ACS

Question 1

What is the immediate management for confirmed STEMI?

Answer 1

ECG + BLOOD MARKERS!!
IV Access
Morphine 2-5mg IV + Metoclopramide 10mg IV
O2: Sats <94%
Nitrates: GT spray 2 puffs + BB STAT
Aspirin: 300mg PO
Ticagrelor: 180mg 
Fondaparinux: Pre-PCI if <12hrs of Sx onset

Question 2

In an NSTEMI how long is LMWH given for?

Answer 2

2-5days

Question 3

What aftercare is given post-NSTEMI/STEMI and how long for?

Answer 3

ABC'S
A: ACEi = indefinitely 
B: Beta-blocker = 12m
C: Dual antiplatelet = Aspirin & Ticagrelor/Clopidogrel = 12m
S: Statin = indefinite

Question 4

What are the signs of an Atypical MI?

Answer 4

Epigastric/back pain
"Silent infarct"
Dyspnoea- pulmonary oedema
Syncope
Coma
Confusion

Question 5

Who is at risk of a silent MI?

Answer 5

Elderly
Diabetic
HTN

Question 6

What are the essential investigations for a suspected MI?

Answer 6

ECG
↑Troponin: ↑3 hrs, peaks 12 hrs, 24-48hrs
Raised if ONE is above reference range
↑CK: ↑4-8 hrs, peak at 24hrs, fall 3-4d

Question 7

What are the signs on an ECG of a STEMI?

Answer 7

ST elevation >1mm in a limb lead 
OR
>2mm in 2 consecutive chest leads 
OR
New LBBB

Question 8

Where do the LAD, Circumflex & RCA supply?

Answer 8

LAD: Anterior heart & LV
C: Lateral heart
RCA: Inferior heart

Question 9

What leads correspond to the RCA, LAD & Circumflex?

Answer 9

RCA: II, III, AVF
LAD: V1-V4
C: I, AVL, V5-V6

Question 10

What are you at risk of with a STEMI caused by a blockage in the RCA?

Answer 10

High risk of heart block

Question 11

What ECG changes are seen in an NSTEMI?

Answer 11

T inversion (normal in aVR)
ST depression
Q waves

Question 12

What would ST depression in V1-V4 make you consider?

Answer 12

Posterior STEMI

Question 13

What are the coronary repercussion therapy options?

Answer 13

Angiography & PCI

Fibrinolysis

Question 14

What are the indications for PCI?

Answer 14

Present <12hr of Sx onset
AND
PCI can be given within 2hrs of ECG diagnosis

Question 15

If PCI cannot be delivered within the indications what is the next best option?

Answer 15

Fibrinolysis: Alteplase

• If PCI not available in 2hrs but still in 12hr window of Sx onset
• If thrombolysis successful then PCI can be done within 24hrs
• Repeat ECG after 60-90mins

Question 16

Other than an MI what conditions can cause a raised troponin?

Answer 16

Cardiac: cHF, CAD, Myo/endo/pericarditis, heart block, HTN, Aortic dissection, AV disease, Hypertrophic cardiomyopathy
Non-Cardiac: PE, severe pulmonary HTN, RF, COPD, DM, Acute neurological event Drugs and Toxins

Question 17

What is the TIMI risk score?

Answer 17

Scored out of 7

• Likelihood of adverse events
• Identifies who will benefit from certain interventions (including PCI): Higher the risk = Greater the benefit

Question 18

What is the GRACE risk score?

Answer 18

Predicts 6month mortality post-MI
>9% = High risk
Treatment strategies recommended depending on risk

Question 19

What are the 3 distinctive features of an NSTEMI on presentation?

Answer 19

Resting angina
New-onset severe angina
Increasing angina (prevention diagnosed)

Question 20

Why is troponin helpful in NSTEMI?

Answer 20

Differentiates between UA (normal troponin) & NSTEMI (a) ↑Trop)

Question 21

In an NSTEMI what do high risk patients require?

Answer 21

Inpatient angiography PCI
AND
Glycoprotein iib/iiia

Question 22

In NSTEMI what is the time frame for PCI?

Answer 22

<12hours

Question 23

What needs to be stopped before a CABG and for how long?

Answer 23

Ticagrelor/Clopidogrel 5-7d pre-CABG

Question 24

What are the complications of an MI?

Answer 24

VF → Cardiac arrest: MOST COMMON cause of death post-MI
Cardiogenic shock
Chronic HF
Tachy/bradyarrhythmias
Pericarditis
Dressler's syndrome
LV free wall rupture
Ventricular septal defect
Acute mitral regurg
LV aneurysm

Question 25

How does cardiogenic shock occur post-MI?

Answer 25

Large part of ventricular myocardium damaged
Usually after anterior MI
↓EF
Systemic hypoperfusion (tachy, ↓sBP, cool peripheries & ↓renal output)
Adequate central venous filling pressures.
Also caused by LV free wall rupture

Question 26

How is cardiogenic shock treated?

Answer 26

PCI

Inotropes +/- intra-aortic balloon pump

Question 27

What type of MI is most likely to cause a bradyarrhythmia?

Answer 27

Inferior MI

Question 28

When does pericarditis post-MI usually present?

Answer 28

First 48hrs

Following transmural MI

Question 29

What is Dressler’s syndrome?

Answer 29

2-6w post-MI
Autoimmune reaction against antigenic proteins formed by recovering myocardium
FEVER + PERICARDITIS + EFFUSION + PLEURITIC PAIN w/↑ESR
Tx: NSAIDs

Question 30

What sign on ECG may indicate an LV aneurysm?

Answer 30

Persistent ST elevation

Question 31

What is someone with an LV aneurysm at risk of?

Answer 31

Thrombus may form in aneurysm

Stroke = Anticoagulated

Question 32

How does an LV free wall rupture present? How is it treated?

Answer 32

1-2w post-MI
Acute HF secondary to tamponade (↑JVP, pulses paradoxes, ↓BP, ↓EF, ↓HS)
Tx: URGENT Pericardiocentesis & thoracotomy

Question 33

How does ventricular septal defect present post-MI? How is it investigated & treated?

Answer 33

First week
Acute HF + Pan-systolic murmur
Ix: ECHO
Tx: Surgical repair

Question 34

In what type of MI is acute mitral regurg most commonly seen?

Answer 34

Infero-posterior MI
May be due to ischaemia or rupture of papillary muscle
Tx: Surgical repair

Question 35

What is unstable angina?

Answer 35

Absence of biochemical evidence of myocardial damage

Prolonged angina at rest/ new onset severe angina/ angina increasing in frequency/ inc duration/ angina post-MI

Question 36

How is a diagnosis of unstable angina chosen over an NSTEMI?

Answer 36

NSTEMI:
ECG = T-wave changes/ST depression/ no ECG changes
Biochem = Trop RISE
UA:
ECG = T-wave changes/ST depression/ no ECG changes
Biochem = No elevation

Question 37

How is unstable angina investigated?

Answer 37

ECG
Bloods: Troponin, FBC, U&E, Glucose, LFTs, lipids, Coag
CXR
ECHO