ACS

Question 1

What is ACS usually a result of?

Answer 1

A thrombus from an atherosclerotic plaque blocking coronary artery

Question 2

What are the mainstays of treatment, why?

Answer 2

• antiplatelets (aspirin, clopidogrel, ticagleror)

- when a thrombus forms in fast-flowing artery it’s made of many platelets

Question 3

What does the Left coronary artery (LCA) become?

Answer 3

1) circumflex

2) left anterior descending (LAD)

Question 4

What does the RCA supply?

Answer 4

RCA curves around R side of the heart + under:

• -> R atrium
• -> R ventricle (RMA)
• -> inferior aspect L ventricle (PDA)
• -> posterior aspect septum (PDA)

Question 5

What does the circumflex supply?

Answer 5

Cx curves around top, L and back of heart:

• -> L atrium
• -> posterior aspect L ventricle

Question 6

What does the left anterior descending artery supply?

Answer 6

LAD travels down the middle:

• -> anterior aspect L ventricle
• -> anterior aspect septum

Question 7

3 types of ACS?

Answer 7

1) unstable angina
2) ST elevation myocardial infarction (STEMI)
3) Non-STEMI

Question 8

symptoms?

Answer 8

Central, constricting chest pain assoc w/:

• n&v
• sweating & clammy
• impeding doom feeling
• SOB
• palpitations
• pain radiates to jaw/neck

Question 9

How long should symptoms continue for?

Answer 9

Sx should continue at rest for at least 20 mins - otherwise consider stable angina

Question 10

What’s a ‘silent MI’

Answer 10

diabetic patients not experiencing typical chest pain during ACS

Question 11

Initial investigation?

Answer 11

ECG

• -> diagnose STEMI if (1) ST elevation or (2) new LBBB
• -> perform drops if no ST-elevation

Question 12

If no ST elevation on ECG, what’s next investigation?

Answer 12

Troponin blood tests

Question 13

Diagnosis of NSTEMI?

Answer 13

1) raised troponin +/OR
2) other ECG changes:
- -> ST depression
- -> T wave inversion
- -> pathological Q wave

Question 14

Diagnosis of unstable angina (or another cause such as MSK chest pain)?

Answer 14

1) normal troponin +

2) no pathological ECG changes

Question 15

Specific regions of MI for left coronary artery (LCA) infarct?

Answer 15

LCA = anterolateral

Changes in I, aVL, V3-V6

Question 16

Specific regions of MI for left anterior descending (LAD) infarct?

Answer 16

LAD = anterior

Changes in V1-4

Question 17

Specific region of MI for circumflex infarct?

Answer 17

Cx = lateral

Changes in I, aVL, V5-6

Question 18

Specific region of MI for right coronary artery (RCA) infarct?

Answer 18

RCA = inferior

Changes in II, III, aVF

Question 19

Troponins:

1) What measurements are required for diagnosis?
2) What is a rise in troponin consistent with?

Answer 19

1) Serial trops - at baseline (3hrs after symptoms) then at 6-12 hrs after symptom onset
2) Myocardial ischaemia - but non-specific

Question 20

Other causes of raised trops?

Answer 20

1) chronic kidney failure
2) sepsis
3) myocarditis
4) aortic dissection
5) PE

Question 21

Baseline investigations?

Answer 21

Obviously ECG –> trops

• FBC (anaemia)
• U&Es (renal function)
• LFTs (statins)
• lipid profile
• TFTs
• HbA1c and fasting glucose

Question 22

Additional investigations (alongside baseline, ECG + trops)

Answer 22

1) CXR - pulmonary oedema?
2) Echo - after event to assess functional damage
3) CT coronary angiogram - assesses coronary artery disease

Question 23

Examples of fibronlytic agents / thrombolysis?

Answer 23

Alteplase, streptokinase or tenecteplase

Question 24

Acute management of MI (STEMI)?

Answer 24

MONA:

• Morphine (w/ metoclopramide)
• Oxygen - according to BTS guidelines, aim >90%
• Nitrates - GTN spray
• Aspirin 300mg PO (
• -> dual anti platelet w/ clopidogrel or ticagleror

THEN consider PCI or thrombolysis is meet criteria

Question 25

PCI vs. thrombolysis for MI (STEMI)?

Answer 25

If presents within 12 hours of pain onset, discuss with local cardiac team: 1) Primary PCI - if <2hrs since first medical contact 2) Thrombolysis - if >2hrs

Question 26

Acute management of NSTEMI?

Answer 26

BATMAN: - Beta-blocker (NOT ACUTE) - Aspirin 300mg PO - Ticagrelor 180mg (or clopidogrel 300mg) - Anticoagulate: treatment dose LMWH (enoxiparin or Fondaparinux) - Nitrates: GTN spray

Question 27

Anti-platelet to use if MI patient going for PCI?

Answer 27

Add prasugrel if patient not on anti-coagulation OR Add clopidogrel if on anti-coagulation

Question 28

How would you assess need for PCI following NSTEMI?

Answer 28

GRACE score - predicts 6-month risk of death or repeat MI after having NSTEMI: <5% low risk 5-10% medium risk >10% high risk

Question 29

What would you offer if GRACE score was high risk?

Answer 29

offer angiogram within 96 hrs (4 days) of symptoms onset

Question 30

Complications of MI?

Answer 30

DREAD: - death - rupture of heart septum or papillary muscles - oEdema --> Heart failure - Dressler's syndrome

Question 31

What is Dressler's syndrome?

Answer 31

Post-MI syndrome, occurs 2-3 weeks after, caused by localised immune response resulting in pericarditis

Question 32

How does Dressler's syndrome present?

Answer 32

- pleuritic CP - low grade fever - pericardial rub on auscultation can cause --> pericardial effusion or tamponade

Question 33

Diagnosis of Dressler's syndrome?

Answer 33

ECG --> global ST elevation, T wave inversion Echo --> pericardial effusion Raised inflammatory markers (CRP, ESR)

Question 34

Management of Dressler's syndrome?

Answer 34

1) NSAIDs (aspirin, ibuprofen) 2) steroids if severe 3) pericardiocentesis

Question 35

Secondary Prevention medical management?

Answer 35

6 A's: 1) Aspirin 75mg OD 2) Atorvastatin 80mg 3) ACEi (ramipril, titrate to 10mg OD) 4) Atenolol (bisoprolol) 5) Another anti platelet - ticagleror or clopidogrel 6) aldosterone antagonist if clinical heart failure (eplerenone)

Question 36

Secondary prevention lifestyle advice?

Answer 36

- stop smoking - stop drinking alcohol - advise on diet, exercise, weight loss (mediterranean) - optimise co-morbidities - cardiac rehabilitation

Question 37

Types of MI?

Answer 37

T1 - traditional MI due to acute coronary event T2 - ischaemia secondary to increased demand or reduced oxygen supply (severe anaemia, tachycardia, hypotension) T3 - sudden cardiac death or cardiac arrest (ischaemic event) T4 - MI requiring procedures (PCI, CABG, stenting)