Acute Coronary Syndrome PDF

‭‬ ‭Acute Coronary Syndrome‬ ‭○‬ ‭Risk Factors for Coronary Artery Disease‬ ‭‬ ‭Non-Modifiable Risk Factors‬ ‭‬ ‭Age, sex, family history, and genetics‬ ‭‬ ‭Modifiable Risk Factors‬...

‭‬ ‭Acute Coronary Syndrome‬ ‭○‬ ‭Risk Factors for Coronary Artery Disease‬ ‭‬ ‭Non-Modifiable Risk Factors‬ ‭‬ ‭Age, sex, family history, and genetics‬ ‭‬ ‭Modifiable Risk Factors‬ ‭‬ ‭Smoking, atherogenic diet, alcohol intake, physical activity,‬ ‭dyslipidemias, hypertension, obesity, diabetes, metabolic‬ ‭syndrome‬ ‭○‬ ‭Spectrum of Ischemic Heart Disease‬ ‭‬ ‭Asymptomatic coronary artery diseas (CAD)‬ ‭‬ ‭Stable angina, chest pain with activity, predictable, lesions are usually‬ ‭fixed and calcified‬ ‭○‬ ‭Acute Coronary Syndrome‬ ‭‬ ‭Due to platelet-mediated thrombosis‬ ‭‬ ‭Can result in sudden cardiac death‬ ‭‬ ‭Multiple Types:‬ ‭‬ ‭Unstable angina‬ ‭○‬ ‭Chest pain at rest, unpredictable, may be relieved with‬ ‭nitroglycerin, troponin negative, ST depression, or T-wave‬ ‭inversion on the ECG.‬ ‭‬ ‭Non-ST Elevation Myocardial Infarction (NSTEMI)‬ ‭○‬ ‭Troponin positive, ST depression, T-wave inversion on the‬ ‭ECG, unrelenting chest pain‬ ‭‬ ‭ST Elevation Myocardial Infarction (STEMI)‬ ‭○‬ ‭Troponin positive, ST elevation in 2 or more contiguous‬ ‭leads, unrelenting chest pain.‬ ‭‬ ‭Variant or Prinzmetal’s Angina‬ ‭○‬ ‭A type of unstable angina associated with transient ST‬ ‭segment elevation.‬ ‭○‬ ‭Due to coronary artery spasm with or without‬ ‭atherosclerotic lesions.‬ ‭○‬ ‭Occurs at rest and may be cyclic (same time each day)‬ ‭○‬ ‭May be precipitated by nicotine, ETOH, cocaine ingestion‬ ‭○‬ ‭Troponin’s will be negative‬ ‭○‬ ‭Nitroglycerin (NTG) administration results in relief of chest‬ ‭pain and ST’s return to normal‬ ‭○‬ ‭Management of Acute Chest Pain‬ ‭‬ ‭Stat ECG, done and read within 10 minutes‬ ‭‬ ‭Allows categorization to STEMI, NSTEMI/Unstable Angina, or No‬ ‭Acute Change‬ ‭‬ ‭Allows risk stratification to high, medium, or low‬ ‭‬ ‭Aspirin‬ ‭‬ ‭Give ASAP; is chewed; improves morbidity and mortality‬ ‭‬ ‭Anticoagulant‬  ‭ ‬ ‭Heparin or Enoxaparin‬ ‭‬ ‭Antiplatelet Agents‬ ‭‬ ‭Clopidogrel (Plavix)‬ ‭‬ ‭Abciximab (Reopro)‬ ‭‬ ‭Eptifibatide (Integrilin)‬ ‭‬ ‭Tirofiban (Aggrastat)‬ ‭‬ ‭Beta Blockers‬ ‭‬ ‭Unless ACS is due to cocaine‬ ‭‬ ‭Use cardioselective sich as metoprolol (Lopressor)‬ ‭○‬ ‭Do not use non-cardioselective such as propranolol‬ ‭‬ ‭Contraindications include hypotension, bradycardia, use of‬ ‭phosphodiesterase inhibitor drugs such as sildenafil (viagra)‬ ‭‬ ‭Treat Pain‬ ‭‬ ‭Nitroglycerin‬ ‭‬ ‭Morphine‬ ‭‬ ‭History, risk factor assessment‬ ‭‬ ‭Lab assessment‬ ‭‬ ‭Cardiac biomarkers, lipid profiles, CBC, electrolytes, BUN,‬ ‭creatinine, magnesium, PT, PTT‬ ‭‬ ‭ECG Lead Changes and Location of Coronary Artery Disease‬ ‭‬ ‭Changes in II, III, aVF - Right Coronary Artery, Inferior LV‬ ‭‬ ‭Changes in V1, V2, V3, V4 - Left Anterior Descending, Anterior LV‬ ‭‬ ‭Changes in V5, V6, I, aVL - Circumflex, Lateral LV‬ ‭‬ ‭Chnages in V5, V6 - Low Lateral LV‬ ‭‬ ‭Changes in I, aVL - High Lateral LV‬ ‭‬ ‭Changes in V1, V2 - Right Coronary Artery, Posterior LV‬ ‭‬ ‭Changes in V3R, V4R - Right Coronary Artey, Right Ventricle‬ ‭Infarct‬ ‭‬ ‭Differentation of the Types of Actue MI‬ ‭‬ ‭Inferior MI‬ ‭○‬ ‭Associated with Right Coronary Artery Occlusion‬ ‭○‬ ‭ST elevation in II, III, and aVF‬ ‭○‬ ‭Reciprocal changes in lateral wall (I, aVL).‬ ‭○‬ ‭Associated with AV conduction disturbances: 2nd degree‬ ‭Type I AV block, 3rd degree AV block, sick sinus‬ ‭syndrome, and sinus bradycardia.‬ ‭○‬ ‭Development of systolic murmur: Mitral valve regurgitation‬ ‭secondary to papillary muscle rupture (posterior papillary‬ ‭muscle has only one source of blood supply - the RCA).‬ ‭○‬ ‭Tachycardia is associated with an inferior MI - leads to‬ ‭higher mortality.‬ ‭○‬ ‭Associated with Right Ventricle infarct and posterior MI‬ ‭○‬ ‭Use Beta Blockers and Nityroglycerin with CAUTION‬ ‭‬ ‭Right Ventricle (RV) Infarct‬  ‭○‬ T ‭ he Right coronary artery, which supplies the inferior wall‬ ‭of the left ventricle, also supplies the right ventricle,‬ ‭therefore about 30% of inferior wall MI patients also have a‬ ‭right ventricular (RV) infarct.‬ ‭○‬ ‭Size of the infarct will determine symptoms‬ ‭○‬ ‭A right sided ICG may demonstrate ST Chnages‬ ‭○‬ ‭Signs/Symptoms‬ ‭‬ ‭JVD at 45 degree , High CVP, hypotension, usually‬ ‭clear lungs, bradyarrhythmias‬ ‭‬ ‭ECG with ST elevation in V3R, V4R‬ ‭○‬ ‭Treatment‬ ‭‬ ‭Fluids‬ ‭‬ ‭Positive Inotrope‬ ‭○‬ ‭Avoid‬ ‭‬ ‭Preload reducers like nitrates or diuretics‬ ‭‬ ‭Caution with beta blockers, often cannot give‬ ‭initially due to hypotension.‬ ‭‬ ‭Anterior MI‬ ‭○‬ ‭Associated with Left Anterior Descening Occlusion‬ ‭○‬ ‭ST elevation in V1-V4: pericordial leads and V leads‬ ‭○‬ ‭Reciprocal changes (ST depression) in inferior wall (II, III,‬ ‭aVF)‬ ‭○‬ ‭May develop 2nd degree Type II AV Block or RBBB‬ ‭‬ ‭The LAD supplies the common bundle of HIS,‬ ‭RBBB is an ominous or worrying sign‬ ‭○‬ ‭Development of systolic murmur: possible ventricular‬ ‭septal defect‬ ‭○‬ ‭Higher mortality than an Inferior MI: Heart Failure‬ ‭‬ ‭Lateral MI‬ ‭○‬ ‭ST Elevation in V5, V6 (Low Lateral)‬ ‭○‬ ‭ST Elevation in I, aVL (High Leteral)‬ ‭○‬ ‭Generally involves the left circumflex‬ ‭ ‬ ‭Treatment of STEMI‬ ‭‬ ‭Determine onset of infarct, if symptoms < 12 hours the goal is‬ ‭REPURFUSION‬ ‭○‬ ‭Percutaneous coronary intervention (PCI) - standard is‬ ‭door-to-ballon within 90 minutes‬ ‭○‬ ‭Fibrinolytic drug therapy - standard is door-to-drug within‬ ‭30 minutes‬ ‭‬ ‭Elgibility Criteria‬ ‭○‬ ‭ST Elevation in 2 or more contiguous leads or new onset‬ ‭Left Bundle Branch Block‬ ‭○‬ ‭Onset of chest pain