CARDIOLOGY

ResponseOngoing chest pain PLUS
STE >1mm in >= 2 adjacent leads, but in V3+V3 its

• >2.5mm <40 yo Male
• >2mm >40 yo Male
• <1.5mm Female of any age

LBBB + unstable
LBBB + Sgarbossa positive
ST depression in V1-V3 = posterior STEMI
De Winter waves V2-V5

ResponseSuggest STEMI
Anatomically contiguous ST and J point elevation
ST depression in aVL
ST elevation in III>II
Absent PR depression (although can occur in STEMI)
Reciprocal ST depression
Prolonged QT may be present
Dynamic ECG changes (Bolded cos I kept forgetting this)
ST elevation that is convex up or horizontal

ResponseOngoing/repetitive chest pain
Persistent ST depression or T wave inversion in 2 contiguous leaads
Haemodynamic compromise
Syncope
Sustained VT
Known poor LV systolic function
AMI/PCI/CABG in last 6 months

ResponseNormal ECG
Normal troponin
Age <40
Absence of known CAD
Atypical symptoms
Chest pain resolved

ResponseCardiac

• Aortic dissection
• Cardiac contusion
• CCF
• Cardiomyopathy
• Cardiotoxic drugs (some chemo)

Non cardiac

• Acute SAH
• Renal failure
• Sepsis
• Hypoxia
• PE
• cocaine

ResponseCardiac

• Previous MI
• Pericarditis
• Myocarditsi
• Ventricular aneurysm
• Ventricular paced rhythm
• LBBB
• Coronay vasospasm
• Takotsubo cardiomyopathy
• Early repolarisation
• Cardiomyopathy
• Brugada
• Wellens

Non cardiac

• ICH
• Hyperkalaemia

ResponseAcute:

• AV block
• Malignant ventricular tachyarrhythmia (VT/VF)
• Acure RV failure with loss of preload
• Cardiogenic shock (pulmonary oedema, B lines on POCUS)
• Acute MR from rupture of anteriolateral chordae ( new systolic murmur)
• Worsening angina
• Septal rupture (new loud holosystolic murmur)
• Ventricular free wall rupture

Chronic

• LV aneurysm
• Mural thrombus, (PE, or DVT also)
• Dressler’s syndrome

ResponseO2 to maintain sats 92-96%
Aspirin 300 mg PO
GTN /morphine if pain not controlled
Transfer directly to cath lab if available
Full monitoring including defib pads in transit

ResponseOxygen – saturations >92% (lots of targets seen).

• Optomising myocardial oxygenation
• Hyperoxia = increased infarct size (free radicles, reduction in coronary flow, and increased vascular resistance >> worse outcome)

Fluid load 10-20 mL/kg aiming SBP >100 or MAP >65 (+/- adrenaline infusion)
Analgesia – fentanyl 25 mics or morphine 2.5mg

• Decrease pain and sympathetic activity which leads to decreased myocardial oxygen demand

Monitoring, defib pads on, repeat ECG’s to assess dynamic change
GTN

• Vasodilation to increase myocardial perfusion

RV specific strategies (no nitrates) vs GTN if no RV involvement
Seek and treat arrythmia/blocks (may need adrenaline/isoprenaline infusion
Antiplatelets, anticoagulation and repurfusion (see below)

ResponseSTEMI
PCI <60 mins, or contraindications for thrombolysis >>> PCI
PCI>60 mins >> Thrombolysis

• Successful >> admit vs transfer
• Unsuccessful >> PCI

PACSA – some guidelines state 90 mins or 2h

ResponseBefore Thrombolysis:
Aspirin 300 mg + Clopidogrel (300 mg <75, 75 mg >=75) – PACSA

• Prevent further platelet aggregation and limit further thrombi from forming and contributing to cardiac ischaemia

Thrombolysis:
Then give TPa (directly converts plasminogen to plasmin - LITFL):
Tenecteplase 0.5mg/kg to 50 mg (Half dose if >75) - PACSA
Or:
Alteplase 15 mg bolus THEN 50 mg over 30 mins THEN 35 mg/kg over 60 mins (less if <65kg, total dose <1.5mg/kg) – Note this is a different regime to stroke which is different to PE – AMH

After thrombolysis - PACSA
Heparin – weight-based infusion no bolus (start 12-15 u/kg/h) – aPPT 60-80
OR
Enoxaparin (more complicated to memorise but easier to give as no infusion)
<75 yo = 30 mg IV @15 mins + 1mg/kg SC @30 mins
>=75yo – 0.75mg/kg SC at 30 mins

ResponseSymptoms largely resolved
HD stable
50% reduction in STE

ResponseBefore PCI:
Aspirin 300 mg
IV heparin 5000 U

• Prevent clotting and limit thrombus formation and hence ischaemia

Ticagrelor 180 mg (or clopidogrel 300-600mg if <75, 75 mg >=75)
Transver/Activation of interventional cardiology for PCI

Response

ResponseCardia biomarkers – Troponin/CK – Pattern of change will indicate if acute/recent infarct
Echo – Regional wall motion abnormality/hypokinesis (Sound like a boss, if given an ECG showing specific infarct – state that’s where you’d see motion defect!)
Posterior EG
CXR – pulmonary congestion/pleural effusion suggestive of significant myocardial infarction

ResponseSTEMI preceeding cardiac arrest
STEMI on post ROSC ECG
New LBBB on post ROSC ECG

ResponseSuggests global ischaemia likely seocnary to prolonged arrest.

ResponsePreoxygenate sitting up
Add 15L O2 NP + NRB
Reduced dose induction agent
Adrenaline prior to induction (50 mics push vs infusion
Bag through apnoea