, LDH ECG CXR? Angiography ECGTroponin T STEMIST elevationPositive NSTEMI+/- ST depressionPositive Unstable angina-Negative

14 ECG Findings

15 ECGs

16 Sites of infarct (1,2)

17 ECG

18 Unstable Angina/NSTEMI (3) Global Registry of Acute Cardiac Events [GRACE] 300mg (vs 600mg) Clopidogrel STAT – followed by 12 months course LMWH (8days) – (If no angio – if angio unfractionated heperin) – Fundaparinux – 2.5mg s/c – Enoxiparin 1mg/kg BD s/c Consider Glycoprotein IIb/IIIa inhibitors for high risk then angiography +/- stent

19 STEMI (4) PCI – percutanous coronary intervention – 600mg Clopidogrel loading dose – <2 hours of chest pain at presentation – Door to table <90 minutes If your to slow: Thrombolysis: – Know some CI – Haemoragic stoke, major surgery (recent), active bleeding, coagulation issues, Ischemic stroke in last 6 months. – tPA or streptokinase

20 Finish the Job Repeat ECGs, bloods Bed rest – 48 hours B-blocker – atenalol 5mg IV (unless asthma/LVF) Transfer to CCU/ICU Don’t forget to call for help Secondary prevention

21 Complications (2) S – Sudden Death P – Pump Failure A – Aneurysm/Arrhythmias R – Rupture papillary muscle/septum E - Embolism D – Dressler’s syndrome / Acute pericarditis

22 Secondary prevention Lifestyle advice – Diet – Exercise – Smoking Reduce stress on heart – ACEI – B-blocker – Statin Reduce acute events – Aspirin – Clopidogrel

23 Case Presentation (5 minutes) 4.45pm. Friday. Mr Geldoff, 83 yo, Male. Psychiatric inpatient Collapses to the floor clutching chest Chest pain – Unable to communicate much more than that. Maybe a bit sharp but achey Obese No previous cardiac history (you think) DDx Initial management and investigation

24 Take home points Finals is about being safe not being a consultant ABCDE approach to all acute patients All vaguely ACS sounding chest pain should be assumed to be an MI until you have evidence otherwise Have a system and stick to it.

25 Questions

26 References 1.Kumar and Clark's Clinical Medicine, 8e, By Parveen Kumar and Michael Clark. Saunders Ltd Cardiology (notes)– Dr R Clarke 3.Unstable angina and NSTEMI, NICE quick reference guide, March Advanced Life Support (6th edition), January 2011

27 Pictures a-chair-drinking-too-much-and-smoking-too-much.jpg a-chair-drinking-too-much-and-smoking-too-much.jpg Kumar and clarke 8 th Deprenyl-%E2%80%93-Part-II-.jpg Deprenyl-%E2%80%93-Part-II-.jpg


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