ACS

Question 1

What are the 3 conditions that come under ACS?

Answer 1

-STEMI
-NSTEMI
-Unstable angina (angina at rest)

Question 2

What is the treatment for angina (spray and tablet)

Answer 2

-Glyceryl trinitrate (GTN) sublingual spray, can be taken every 5 mins up to 3 times
-Isosorbide mononitrate is tablet form, taken BD

Question 3

What are the 3 characteristics of angina?

Answer 3

-Constricting discomfort in chest, neck, shoulders, jaw or arms
-Precipitated by physical exertion (stable)
-Relieved by rest or GTN spray within 5 mins

Question 4

What are the steps taken to diagnose / exclude ACS?

Answer 4

-ECG (within 10 mins of medical contact)
-Cardiac troponin on arrival to hospital (serial troponin testing)
-Coronary angiogram if raised troponin and persistent chest pain
-FBC if suspected anaemia
-BG, U+Es and TFTs if considering starting anticoagulants
-CRP as inflammation marker

Question 5

What 3 things are considered indicative of ACS, 2 of which are required to confirm a diagnosis?

Answer 5

-ECG changes
-Troponin
-History concurrent with MI

Question 6

When is most appropriate to measure troponin, and what is considered raised?

Answer 6

-At 6 and then 12 hours after initial onset of pain
->50 ng/L is considered raised but is usually in the hundreds

Question 7

How is ST elevation defined?

Answer 7

-Elevation >1mm (1 small square) in 2 or more contiguous limb leads
OR
-Elevation >2mm in 2 or more chest leads

Question 8

What ECG findings indicate a STEMI/NSTEMI?

Answer 8

-Sinus tachy
-Transient ST elevation
-ST depression
-T wave inversion
-Q waves (late sign)

Question 9

How is a STEMI managed?

Answer 9

1. GTN spray for pain relief (IV / buccal route or IV morphine if no effect)
2. Single dose 300mg aspirin then 75mg
3. Oxygen if sats <94%
4. 180mg ticagrelor if ischaemic changes seen in ECG / troponin is raised then 90mg BD
5. PCI if STEMI and presented to A+E within 12 hrs of onset
6. Fibrinolysis if STEMI and PCI not possible in 120 mins

Question 10

How are NSTEMIs and unstable angina managed?

Answer 10

-Assess for risk of mortality from future CV events using GRACE
-If risk is >3% then should be offered coronary angiogram and may go on to have PCI
-GRACE includes age, HR, BP, creatinine, elevated troponin etc

Question 11

What ECG changes are required for PCI to be justified?

Answer 11

-ST elevation in 2 adjacent leads >2mm in chest leads / >1mm in limb leads