Presentation on theme: "ACS – Finals Revision Dr Ian Hunt, FY1"— Presentation transcript:
ACS – Finals Revision Dr Ian Hunt, FY1
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
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.
ACS Definition and Types Pathophysiology Signs and Symptoms Clinical approach to the patient – Investigations: Bloods, ECG, Angiography, Other – Management Acute Chronic Complications Case Discussion
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
3 is the magic number (De-La-Soul 1989) 3 parts: – Unstable Angina – NSTEMI – Non-ST Elevated MI – STEMI – ST Elevated MI
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
Pathophsyiology – Plaque formation
Pathophysiology – From plaque to ACS (1) Plaque can lead to ACS by – Erosion/Fissure – Rupture This leads to: – Thrombosis (which can also embolise)
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
How to approach the patient
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?
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
Sites of infarct (1,2)
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
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
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
Complications (2) S – Sudden Death P – Pump Failure A – Aneurysm/Arrhythmias R – Rupture papillary muscle/septum E - Embolism D – Dressler’s syndrome / Acute pericarditis
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
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.
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