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Tachycardia – Broad Complex
Regular
• Ventricular tachycardia
Irregular
• Ventricular fibrillation
• Polymorphic VT (Torsades
de Pointes)
Ventricular Tachycardia
Ventricular Tachycardia -> VF
Ischaemic Heart Disease
Stable Angina
PATH
• Atherosclerosis ->
coronary stenosis ->
ischaemia
• RF!
PREC
• Emotion
• Cold
• Heavy Meals
Angina Chest Pain
1. Constricting
discomfort in front of
chest, neck, shoulders,
jaw or arms
2. Precipitated by
physical exertion
3. Relieved by rest or
GTN within 5 minutes
Stable Angina
INV
• ECG (possibly ST depression, old infarct)
• Stress Echo / Coronary Angiography /
Cardiac CT calcium score / Myocardial
perfusion scan with SPECT
Mx
• RF Mx
• Aspirin, Statin, Glyceryl
Trinitrate (SL)
1. BB (atenolol)/CCB
(verapamil/diltiazem)
2. BB + CCB (nifedipine), OR
monotherapy + long-acting
nitrate/ivabradine/nicorandil
/ranolazine
3. Can use BB + CCB + 3rd Drug
whilst waiting for PCI/CABG
• PCI
• Surgery (CABG)
Acute Coronary Syndromes
PATH
• Plaque Rupture = Thrombosis =
Inflammation
(emboli, coronary spasm, vasculitis)
ACS Types
• Unstable Angina
• NSTEMI ~subendocardial
• STEMI ~transmural
PRES
• Acute Central Chest Pain
(>15min)
+/- N+V/ SOB/ Palpitations/
Sweating
‘silent’ in elderly/DM:
Syncope/Epigastric
Pain/Delirium
ECG MI
Myocardial Infarction (MI) DEF:
1. Rise +/- Fall of Cardiac
Troponin
2. One Troponin Measurement
Above Upper Limit
3. One of:
• Symptomatic
• New ST-T changes, LBBB or
pathological Q waves
• Intracoronary thrombus (CT
coronary angiography)
• New loss of viable myocardium
or new regional wall motion
abnormality (MPS with SPECT,
stress echo, stress MRI)
STEMI DEF
• ST Elevation
- >1mm in =>2 contiguous limb leads
- >2mm in => 2 contiguous chest leads
• New LBBB
Inferior STEMI
Anterior STEMI
Lateral STEMI
Management
BOTH: (STEMI and NSTEMI)
• Pre-Hospital: Aspirin 300mg and GTN
• Acute (MONA)
1. ECG, Troponin, Other Bloods, CXR
2. Analgesia: GTN, Morphine (5-10mg) +/- Metoclopramide IV
3. Aspirin (300mg) + Clopidogrel
4. Heparin
5. O2 (only if hypoxic)
STEMI:
1. PCI (within 12hrs symptom onset, 90mins after thrombolysis and
ST elevation not resolved), Thrombolysis (if can’t get PCI within
2hrs)
Management
NSTEMI
Assess Risk (High = Continued Pain, ST depression, DM, Raised
Troponin)
Intermediate/High:
1. GPIIb/IIIa Infusion (tirofiban) + Angiography (within 96hrs of
admission)
2. Optimise Drugs (+Statin, +CCB, +ACE-i)
3. (continued symptoms) PCI/CABG
Subsequent Management
•
•
•
•
Bed Rest
Daily Examination, Bloods, ECG
LMWH (DVT prophylaxis)
Cardiac rehab
DRUGS (BACAS)
• Aspirin
• Clopidogrel (or other PY12)
• Beta-Blocker
• ACEi
• Statin
Complications
(short-term)
• Cardiac Arrest
• Cardiogenic Shock
• Acute Heart Failure
• Dysrhythmias (heart block,
tachyarrhythmia)
• Pericarditis (<48hrs)
(long-term)
• Unstable Angina
• Mitral Regurgitation (papillary
muscle rupture)
• Chronic Heart Failure
• Dresslers Syndrome (2-6wks)
• Left Ventricular Aneurysm
(persistent ST elevation + LVF)
Pericarditis