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ACS – Finals Revision

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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