Acute coronary syndrome

Question 1

Right coronary artery (RCA) supplies which parts of the heart?

(4)

Answer 1

• R atrium
• R ventricle
• Inferior aspect of the L ventricle
• Posterior septal area

Question 2

The left coronary artery becomes the?

(2)

Answer 2

• Circumflex artery
• Left anterior descending (LAD)

Question 3

Which parts of the heart does the circumflex artery supply?

Answer 3

• Left atrium
• Posterior aspect of left ventricle

Question 4

Which part of the heart does the LAD supply?

Answer 4

Anterior aspect of the L ventricle
Anterior aspect of the septum

Question 5

Suspect ACS if pain is in the and lasts for how long?

Answer 5

Chest, arms, back or jaw and lasts longer than 15 mins

Question 6

In ACS the chest pain will be described as?

Answer 6

• Dull, central and/or crushing
• Will occur with little or no excergion and often lasts longer than 15 mins

Question 7

In ACS what is teh chest pain associated with?

Answer 7

• Nausea, vomitting, sweating, breathlessness, palpitations
• Associated with haemodynamic instabiity ( systolic PB less than 90)

Question 8

What test can be done to differntiate unstable angina from MI?

Answer 8

Serum troponin- remains elevated for up to 2 weeks after an MI
It is realsed from ischaemic heart muscle tissue

Question 9

What is a silent MI and who is at risk of these?

Answer 9

Someone whp does not experince typical chest pain during acute conoary syndrome
* Patienst with diabetes are at risk of these

Question 10

ECG changes in STEMI?

Answer 10

ST elevation
LEft bundle branch block

Question 11

ECG chnages in NSTEMI?

Answer 11

ST depression
T wave inversion

Question 12

Difference between an NSTEMI and STEMI?

Answer 12

NSTEMI- partial blockage of artery- can be diagnosed with troponin levels- high or rising= NSTEMI

STEMI- complete blockage- diagnosed on clinical findings and ECG

Question 13

Alternative causes of raised troponin levels? (5)

Answer 13

• Chronic kidney disease
• Sepsis
• Myocarditis
• Aortic dissection
• Pulmonary embolism

Question 14

STEMI is diagnosed when investigations show?

Answer 14

ECG shows either ST elevatio or new left bundle branch block

Question 15

NSTEMI is diagnosed when investigations show?

Answer 15

Raised troponin with
* A normal ECG
* Other ECG chnages (ST depression or T wave inversion)

Question 16

Unstable angina is diagnosed when investigations show?

Answer 16

Symptoms suggest ACS
Troponin is normal and either
* Normal ECG
* ECG chnages (ST depression or T wave inversion)

Question 17

Initial management of chest pain? “CPAIN”

Answer 17

Call an ambulance
Perform an ECG
Aspirin 300mg
Intravenous morphine for the pain if required
Nitrate (GTN)

Question 18

Management of STEMI presenting witin 12 hours of onset?

Answer 18

• Percutaneous coronary intervention (PCI)- within 2 hours of presentation
• Thrombolysis

Question 19

What is percutaneous coronary intervention (PCI)?

Answer 19

Catheter into the patients radial or femoral artery undr x-ray guidance and injecting contrast to identify the blockage (angiography)

Blocakges can be treated with an angioplasty- balloon to widen the lumen of the artery and then stent inserted to keep the artery open

Question 20

What is thrombolysis?

Answer 20

Injecting fibriolytic agent which breaks down fibrin in blood clots

Question 21

Managment of NSTEMI? (BATMAN)

Answer 21

B- base the decsion about angiography or PCI on the GRACE score
A- Aspirin 300mg stat
T- Ticagrelor 180mg stat
M- morphine to control pain
A- Antithrombinn therapy with fondaparinux
N- Nitrate

Question 22

What does the GRACE score predict in NSTEMI management?

Answer 22

Gives a 6 month probability of death after having an NSTEMI
* 3% or less is considered low risk
* Above 3 % is considered medium to high risk

Question 23

What is Dressler’s syndrome and how does it present? Diagnosed and managed?

Answer 23

Also called post-myocardial infarction syndrome- usually occurs 2-3 weeks after MI- immune response causes inflammation to the pericardium

Presents:
* Pleuritic chest pain
* Low grade fever
* Pericardial rub on auscultation

Diagnosis:
* Made with an ECG- global ST elevation and T wave inversion
* echocardiogram
* Raised inflammatory markers (CRP and ESR)

Managment:
* NSAIDs
* Severe cases- steroids

Question 24

Name the condition:
Sudden onset pleuritic pain either left sided or right sided, with associated dyspnoea and syncope

Answer 24

Pneumothorax

Question 25

Name the cause: Pain typically persistent (typically days or longer), worsened with passive and active motion and sometimes reproducible chest tenderness.

Answer 25

Musculoskeltal

Question 26

Name the cause: Exertional pain/discomfort in the centre or left side of chest, throat, neck or jaw relieved by rest or GTN within a few minutes. May radiate to neck, jaw or left arm. Sometimes there may not be any pain but breathlessness (angina equivalent).

Answer 26

Angina

Question 27

Name the condition: Constant or intermittent central pleuritic sharp pain often aggravated by position (classically worse on lying down and relieved by sitting or leaning forward)

Answer 27

Pericarditis

Question 28

Name the condition: Recurrent, vague epigastric discomfort, that is relieved by food, antacids, or both

Answer 28

Peptic ulcer disease

Question 29

Name the conditon: Sudden onset pleuritic pain with associated dyspnoea and tachycardia. Sometimes mild fever, haemoptysis and syncope

Answer 29

Pulmonary embolism

Question 30

Name of the tool used in GP to determine a patients cardiovascular risk?

Answer 30

QRISK3- established a patients 10 year risk of cardiovascular events

Question 31

Drugs used in secondary prevention in people who have had an MI?

Answer 31

ACE inhbitor Antiplatelet therapy Beta-blocker Statin

Question 32

What is angina and difernce between stable and unstable angina?

Answer 32

Angina= chest pain caused by an insufficient blood supply to myocardium. Stable- occurs predictably with physical exertion or emotional stress and relived within minutes of rest or GTN spray Unstable angina- new onset, often occuring at rest- requires immediate admission to hopsital

Question 33

Key side effects of GTN spray?

Answer 33

Headaches and dizziness caused by vasodilation

Question 34

Medications for secondary prevention of angina? 4 A's

Answer 34

A- Aspirin 75mg once daily A- Atorvostatin 80mg once daily A- ACE inhibitor A- already on a beta blocker for symptomatic relief

Question 35

What is a Coronary artery bypass graft (CABG)?

Answer 35

Offered to patients with severe stenosis Opens chest along sternum and attch graft vessel to the affected coronary artery, bypassing the stenoitc area 3 main options for graft vessel are: * Saphenous vein * Internal thoracic artery * Radial artery

Question 36

In patient with angina where beta blocker is contraindicated e.g. asthma. What else can be given alongside GTN and verapamil?

Answer 36

Long acting nitrate e.g. isosorbide mononitrate

Question 37

Prior to percutaneous coronary intervention (PCI) what are patients given?

Answer 37

Dual antiplatelet therapy * Aspirin and Clopidogrel (if on anticoag already) * Aspirin and prasugrel (if not on anticoag already)

Question 38

Patients undergoing fibrinolysis for a STEMI should also be given?

Answer 38

Antithrombin drug- Fondaparinux