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Module 4 - logbook 8: definition (MI)

STEMI = ST elevation and raised troponin - total blockage


NSTEMI = ST depression/nothing and raised troponin - partial blockage

Module 4 - logbook 8: epidemiology (MI)

114,000 ACS admissions per year STEMI/NSTEMI divide difficult to calculate

Module 4 - logbook 8: risk factors - modifiable (MI)

Smoking, hypertension, alcohol, BMI, cholesterol, diabetes and physical inactivity

Module 4 - logbook 8: risk factors - non modifiable (MI)

Family history (hyperlipidemia), ethnicity (India, Pakistan and Bangladesh), age and gender

Module 4 - logbook 8: common presentation (MI)

Chest pain > 20 mins at rest. May be associated with sweating, nausea, vomiting, dyspnoea, fatigue,shortness of breath and palpitations. Women - arm, back neck and jaw

Module 4 - logbook 8: investigations (MI)

12 lead ECG, cardiac enzymes (troponin I ant T) peak at 12-24 hours

Module 4 - logbook 8: pathophysiology (MI)

Total blockage leading to myocardial cell death

Module 4 - logbook 8: anatomy (MI)

Right coronary artery - inferior - II III AVF


Left anterior descending - anterior - V1-V6 AVL


Left circumflex - lateral 1, AVL, V5 V6


Posterior V1-V4 depression

Module 4 - logbook 8: prognosis (MI)

5-10% mortality in hospital. 5-10% have an MI within a month. Much worse with left dominance

Module 4 - logbook 8: management (and NICE guidelines) (MI)

Morphone, GTN, oxygen (if O2 < 94%), ASPIRIN 300mg and CLOPIDOGREL 300mg) Immediately assess eligibility for coronary reperfusion therapy. Offer fibrinolysis (prevents blood clots from growing and becoming problematic) to people with acute STEMI presenting within 12 hours of onset of symptoms.

Module 4 - logbook 8: drugs - ASPIRIN

Antiplatelet - Acetyl donor to COX rendering it inactive which reduces thromboxane A2

Module 4 - logbook 8: drugs - TICAGRELOR

Antiplatelet - prevents binding of ADP preventing activation of clotting factors stopping fibrinogen and platelet aggregation

Module 4 - logbook 8: drugs - SIMVASTATIN

Hypercholesterolemia - enzyme inhibitor HMG coA reductase, reducing quantity of mevalinic acid, a precursor of cholesterol

Module 4 - logbook 8: drugs - BISOPROLOL

MI prophylaxis - beta blocker - blocks beta 1 receptors reducing sympathetic stimulation

Module 4 - logbook 8: drugs - LANSOPRAZOLE

PPI. Reduces gastric acid by inhibition of H+K+ ATPase enzyme system

Module 4 - logbook 8: drugs - FONDAPARINUX

Anticoagulant - ATIII mediated inhibition of factor Xa interrupting clotting cascade. less likely thrombocytopenia vs LMWH

Module 4 - logbook 8: anatomy (pericardium)

Double walled sack containing heart


Fibrous pericardium (superficial - connective tissue)


Serous pericardium (parietal and visceral) - lubricates the heart


Functions: 1. lubrication 2. stops heart over-dilating 3. prevents transfer of infection


4. fixes heart in mediastinum

Module 4 - logbook 8: epidemiology (pericarditis)

1/20 chest pain A&E visits. Men > women. Adults > children

Module 4 - logbook 8: pathophysiology (pericarditis)

Acute inflammation. fibrinous reaction can result in exudate and adhesions within the pericardial sac > effusions and tamponade

Module 4 - logbook 8: aetiology (pericarditis)

Usually post-viral or idiopathic. Viral: Coxsackievirus, influenza, Rheumatological: RA, SLE Bacterial: Staphylococcus, neoplasm, drugs and MI

Module 4 - logbook 8: common presentation (pericarditis)

Symptoms: pain - aggravated by inspiration, swallowing, coughing and lying flat, relieved by sitting up and leaning forward.


Signs: pericardial friction rub (extra heart sound - grating. Also tachycardia and fever

Module 4 - logbook 8: ECG and other investigations (pericarditis)

Stage 1: wide spread saddle shaped ST elevation


Stage 2: ST segments down T waves flatten


Stage 3: T waves invert


Stage 4: T waves return to normal


(electrical alternans in tamponade)


CXR (flask shaped heart in tamponade), blood tests, echocardiogram and CT/MRI if in doubt

Module 4 - logbook 8: management (pericarditis)

Community: underlying cause and NSAIDs. High risk (e.g. high temp, Warfain, traums) > hosptial


If tamponade develops then pericardiocentesis

Module 4 - logbook 8: prognosis (pericarditis)

Normally self limiting in days-weeks. Rapid response to NSAIDs >> good prognosis. Re-occurrence common.


Mortality rate approaches 85% for untreated TB pericarditis