Diagnosis and management of Acute Coronary Syndromes - NSTEMI and Unstable angina

Question 1

What is acute coronary syndrome

Answer 1

Spontaneous plaque rupture leading to local thrombosis, with degrees of occlusion in the coronary artery

Question 2

What components make up acute coronary syndrome

Answer 2

Unstable angina
NSTEMI
STEMI
Sudden cardiac death

Question 3

What factors is important in deterring platelet stability

Answer 3

inflammation

Sheer stress

Question 4

What is the differing symptoms of ACS compared to stable angina

Answer 4

Symptoms are occurring at rest

Question 5

What is the history In diagnosing ACS

Answer 5

Site of pain: retrosternal
Character of pain: often tight band/pressure/heaviness.
Radiation sites: neck and/or into jaw, down arms.
Aggravate with exertion
incomplete improvement with GTN, or physical rest; and/or ongoing.

Question 6

What is the modifiable risk factors for ACS

Answer 6

Smoking
Diabetes mellitus 
Hyperlipidaemia
Hypertension
Lifestyle- exercise & diet

Question 7

What is the history in unstable angina diagnosis

Answer 7

angina originally only happened on exertion

Now progressively increasing in frequency and severity, Until provoked by less exertion and/or then at rest

Question 8

What is the history in NSTEMI diagnosis

Answer 8

more often start with myocardial ischaemic symptoms i.e. angina occurring at rest

Question 9

What is the clinical signs of NSTEMI and unstable angina that could be seen on examination

Answer 9

May look very unwell or May look completely fine
Often no specific features to find
Monitor: HR, BP
Listen for murmurs, crackles in chest

Question 10

What can potentially be seen in an ECG of NSTEMI and unstable angina

Answer 10

may be normal, but:

commonly ST-segment depression, transient ST-segment elevation and/or T-wave inversion;

Question 11

When can changes be seen in an ECG for unstable angina vs NSTEMI

Answer 11

ECG returns to normal after the pain has went away in unstable angina however persists in NSTEMI - but not always

Question 12

What is problems that occur in making the diagnosis

Answer 12

Typical symptoms not always present

Atypical presentation can arise (missing core features)

Question 13

What patients are likely to present atypical presentation of ACS and why

Answer 13

women the elderly or diabetics as are all influenced by reduced pain sensation

Question 14

What are the cardiac biomarkers of unstable angina and NSTEMI and h

Answer 14

cardiac troponin (cTn)

if it becomes detectable it means there is damage (as cells wall is leaking them)
therefore acts as sensitive and specific marker of cardiac myocyte damage.

Question 15

What is the limiting factor in cardiac troponin biomarker

Answer 15

Doesn’t define source or site of damage

not all troponin elevations are a ACS and caused by atherothrombosis

Question 16

What is the immediate treatment plan for unstable angina and NSTEMI

Answer 16

Morphine (or diamorphine)
Oxygen
Nitroglycerine (GTN spray or tablet)
Aspirin 300 mg orally (crush/chew)

Question 17

What is dual anti-platelet therapy that all ACS patients should receive one year after the event

Answer 17

both aspirin and a ADP receptor blocker

Question 18

What is examples of ADP receptors blockers and their dosage

Answer 18

Clopidogrel: Bolus 300mg and 75mg daily.
Prasugrel: Bolus 60mg and 10mg daily.
Ticagrelor: Bolus 180mg and 90mg BD daily

Question 19

What is examples of Anti-thrombotic therapy in unstable angina and NSTEMI

Answer 19

Intravenous unfractionated heparin (UFH) or s/c low molecular weight heparin (LMWH)
Fondaparinux (new)

Question 20

Why is LMWH better than UFH

Answer 20

improved clinical outcome, is easier to administer: given subcutaneously and not need to be monitored

Question 21

When are beta blockers recommend in the treatment of unstable angina and NSTEMI

and what is the purpose of beta blocker treatment

Answer 21

in the absence of contraindications - asthma, acute left ventricular dysfunction, impaired AV nodal conduction

To reach target heart rate should be between 50 and 60 bpm and reduce the myocardial oxygen demand

Question 22

What is the benefit of statin in the treatment of unstable angina and NSTEMI

Answer 22

reduces plaque acutely therefore chronically reduce further events

Question 23

When would ACE inhibitors be used the treatment of unstable angina and NSTEMI

Answer 23

if left ventricular dysfunction is present

is controversial if normal function

Question 24

What patients receive Coronary revascularisation treatment

Answer 24

High risk patients - benefit from invasive strategy compared to medical treatment

Question 25

What coronary revascularisation procedures can be performed in unstable angina and NSTEMI

Answer 25

coronary angiography and revascularisation by PCI CABG

Question 26

What is the time frame for coronary revascularisation procedure to prevent reoccurrence

Answer 26

PCI - as soon as possible

CABG- within 3-12 hours

Question 27

what is the process of coronary angiography and revascularisation by PCI

Answer 27

Coronary guided wire advances to atherosclerotic plaque,
ballon is slide over the wire and inflated to compress the plaque and open the construction,
stent is then placed in the dilated area,
Balloon expands and deploys the stent
The catheter is then removed