Acute Coronary Syndromes

• What does acute coronary syndrome (ACS) refer to?


  A set of symptoms and signs due to reduced blood flow to the heart at rest
• What are the three distinct diagnoses encompassed by ACS?


  Unstable angina, NSTEMI, and STEMI
• Why is infarction considered a medical emergency?


  It requires urgent treatment to prevent heart damage
• What is the most common cause of ACS?

  Rupture of atherosclerotic plaques in coronary arteries
• What methods are used for diagnosing ACS?


  Clinical evaluation, ECGs, and troponin levels
• What treatment strategies differ for STEMI and NSTEMI/unstable angina?


  They include different medications and interventions
• What are some treatments included for ACS?


  Oxygen therapy, antiplatelet medication, and morphine
• What does post-MI management typically include?


  Aspirin, dual antiplatelet therapy, and beta-blockers
• What are some complications to be aware of post-ACS?

  Arrhythmias, heart failure, and cardiac tamponade
• How many hospital admissions are due to ACS?

  80,000
• What is the largest cause of death in the UK?


  Coronary artery disease
• What does coronary artery disease refer to?


  Narrowing of coronary arteries by atherosclerosis and plaque formation
• What happens in stable angina during exertion?


  Narrowed coronary arteries cannot meet increased myocardial oxygen demand
• Why do symptoms of ACS occur at rest?


  Due to sudden plaque rupture and clot formation in narrowed arteries
• What leads to myocardial infarction in ACS?


  Significant hypoperfusion of the myocardium due to occlusion
• What are the non-modifiable risk factors for ACS?


  • Age
  • Male sex
  • Family history
  • Ethnicity (particularly South Asians)
• What are the modifiable risk factors for ACS?


  • Smoking
  • Hypertension
  • Hyperlipidaemia
  • Hypercholesterolaemia
  • Obesity
  • Diabetes
  • Stress
  • High fat diets
  • Physical inactivity
• What does the SOCRATES mnemonic help to assess?


  The classical presentation of chest pain in ACS
• What does the 'S' in SOCRATES stand for?


  Site - Central/left sided
• What does the 'O' in SOCRATES stand for?


  Onset - Sudden
• What does the 'C' in SOCRATES stand for?

  Character - Crushing ('like someone is sitting on your chest')
• What does the 'R' in SOCRATES stand for?


  Radiation - Left arm, neck, and jaw
• What does the 'A' in SOCRATES stand for?


  Associated symptoms - Nausea, sweating, clamminess, shortness of breath
• What does the 'T' in SOCRATES stand for?


  Timing - Constant
• What does the 'E' in SOCRATES stand for?


  Exacerbating/relieving factors - Worsened by exercise, improved by GTN
• What does the 'S' in SOCRATES stand for?


  Severity - Often extremely severe
• What are some atypical presentations of ACS?


  • Epigastric pain
  • No pain (more common in elderly and patients with diabetes)
  • Acute breathlessness
  • Palpitations
  • Acute confusion
  • Diabetic hyperglycaemic crises
  • Syncope
• What are the differential diagnoses for chest pain?

  • Cardiac: Myocarditis, Pericarditis, Cardiomyopathy, Valvular disease, Cardiac trauma
  • Pulmonary: PE, Pneumonia, Pneumothorax
  • Vascular: Aortic dissection
  • GI: Oesophageal spasm, Oesophagitis, Peptic ulcer, Pancreatitis, Cholecystitis
  • MSK: Rib fracture, Costochondritis, Muscle injury, Herpes zoster
• What is the primary investigation for ACS?


  ECG
• What should be looked for in an ECG for ACS?


  ST-elevation, LBBB, or other ST abnormalities
• Why should an ECG not be delayed for other investigations?


  It defines immediate management
• What does a STEMI ECG indicate?


  Troponin is irrelevant and immediate treatment is required
• When should troponin be performed after pain starts?


  At least 3 hours
• What is required for a coronary angiogram +/- PCI?


  Good renal function
• What is the purpose of checking HbA1c and lipid profile in ACS?


  To identify modifiable risk factors for coronary artery disease
• What is the role of FBC and CRP in ACS diagnosis?


  To rule out infectious causes of chest pain
• When is D-dimer used in ACS investigations?


  To rule out PE in appropriate patients
• What does a raised CK indicate after MI?


  Myocardial injury
• Why should a CXR be completed in all patients with chest symptoms?


  To rule out other causes of chest pain and look for complications
• What does a low troponin level indicate?


  No myocardial cell death; the patient is not having an MI