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Acute Coronary Syndrome Nicholas Shaw Slide 2 ACS STEMI New onset LBBB NSTEMI Unstable angina Slide 3 Risk Factors for ACS Smoking Obesity Dyslipidaemia Hypertension Age Male Ethnicity Family history CKD Slide 4 Stable Angina Cardiac chest pain precipitated by exercise Caused by atheroma, but also: anaemia, AS, tachyarrhythmias, HOCM Eases with rest / GTN 4 classes: I: angina on strenuous exercise II: Slight limitation of ordinary activities III: difficulty climbing stairs IV: unable to carry out any physical activity Risk of progression to ACS (1% non-fatal MI/year) Slide 5 Angina investigations ECG Ecercise ECG FBC anaemia Glucose diabetes Lipids dyslipidaemia TFTs - thyrotoxicosis Slide 6 Angina Management Lifestyle modification Modifying risk factors Medication Aspirin Beta blockers Calcium channel blockers Statins Nitrates Surgical PTCA, CABG Slide 7 Unstable Angina Presence of angina without precipitating cause / at rest Spectrum with stable angina and NSTEMI Slide 8 Presentation of ACS Typical chest pain Male Left sided chest pain Radiating to left arm Radiating to neck Atypical chest pain Right sided chest pain Abdominal pain Female Diabetic Elderly Silent MI Cool Clammy Nausea Dyspnoea Pulmonary oedema Confusion Palpitations Collapse Death Slide 9 Differential Diagnosis Musculoskeletal chest pain Pulmonary embolus Aortic dissection Gastric reflux Slide 10 Diagnostic criteria of acute MI 2/3 of: ECG changes Chest pain Rise in cardiac enzymes Slide 11 Investigations ECG Bloods FBC U&E Trop T CXR Cardiomegaly Pulmonary oedema Widened mediastinum Slide 12 NSTEMI Subocclusive thrombus ECG changes: ST depression T wave inversion Slide 13 NSTEMI Slide 14 ECG Leads Anterior Septal Lateral Inferior High lateral Slide 15 Arteries Affected Location of MIArtery LateralLeft circumflex AnteriorLAD SeptumLAD InferiorRCA PosteriorRCA Right VentricleRCA Slide 16 Slide 17 Slide 18 Anterior MI ST elevation is maximal in the anteroseptal leads (V1-4). Q waves are present in the septal leads (V1-2). There is also some subtle STE in I, aVL and V5, with reciprocal ST depression in lead III. There are hyperacute (peaked ) T waves in V2-4. These features indicate a hyperacute anteroseptal STEMI Slide 19 Tombstoning Slide 20 Posterior MI Slide 21 Slide 22 Inferior MI Slide 23 STEMI - ST elevation > 1mm in two or more limb leads and/or - ST elevation > 2mm in two or more consecutive precordial leads and/or - Left Bundle Branch Block (LBBB) which is known or suspected to be of new onset and in the presence of cardiac symptoms Slide 24 Treatment of STEMI Morphine Antiemetics (metoclopramide) Antiplatelets aspirin (300mg) and ticagrelor (180mg) IV access Bloods Primary Coronary Intervention Thrombolysis (tPA / streptokinase) Slide 25 Further inpatient management Education Echocardiogram (LV function) Clopidogrel (or ticagrelor) Beta blockers ACE-I Statins Risk factor modification Slide 26 Late Complications Dresslers syndrome Papillary muscle rupture Fibrosis Aneurysm Heart failure Death