ACS

Question 1

What are the different acute coronary syndromes?

Answer 1

Step up from stable angina.

Involves Unstable angina, NSTEMI, STEMI and Sudden cardiac death

Question 2

What causes an ACS?

Answer 2

Either the rupture of a plaque or thrombosis which makes the occlusion of vessel worse than in stable angina

Question 3

What is the difference between unstable angina and NSTEMI?

Answer 3

An NSTEMI is an actual infarct which causes necrosis and a rise in serum troponins or creatine kinase-MBs due to that breakdown of muscle

Unstable angina is kind of like stable angina at rest but not enough to cause a MI

Question 4

Non-modifiable risk factors for an ACS?

Answer 4

Age
Gender
Family/genetics

Previous angina, cardiac event or surgery

Question 5

Modifiable risk factors?

Answer 5

Smoking
Bad diabetic control leading to hyperglycemia
Hypertension
Hyperlipidaemia
Poor exercise/diet

Question 6

What will you want to ask the patient about the angina pain?

Answer 6

Onset at rest

Relieving factors - does GTN spray help?

Question 7

In a history - what would make you suspect unstable angina/NSTEMI?

Answer 7

Angina on rest

Question 8

How does an NSTEMI typically start presenting - Angina getting progressively worse or angina on rest?

Answer 8

NSTEMI will show first as angina on rest

as it has reached that point and has been reclassified to an actal MI

Question 9

Examination wise - will patients look very unwell on an end of bed inspection?

Answer 9

They can do, but not all the time

Question 10

Is there any remarkable features to look for in an examination?

Answer 10

Not really

Question 11

What should be checked in an examination anyway?

Answer 11

HR
BP
Auscultate for murmurs and crackles

Question 12

What should you keep in mind when looking for symptoms for an ACS in different patients?

Answer 12

You always get atypical patients in which typical symptoms do not show

In this case - women, elderly or diabetics due to a reduced pain sensation

Question 13

What symptoms should you keep your eye open for instead with atypical patients?

Answer 13

Breathlessness
Signs of heart failure
Nausea and vomiting
Epigastric (upper abdomen) pain

Question 14

What to look for in an ECG?

Answer 14

Can have but not always;

ST segment depression
Transient ST segment elevation and/or T wave inversion

Question 15

What happens to ECG changes in unstable angina when the pain subsides?

Answer 15

The ECG tends to return to normal

Question 16

What happens to ECG changes in NSTEMI when the pain subsides?

Answer 16

Changes tend to persist

Question 17

Should ECGs be done routinely?

Answer 17

Yes to detect any changes

Question 18

What are some biomarkers which indicate a high risk of an adverse event?

Answer 18

Cardiac troponin - I and T proteins types

Question 19

What is cardiac troponin?

Answer 19

Contractile apparatus unique to heart

Question 20

Should cardiac troponin be detectable in normal instances?

Answer 20

No

Question 21

Is troponin elevation always a sign of ACS?

Answer 21

No

Question 22

What is the immediate treatment response to give to someone having an ACS?

Answer 22

MONA

Morphine/dimorphine
Oxygen
Nitrates - GTN spray or tablet
Aspirin - 300mg orally

Question 23

What is the further medical treatment from someone with unstable ACSs?

Answer 23

Anti-platelet
Anti-thrombotic (anticoagulants)
Glycoprotein llb/lllb inhibitor 
Beta blockers
Statins
ACEIs

Question 24

What are the anti-platelet drugs and doses?

Answer 24

Aspirin - 75-100mg

Clopidogrel - 300mg initially then 75mg daily

Ticagrelor - 60mg initially then 10mg daily

Prasugrel - 180mg then 90mg daily

Question 25

How does aspirin work?

Answer 25

Platelet thromboxane A2 production inhibitor Stops platelet aggregation and vasoconstriction

Question 26

How does ticagrelor/prasugrel work?

Answer 26

ADP receptor blocker - stops pathway reaching Glycoprotein llb/lllb pathway In turn stops platelet aggregation and fibrin linking

Question 27

Should patients be on one or more than one of these antiplatelet drugs and for how long after an event should they be used?

Answer 27

Dual therapy for one year after event is best

Question 28

Name some glycoprotein llb/lllb receptor blockers?

Answer 28

Tirofiban

Question 29

What do these glycoprotein llb/lllb blockers do?

Answer 29

Stop the protein undergoing a conformational change and binding fibrinogen and activating platelets

Question 30

Adverse effects of glycoprotein llb/lllb blocker therapy?

Answer 30

Bleeding

Question 31

What are some anti-thrombotic (anti-coagulant) agents?

Answer 31

Unfractionated heparin Low molecular weight heparin Fondaparinux - a LMWH like drug

Question 32

Which ones IV administered?

Answer 32

Unfractionated heparin

Question 33

How is LMWH given?

Answer 33

Sub/c

Question 34

Which one of the 2 heparins has a better clinical outcome and why?

Answer 34

LWMH Easier to give No need to be monitored

Question 35

Name some IV beta blockers used to treat unstable angina/NSTEMI.

Answer 35

Atenolol | Metoprolol

Question 36

Should oral beta blockers be started?

Answer 36

Yes - shown to reduce morality

Question 37

How do beta blockers work?

Answer 37

Rate limiting | Reduce myocardial O2 consumption

Question 38

B/Blocker contraindications?

Answer 38

Asthma Heart failure Bradycardia/Heart block

Question 39

What type of patients have been shown to die if given beta blockers?

Answer 39

``` Over 70s HR is below 110bpm S. BP is below 120 Coronary vasospasm Cocaine use ```

Question 40

Should stains be used?

Answer 40

Yes -acutely and chromically to reduce risk of further events

Question 41

In who should ACEIs be used for a ACS?

Answer 41

Abnormal LV function, unstable angina or an MI

Question 42

What are the 2 surgical ways to treat an ACS?

Answer 42

PCI | CABG

Question 43

Why is a STEMI treated differently?

Answer 43

The occlusion is larger and needs to be reduced rapidly (I think)

Question 44

What are the 2 main treatments for a STEMI?

Answer 44

Primary PCI (Surgical) Fibrinolysis/Thrombolysis (medical)

Question 45

Features of PCI.

Answer 45

Better than fibrinolytic therapy Used to unblock artery and save muscle cells so time is muscle

Question 46

When is fibrinolysis used?

Answer 46

When PCI not an option

Question 47

What is fibrinolysis?

Answer 47

Drugs that thin out the thrombus that has grown on top of plaque and blocked artery even more

Question 48

How does fibrinolysis work?

Answer 48

Serine proteases convert plasminogen to plasmin Plasmin works to lyse a clot by breaking down fibrinogen and fibrin

Question 49

2 types of fibrinogen agents?

Answer 49

Fibrin specific | Non fibrin specific

Question 50

Name some fibrin specific agents?

Answer 50

Alteplase Reteplase Tenecteplase

Question 51

Name the non-fibrin specific agent

Answer 51

Streptokinase

Question 52

Contraindictions of fibrinolysis

Answer 52

Suspected aortic dissection Bleeding due to HYPOcoagubiltiy Brain tumours/bleeds/stokes

Question 53

What increases the risk of an intra-cranial bleed in fibrinolysis therapy?

Answer 53

``` Over 75 Female Previous stroke history Low body weight Severe hypertension INR of over 4 Chronic kideny disease and elevated creatine ```

Question 54

What is some secondary prevention regarding lifestyle after an ACS event?

Answer 54

Stop smoking Better diet/exercise Control co-morbities - BP/glycemia

Question 55

What is some further medical therapy to use after an ACS?

Answer 55

``` Aspirin/clopidogrel for 1 year Beta blocker (if tolerable_ ``` ACEIs if LV dysfuntion

Question 56

What investigations should be done post ACS?

Answer 56

An echocardiogram for myocardial dysfunction

Question 57

What is the most important determinant for an MI survival?

Answer 57

Age | LV ejection fraction

Question 58

Sudden cardiac death - survival rate?

Answer 58

~2% are get past resus and survive

Question 59

In those resus'd - what do they end up with?

Answer 59

about 80% have V-tachy or V-fib

Question 60

How is sudden cardiac death seen?

Answer 60

Seen as V-fib. multiple wavelets on ecg - rapidly progresses to asytole

Question 61

How to treat SCD?

Answer 61

Defib only way to treat a V-fib arrest If progresses to asytole then prognosis isn't good

Question 62

List the major trials which have proven the advantage of thrombolytic therapy

Answer 62

local GREAT study

Question 63

Describe rehabilitation following myocardial infarction

Answer 63

build up easy exercise and keep bp low