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What are the acute coronary syndromes?


  • Unstable angina
  • Sudden cardiac death




What is the unstable angina?


Defined by the absence of biochemical evidence of myocardial damage. It is characterised by specific clinical findings of:

  • Prolonged (>20 minutes) angina at rest
  • New onset of severe angina
  • Angina that is increasing in frequency, longer in duration, or lower in threshold
  • Angina that occurs after a recent episode of MI.




What is an NSTEMI?

Non-ST elevated myocardial infarction

MI, but without ST-segment elevation. May have other ECG changes, such as ST-segment depression or T-wave inversion. Will have elevated cardiac biomarkers.

This pathologyically results in a subendocardial infarct - partial thickness infarct




What is a STEMI?

ST elevation myocardial infarction

 MI as defined as in acute myocardial infarction, with ST-segment elevation more than 0.1 mV in two or more contiguous leads, and elevated cardiac biomarkers.


Pathologically this is classed by a transmural infarct




What is the difference between an NSTEMI and Unstable angina?



NSTEMI there are biochemical signs of infarction (troponin rise), whereas in unstable angina there are not




What are modifiable risk factors for ACS?


  • Smoking
  • Alcohol intake
  • Calorie intake
  • Sedentary lifestyle
  • Diabetes
  • Obesity
  • Hyperlipidaemia/Dyslipidaemia




What are non-modifiable risk factors for ACS?


  • Increasing age
  • Sex - male
  • FH
  • Ethnicity




What are symptoms of an acute coronary syndrome?


  • Chest pain - crushing, radiates to jaw, neck and arm, not relieved by rest or GTN
  • Dyspnoea
  • Diaphoresis
  • Nausea
  • Palpitations
  • Syncope
  • Sense of impending doom




What signs may be seen in someone with an acute coronary syndrome?


  • Brady/tachycardia
  • Signs of HF - Increased JVP, basal creps, 3rd heart sound etc
  • Pallor, sweatiness
  • 4th heart sound
  • Pansystolic murmur
  • Late signs - Pericardial rub, Peripheral oedema




What are the features of NSTEMI on an ECG?

Horizontal/downsloping ST depression >0.5 mm in > 2 leads

  • ST depression ≥ 1 mm is more specific and conveys a worse prognosis.
  • ST depression ≥ 2 mm in ≥ 3 leads associated with a high prob. of NSTEMI 

T wave inversion/flattening at least 1mm deep in > 2 leads with dominant R-waves




What are the features of a STEMI on ECG?


  1. ST elevation in >/=2 adjacent chest leads of >/=0.2mV in leads V1, 2 or 3
  2. ST elevation in >/= 2 adjacent limb leads of >/=0.1 mV in other leads
  3. Pathological Q waves
  4. T-wave inversion
  5. New LBBB/RBBB




What would indicate a septal infarct?



Maximal ST elevation in V1-2




Why might you get a pansystolic murmur in an MI?



Papillary muscle rupture or a VSD




What would indicate an anterioseptal infarct on ECG?



Maximal ST elevation in leads V1-4




What would indicate an anterolateral infarct on ECG?



Maximal ST elevation in V3-6, 1 and aVL




What patient groups may present without chest pain but have a MI?

Reduced sensation in mediastinal area

  • Elderly
  • Diabetics




How might an elderly or diabetic patient present with an MI?


  • Syncope
  • Pulmonary oedema
  • Epigastric pain and vomiting
  • Acute confusional state
  • Stroke
  • Diabetic hyperglycaemia




If you suspected an ACS, what investigations would you do?


  • 12 lead ECG, then continuous cardiac monitoring
  • Bloods - FBC, U+E's, LFTs, CRP, Glucose, Troponin, magnesium, phosphate, lipid profile, CK-MB, myoglobin
  • CXR




What changes would you see in an ECG minutes after an infarction begins?



T waves become tall, pointed and upright and there is ST segment elevation




What changes would you see in an ECG after a few hours following an infarction?



T waves invert, the R wave voltage is decreased and Q waves develop.





What changes would you see in an ECG a few days following an infarct?



After a few days the ST segment returns to normal, but T waves may still be inverted and pathological Q-waves may be present




What changes in an ECG might you see in someone weeks after having a STEMI?



T wave may return to upright but the Q wave remains.




What would indicate an anterior infract on ECG?



Maximal ST elevation ST elevation in V2-V5




Why when lookign at cardiac enzymes would you take an immediate level then take a level 12 hours later?



It can take 10–12 hours after a heart attack for troponin levels to rise, so 2 troponin tests are carried out (10–12 hours apart) to see if there is a change in troponin level




What would indicate purely lateral infarct on ECG?



Maximal ST elevation in I and aVL





What would indicate an inferior infract on ECG?



Maximal ST elevation on II, III and aVF




How would you initially manage someone with an Acute coronary syndrome?


Gain IV access


  • DiaMorphine - 2.5 - 10mg in 10 ml slowly IV + 10 mg Metoclopramide IV
  • Oxygen - 94-98%
  • Nitrates - Sublingual GTN spray x2 if not hypotensive
  • Aspirin - 300mg loading dose, then 75 mg OD
  • Clopidogrel - 300-600 mg loading dose, then 75 mg OD, or Ticagrelor - 180 mg loading dose, then 90 mg OD




In the initial management of an ACS, what dose of morphine would you give?


2.5 - 10 mg in 10 ml - titrate to the pain




What oxygen saturations would you aim for in someone with ACS?



94-98% unless COPD (aim 88-92% using 24-28% through venturi mask)




What dose of GTN would you give someone initially with ACS?



2 puffs (unless hypotensive), then PRN




When would you not give nitrates as part of the initial management of an ACS?



If they are hypotensive




What dose of aspirin would you give someone in the initial management of ACS?



300 mg loading dose, then 75 mg OD




What dose of clopidogrel would you give someone in the initial management of ACS?



300-600 mg loading dose, then 75 mg OD




After initial management, how would you manage someone with a STEMI?


  • Admit to CCU
  • Reperfusion ASAP - PCI (gold standard) or Thrombolysis
  • Medications - add B-blockers and ACEi




When performing a rapid examination in someone with ACs, what  specific things are you looking for?


  • Hypotension
  • Murmurs  - ruputre/VSD
  • Acute pulmonary oedema
  • Signs of dissection - AR + unequal BP in both arms




After initially managing someone (using MONACT) with an NSTEMI/UA, how would you manage them?


  • Continue aspirin, clopidogrel and Nitrates
  • B-blockers
  • High dose Statins - reduce mortality and recurrent MI
  • Fondaparinaux/LMWH - if no PCI/CABG in next 24 hrs

THEN PERFORM EARLY RISK STRATIFICATION - GRACE Score - divide into high and low risk




After risk stratifying using the GRACE scoring system, if someone with an NSTEMI/UA was found to be high risk, how would you manage them?

Move to CCU


  • Continue Dual antiplatelet, LMWH and anti-ischaemic meds - b-blocker and GTN
  • Add Glycoprotein IIb/IIIa inhibitor

Aim for PCI/angiogrpahy




If someone with NSTEMI/UA was deemed to be low/intermediate risk, how would you manage them?

Admit for monitoring in step down ward. If still symptomatic, treat as high-risk; if not, continue on:

  • Dual antiplatelet
  • LMWH
  • Anti-ischaemic hterapy - B-blockers, GTN

Then perform 2nd risk assessment - If high risk go for in-patient angiography; if low risk for outpatient angiopraphy




When would you give GIIb/IIIa inhibitors in an ACS?


NSTEMI/UA - High risk patients only - Under consultant supervision




Following administering MONACT as part of your initial management of ACS, what should you start someone on asap if they were having a STEMI?



B-blockers - reduce cardiac workload





What reperfusion options are there in ACS?


  • PCI
  • Thrombolysis




When would you consider giving thrombolysis in someone with a STEMI?

No PCI available, plus STEMI with:

  • ST Elevation in two adjacent ECG leads
    • > 1mm in limb leads
    • >2 mm in chest leads
  • Or, new LBBB




What are contraindications for thrombolysis?


  • Aortic dissection
  • GI bleed
  • Allergic Reaction
  • Iatrogenic: recent surgery
  • Neuro: cerebral neoplasm/CVA
  • Severe hypertension
  • Trauma




What mnemonic can you use for remembering the absolute contraindications of thrombolysis?







What are examples of different thrombolytic agents?


  • Alteplase
  • Streptokinase
  • Reteplase
  • Tenectaplase




If thrombolysing someone, what would you start them on post thrombolysis?



LMWH - except with SK use




What are the complications of thrombolysis?


  • Bleeding
  • Hypotension - SK
  • Allergic reactions - SK
  • Systemic embolisaton
  • Intracranial haemorrhage
  • Reperfusion arrhythmia




What are the indications for primary PCI?


  • Chest pain + STT or new LBBB
  • Contraindications to thrombolysis




In someone with STEMI who has already had B-Blockers, antiplatelet therapy and reperfusion therapy, what long term management would you continue them on?


  • Continue B-blockers - 12 months
  • Lifestyle modification
  • Continue ACEi
  • Cardiac rehab
  • Clopidogrel
  • Aspirin
  • GTNitrate spray PRN
  • Echo - look for any lasting damage
  • Statin




What are the components of CVS risk reduction therapy?


  1. Dual antiplatelet
  2. Statins
  3. Lifestyle modification
  4. Cardiac rehabilitation
  5. BP control




When should someone with a STEMi be started on B-blockers?



As soon as possible




When would you start someone on ACEi if they had a STEMI?



Within 24 hours MI - After starting aspirin, B-blockers and reperfusion




What LMWH can be used in treating someone with an NSTEMI/UA?



  • Dalteparin
  • Enoxaparin




In someone with NSTEMI/UA who has had all initial and hospital management they require, what long term management would you continue them on?


  • Continue B-blockers - 12 months
  • Lifestyle modification
  • Continue ACEi
  • Cardiac rehab
  • Statin
  • GTNitrate spray PRN
  • Aspirin + Clopidogrel
  • Echo - look for any lasting damage




What is the critical time period for transfer of a patient with an ACS to a PCI centre (after which thrombolysis should be used)?



90 minutes




How long should patients be on bed rest for after an ACS?



48hrs with cardiac monitoring




What are complications of myocardial infarction?

  • Cardiac death
  • Heart failure
  • Pericarditis
  • Arrhythmias
  • Myocardial rupture
  • Ventricular aneurysm
  • Embolism
  • DVT + PE
  • Tamponade
  • Dressler's syndrome
  • Valve problems - papillary muscle rupture




What is dressler's syndrome?


Dressler's syndrome is believed to be an immune system response after damage to heart tissue or to the pericardium, from events such as a heart attack, surgery or traumatic injury. It consists of fever, pleuritic pain, pericarditis and/or a pericardial effusion.




When would you give someone unfractionated heparin in an ACS scenario?



If they were going for PCI in next 24 hrs, otherwise give LMWH




What lifestyle advise would you give someone post-MI?


  • Stop smoking
  • Diet: oily fish, fruit, veg, ↓sat fats
  • Weight Loss
  • Exercise: 30min OD
  • Work: return in 2mo
  • Sex: avoid for 1mo
  • Driving :avoid for 1mo




If using ticagrelor as part of you initial management of ACS, what dose would you use?



180mg loading dose, then 90 mg twice daily




If someone had UA/NSTEMI, and there were no facilities to perform PCI or CABG within 24 hrs from initial presentation, what would you treat them with?







What are features of dressler's syndrome?


  • Mild fever
  • Pleuritic chest pain - positional - relived sitting forward
  • Friction rub




What do q waves on an ECG imply?



Full thickness infarct




Why would you perform FBC in suspected ACS?



Anaemia could be causing cardiac ischaemia




Why would you perform U+E's in ACS?


  • Impaired renal function can cause false positive elevations in troponin
  • Baseline levels required prior to ACEi use
  • Hypo/hyperkalaemia associated with arrhythmias




Why would you perform LFTS in someone with ACS?


  • Baseline prior to statin use
  • Hepatic impairment is a contra to ticagrelor use




Why wou perform blood glucose in someone with suspected ACS?



Check for diabetes - aim for 4-11 mmol/L




What mnemonic could you use to remember the complications of an MI?




What anti-coagulant therapy would you start someone on if they were having an ACS  but weren't going for PCI in the next 24 hrs?



Fondaparinaux/LMWH - if no PCI/CABG in next 24 hrs




What anti-coagulant therapy would you start someone one who was having an ACS and was scheduled to have PCI within the next 24 hours?



Unfractionated heparin




How long would you admit someone for who was having an ACS?



5-7 days - first 48 hrs bed rest with cardiac monitoring




How long after having an MI should individuals not be allowed to drive?



1 month




How long after having an MI should individuals ideally return to work?



2 months