ACS

Question 1

How are the plaques formed in atherosclerosis?

Answer 1

Injury triggers lipoproteins to be oxidised and taken up by macrophages causing foam cell formation. Cytokines are released leading to accumulation of fat and smooth muscle proliferation. Plaque is formed

Question 2

How does a plaque cause myocardial ischaemia?

Answer 2

Rupture of the plaque causes platelet adhesion and aggregation, localised thrombus and vasoconstriction.

Question 3

What are the non modifiable risk factors for ACS?

Answer 3

Increasing age
Gender (Male)
FH
Ethnic origin

Question 4

What are the modifiable risk factors for ACS?

Answer 4

Smoking
Diabetes
HTN
Hypercholesterolaemia

Question 5

How would you initially manage a patient with ACS?

Answer 5

A-E
12 lead ECG
M - Morphine (Usually Diamorphine 2.5-10mg) plus antiemetic
O - Oxygen if needed
N - Nitrates (GTN 2 sprays)
A - Aspirin (300mg)

Question 6

What initial investigations need to be done in a patient with ACS?

Answer 6

Bloods - FBC, Troponin, U&Es, Glucose, Lipids, Creatinine Kinase, LFTs
CXR

Question 7

What are the symptoms of a STEMI?

Answer 7

Chest pain, central & crushing not relieved by GTN. May radiate into neck, face, arms
N&V, Sweating (Pallor - activation of sympathetic nervous system)
Syncope
SOB - Especially as may present with acute pulmonary oedema
Diabetics can have painless/atypical presentations of STEMIs

Question 8

What are the possible ECG findings in a STEMI?

Answer 8

ST evelation
New onset LBBB
T wave inversion
Pathological Q waves

Question 9

How would an Anteroseptal STEMI show on ECG?

Answer 9

ST elevation in V1-4 (LAD)

Question 10

How would a Lateral STEMI show on ECG?

Answer 10

V5-6 (Circumflex)

Question 11

How would a High lateral STEMI show on ECG?

Answer 11

I, aVL (Circumflex)

Question 12

How would a Inferior STEMI show on ECG?

Answer 12

II, III, aVF (RCA)

Question 13

How would a Posterior STEMI show on ECG?

Answer 13

ST depression in V1-4 due to seeing the reciprocal changes

Question 14

What are the treatment options for a STEMI?

Answer 14

Primary coronary intervention - within 90 minutes of onset of symptoms
Thrombolysis - within 12 hours of onset of symptoms. Usually Alteplase or Reteplase used

Question 15

What are the absolute contraindications to Thrombolysis?

Answer 15

Haemorrhagic or Ischaemic stroke within the last 6 months
CNS neoplasia
Recent trauma or surgery
GI bleed within the last month
Any bleeding disorders
Aortic dissection

Question 16

What are the relative contraindications to Thrombolysis?

Answer 16

Warfarin
Pregnancy
Advanced liver disease
Infective endocarditis

Question 17

What are some of the complications of Thrombolysis?

Answer 17

Bleeding
Hypotension
Intracranial haemorrhage
Reperfusion arrhythmias
Systemic embolisation of the thrombus
Allergic reaction - especially if streptokinase is used

Question 18

What are the complications of a STEMI?

Answer 18

S - Sudden death
P - Pump failure/Pericarditis
R - Ruptured papillary muscles/septum
E - Embolism
A - Aneurysm/Arrhythmias
D - Dressler's syndrome (Secondary form of Pericarditis)

Question 19

What drugs should a patient who has had an MI be discharged on?

Answer 19

A - ACEi (Helps with remodelling of the heart). Aspirin (Lifelong). Address modifiable risk factors
B - B Blocker (Atenolol, Bisoprolol)
C - Clopidogrel (12 months). Cholestoral lowering - Statin (80mg Atorvastatin)
Minimum of 1 month off work
Inform the DVLA, no driving for 4 weeks

Question 20

How can you differentiate between an NSTEMI and Unstable Angina?

Answer 20

An NSTEMI will have a positive Troponin

Question 21

What ECG changes are present in an NSTEMI and Unstable Angina?

Answer 21

T wave inversion

ST depression

Question 22

How do you manage a patient with suspected Unstable angina or NSTEMI?

Answer 22

Analgesia - Morphine and Anti emetic
Anti Ischaemic - GTN infusion, ACEi, B BLOCKERS, Ca2+ channel antagonists, Statins
Antiplatelet - Apirin, Clopidogrel
Antithrombotic - LMWH

Question 23

When would you consider invasive management (PCI) of an NSTEMI or unstable angina?

Answer 23

Increased Troponin
Recurrent angina or ischaemic changes on ECG despite medical therapy
Features of HF
Poor LV function
Haemodynamic instability
PCI within the last 6 months or a previous CABG