ACS

Question 1

What is the pathophysiology of ACS?

Answer 1

Artheromstous plaque formation in coronary vasculature, exposing fibrin, collagen, cholesterol and cellular debris
This creates stimulation for: platelet adhesion, aggregation, thrombus formation and localised vasoconstriction

Question 2

ACS is a …

Answer 2

Critical stage of IHD with differing degrees of occlusion and embolisation

Question 3

What is the pathophysiology for a stable angina?

Answer 3

Stable intact lesion

Question 4

What is the pathophysiology of unstable angina?

Answer 4

Breached endothelium with or without superimposed fibrin clot and coronary spasm

Question 5

What is the pathophysiology of an MI?

Answer 5

Plaque rupture with superimposed fibrin clot leading to total coronary occlusion and coronary spasm

Question 6

How do you diagnose ACS?

Answer 6

Pt history
Typical symptoms
ECG changes
Biochemical markers

Question 7

What is the rational for the assessment of ACS?

Answer 7

Diagnostic
Therapeutic
Humanistic concern
Improve and maintain pt nurse relationship
Accountability

Question 8

What are the possible differential diagnosis for a of presenting with ACS?

Answer 8

Angina pectoris
MI
Pericarditis
Dissecting aortic aneurysm 
Tracheobronchitis
Pleural pain
Reflux oesphagitis
Chest wall pain
Anxiety

Question 9

What is the PQRST assessment of chest pain?

Answer 9

Precipitating factors
Qualitative factors
Region and radiation
Severity and associated symptoms
Timing

Question 10

What is included in precipitating factors for Chest pain assessment?

Answer 10

What factors precipitated discomfort?

What was happening at symptom onset?

Question 11

What is included in qualitative factors in chest pain assessment?

Answer 11

Describe pain
What does pain feel like in own words
How did or feel at time of pain?

Question 12

What is included in region and radiation for chest pain assessment?

Answer 12

Where and how far pain spreads

Pain normally in left arm, inner aspect of arm sometimes as far as fingers, jaw (not to ear), neck, back, epigastrium

Question 13

What is included in severity and associated symptoms for chest pain assessment?

Answer 13

How bad is the pain?
0-10
Aware of any other pain?

Question 14

What is included in timing for the chest pain assessment?

Answer 14

How long did it last?

What makes the pain better?

Question 15

What are the or groups with atypical presentations of ACS?

Answer 15

Women
Elderly
Diabetes
Ethnic minority

Question 16

What are the risk factors for ACS?

Answer 16

Smoking
Hypercholestraemia
Diet
Sedentary lifestyle
Alcohol consumption
Hypertension
Obesity
Socioeconomic deprivation 
Diabetes

Question 17

What are the symptoms of ACS?

Answer 17

Chest pain
Hypotension
Autonomic nervous system activation
Pallor
Sweating
Rhythm disturbances

Question 18

What does ST depression mean?

Answer 18

Ischaemia, left ventricular hypertrophy,

Digoxin toxicity

Question 19

What does ST elevation mean?

Answer 19

Acute MI

Question 20

What does T wave flattening mean?

Answer 20

Ischaemia and hypokalaemia

Question 21

What are the STEMI ECG changes?

Answer 21

Total coronary occlusion
Ongoing chest pain
Persistent ST elevation
New LBBB
Raised biochemical markers

Question 22

What are the non STEMI ECG changes?

Answer 22

Acute ishaemic event
Chest pain
Various ECG changes: persistent ST depression and/or T wave inversion, flattened T waves, normal ECG
Raised biochemical markers

Question 23

What are the biochemical markers associated with ACS and how long are they present?

Answer 23

CK creatin kinase: released after irreversible clear injury from hypoxia, takes 4-6 hrs to rise and 24hrs to peak
Troponin: released after myocardial damage, 3-4 hrs to detect and elevated 1-2 weeks

Question 24

What is the treatment for an MI?

Answer 24

Immediate treatment
ECG
Aspirin 300 mg chewed
Clopidogrel
Pain relief

Question 25

What are the key priorities NICE guidelines (2010) for ACS?

Answer 25

12 lead ECG asap Recording and sending ECG should not delay transfer to hospital Don't routinely administer O2 (monitor SATs) Don't assess symptoms of an ACS differently in ethnic groups

Question 26

What is the treatment for angina?

Answer 26

Drugs that reduce cardiac workload: beta blockers, nitrates, calcium channel blockers Drugs that reduce the risk of infarction: anti platelet drugs Drugs that reduce cholesterol: statins

Question 27

What is the treatment for MI?

Answer 27

Primary angioplasty reduces death, stroke and non fatal infarction CABG of diffuse disease PTCA PCI = reperfusion and stroke reduction benefits after 3 hrs Thrombolysis where no PCI available

Question 28

What are the benefits of primary angioplasty for ACS pts?

Answer 28

``` More effective restoration of patency Improved LV function Reduction in re-occlusion Reduced stroke risk Improved survival Reduction in hospital stay ```

Question 29

What is the continuing care of a pt with an MI?

Answer 29

Monitor for arrhythimas Pain management Secondary prevention/rehab (lifestyle, cardiac rehab, drug therapy, cardiologist review)

Question 30

What is cardiac rehab?

Answer 30

Tailored to individual needs Culturally sensitive Includes: health education, stress management and exercises

Question 31

What is the drug therapy for pts post MI?

Answer 31

``` ACE inhibitors Aspirin indefinitely Clopidogrel Beta blockers Statins ```

Question 32

What is the definition of ACS?

Answer 32

A combination of clinical signs and symptoms resulting from myocardial ischaemia Includes: unstable angina, STEMI and non STEMI