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Mastering Acute Coronary Syndromes: Essential Knowledge for Finals Preparation

This comprehensive session aims to strengthen your understanding of Acute Coronary Syndromes (ACS) in preparation for finals. Attendees will identify their current knowledge, essential for passing, and learn how to effectively manage ACS in acute settings. Key topics include the definition and types of ACS, pathophysiology, clinical signs and symptoms, patient management strategies, and investigations. Participants will engage in case discussions to apply theoretical knowledge to practical scenarios, ensuring competency in ACS management.

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Mastering Acute Coronary Syndromes: Essential Knowledge for Finals Preparation

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  1. ACS – Finals Revision Dr Ian Hunt, FY1 Ian.Hunt@gmail.com

  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)

  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

  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 angiounfractionatedheperin) • 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 • Kumar and Clark's Clinical Medicine, 8e, By Parveen Kumar and Michael Clark. Saunders Ltd. 2013 • Cardiology (notes)– Dr R Clarke www.askdoctorclarke.com. • Unstable angina and NSTEMI, NICE quick reference guide, March 2010. • Advanced Life Support (6th edition), January 2011

  27. Pictures • http://www.davart.net/awg/wp-content/uploads/2012/08/shockedface.jpg • http://blog.vh1.com/files/2008/08/de-la-soul.jpg • http://digitaldeconstruction.com/wp-content/uploads/2012/06/overweight-mature-man-sitting-in-a-chair-drinking-too-much-and-smoking-too-much.jpg • Kumar and clarke 8th • http://kingmagic.files.wordpress.com/2008/10/chest_pain.jpg • http://www.gcu.ac.uk/media/gcalwebv2/library/content/help%20button.jpg • http://www.d-tect.net/images/accident_investigations.jpg • http://www.emedu.org/ecg/images/ami1a_ia.jpg • http://www.ekginterpretation.com/wp-content/uploads/2011/05/pericarditis-ekg-ecg.png • http://farm6.staticflickr.com/5021/5794684602_9dee38f5d3_z.jpg • http://en.hdyo.org/assets/ask-question-3-049ac6f2a4e25267fa670b61ee734100.jpg • http://www.mindandmuscle.net/articles/wp-content/uploads/2011/09/Chemically-Correct-L-Deprenyl-%E2%80%93-Part-II-.jpg • http://ankitremembers.files.wordpress.com/2012/08/pass1.gif • http://www.blogging4jobs.com/wp-content/uploads/2012/07/Job-Done.jpg

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