Differentials- ACS
- Angina
- Chostochondritis
- GORD
- PE
- Pericarditis
- Usually preceded by a viral illness
- Listen for friction rub
- Pneumonia
- Pleural effusion
- Dissection
- May spread to carotids and => focal neurological deficit
Oxygen in ACS
- Pts actually do better without oxygen, as long as sats are 98% -ish
- Free radicals => myocardial damage
Anaemia
- => Rise in cardiac output => Chest pain
- => Give blood for symptomatic anaemia, even if Hb is >8
ECGs
- Grrrr
- Check the Hx at the time the ECG is taken
- Look for EVOLVING CHANGES
- Consider V4R for RV infarcts
Enzymes
- Trop
- Immediately on admission, then 4 hours later
- Make sure you check renal function too!
- CK
- First thing to rise
- Check on admission as part of cardiac enzymes
Bloods- Don't forget:
- Renal function
- Lipid profile
- Glucose
- TFTs
Focused Assessment with Sonography for Trauma (FAST)
- Limited ultrasound examination directed solely at identifying the presence of free intraperitoneal or pericardial fluid
- Can exclude pericarditis, tamponade
ACS management- Aspirin
- 300 mg initially, then 75 md OD
- Clopidogrel
- But cf NSTEMI / need for PCI
- Morphine
- GTN
- LMW heparin
- Beta blocker
- Statin
- Immediate benefit
- Even if lipids "normal" (they're not normal for him)
- BEWARE BLEEDING
- Manage on a monitored bed
Interesting other causes of ST elevation- LV aneurysm from previous MI
- Stroke / CNS pathology
Glycoprotein IIb/IIIa inhibitors
- IV antiplatelet agents
- Examples:
- Abciximab
- Eptifibatide
- Tirofiban
- Useful in ACS if clopidogrel is contraindicated (e.g. need a stent)
Notes- Most common cause of chest pain
- Obesity => Sliding hiatus hernia => Reflux
- Semi-urgent referral
- Make a note of risk factors at the top of your clerking
- No risk factors at all => Manage conservatively
- Maybe an ETT
- cf Angiogram for the old, male smoker
- Heart failure => ASCITES
- RENAL FUNCTION is a key investigation
- Hypothyroidism => Hypercholesterolaemia
- Umbra + Penumbra
- Reperfusion arrhythmias from toxic wash-out
- GLP1 => Reduced appetite
- NSAIDs => Clotting risk
- Avoid for pain relief in ACS
- Cardiac rehab has NO survival benefit
- But good psychological effects
- NSTEMI has a WORSE prognosis than STEMI
- Tends to be from diffuse, small-vessel disease (e.g. from diabetes)
- Less treatable by PCI
- Entire pericardium is affected
- Give clopidogrel for 1 year post-MI
- Especially important if stented (90X thrombus risk without)
- Monitor BP if you're giving nitrates
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