Acute coronary syndrome

Question 1

Describe : MYOCARDIAL INFARCTION (MI)

Answer 1

Myocardial cell death caused by ischemia,
evidenced by a rise and fall in cardiac biomarkers.

Question 2

Describe : ACUTE CORONARY SYNDROME (ACS (3)

Answer 2

• An ischemic chest pain syndrome usually associated with coronary artery plaque rupture and occlusion.
• ACS entities : include STEMI, NSTEMI, and Unstable Angina.

Question 3

Describe : UNSTABLE ANGINA (UA) (3)

Answer 3

• A type of ACS in which biomarkers are not elevated
• and chest pain is of new onset, is changing in frequency or severity, or occurs at rest. Interestingly
• the advent of high-sensitivity troponin assays has led to greater detection of subtly elevated cardiac biomarkers; as a result, the diagnosis of UA is being made less frequently.

Question 4

Describe : NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTEMI) (2)

Answer 4

• A type of ACS that lacks new ST elevation on ECG
• and in which cardiac biomarkers are eventually elevated.

Question 5

Describe : ST-ELEVATION MYOCARDIAL INFARCTION (STEMI) (35)

Answer 5

• A type of ACS in which significant ST elevation is found in two or more contiguous ECG leads.
• It is typically associated with epicardial coronary artery occlusion and transmural infarction, resulting in myocardial cell death.
• Q waves will manifest on the ECG if perfusion is not restored quickly.
• STEMI occurs when the affected coronary artery is completely occluded.
• It is treated with immediate reperfusion therapy, such as thrombolysis or PCI.

Question 6

What’s the difference between NSTEMI and Unstable Angina? (1)

Answer 6

Elevation in cardiac
markers eventually distinguishes NSTEMI from UA.

Question 7

Name the leads for each territory

Answer 7

• Lateral : I, aVL, V5, V6
• Inferior : II, III, aVF
• Septal : V1,V2
• Anterior : V3,V4

Question 8

Name : RISK FACTORS FOR CORONARY HEART DISEASE (7)

Answer 8

• DB
• Hypercholesterolemia; high-density lipoprotein (HDL) cholesterol less than 40 mg/dL
• Current tobacco use
• HTA
• Age (45 or older if male; 55 or older if female, or premature menopause)
• Family history of premature CHD (MI or sudden death before age 55 years in male first-degree relative; before 65 years in female first-degree relative)
• Sympathomimetic use (cocaine and amphetamines)
• Rheumatologic conditions (rheumatoid arthritis and systemic lupus erythematosus)

Question 9

What (HEART) score have been developed to help risk-stratify patients with undifferentiated chest pain?

Answer 9

HEART score
(History, ECG, Age, Risk factor, and Troponin)

Question 10

Traitements à débuter en cas de SCA

Answer 10

• À DISCUTER AVEC LE SÉNIOR/PATRON
• Double antiplaquettaire :
• 1er antiplaquettaire : ASA 360mg PO x1, puis 80 mg PO die
• 2e antiplaquettaire :
  Ticagrelor 180mg PO x1, puis 90mg PO bid
  (Le premier choix la majorité du temps en SCA)
  C-I si atcd de saignement intracrânien

Plavix 300-600mg PO x1, puis 75mg PO die
(À choisir si patient anticoagulé ou thrombolysé)
* Anticoagulant
Héparine IV (le plus souvent utilisé; il y a un protocole à remplir)

Héparine de bas poids moléculaire : Fragmin 120 unités/kg (max 10 000
unités/dose) s/c bid

Fondaparinux : si on peut pas donner d’héparine (ex. atcd de HIT)

• Statines
  Lipitor 80 mg PO die
  Crestor 40 mg PO die
• Éventuellement B-bloqueurs (peut être débuté d’emblée si patient stable) et IECA (après coro)

Question 11

Describe : Pour soulager DRS si persiste/récidive (4)

Answer 11

• Nitro spray PRN +/- Timbre de Nitro +/- Nitro IV (nécessite une unité monitorisée et des pressions adéquates)
• Opioïdes (fentanyl/morphine/dilaudid)
• B-bloqueurs
• Si DRS persiste malgré traitement adéquat et/ou TA trop basse pour optimiser traitement Possible indication de coro urgente = À DISCUTER AVEC LE SÉNIOR/PATRON

Question 12

When the ECG reveals STEMI and symptoms have been present for less than 12 hours, what to do?

Answer 12

immediate reperfusion therapy is indicated. Optimally, total ischemic time should be limited to less than 120 minutes.

Question 13

There are two ways to achieve
reperfusion. Name them.

Answer 13

• primary PCI (angioplasty or stent placement)
• thrombolysis.

Question 15

The standard “door-to-balloon time” goal is what?

Answer 15

is 90 minutes, although benefit extends to 12 hours from the time of pain onset.

Question 16

Recent studies suggest that if a patient presents to a hospital that does not offer PCI, transfer to a neighboring facility for primary PCI is superior to thrombolysis if what?

Answer 16

if transfer can be accomplished within 120 minutes.

Question 17

Thrombolysis should be done within what time frame?

Answer 17

Though the benefit of thrombolysis extends out to 12 hours, it is greatest when begun within four hours and approaches that of primary PCI when started within 30 minutes.

Question 18

Should PCI still be done after thrombolytic therapy?

Answer 18

Even if there is evidence of successful reperfusion, PCI is indicated and should be performed within 24 hours of thrombolytic therapy.

Question 19

Describe tx : UA and NSTEMI (5)

Answer 19

• based on ECG findings, cardiac marker results, TIMI risk score, and whether the patient is likely to undergo early angiography and PCI.
• Aspirin and nitroglycerin = minimum therapy.
• Morphine is added when chest discomfort continues despite nitroglycerin therapy.
• Beta-blockers, such as IV metoprolol, may be added in cases presenting with hypertension or tachycardia; however, they should be used with caution (risk of caridogenic shock).
• In high-risk patients, such as those with ischemic ECG changes, elevated cardiac
  markers, and TIMI risk score of 3 or greater, adding an anticoagulant agent, such as unfractionated heparin or LMWH, may work to halt the thrombotic process.
• IV glycoprotein IIB/IA inhibitors, such as abciximab, or direct thrombin inhibitors, such as bivalirudin, are sometimes used in patients undergoing early angiography and PCI.

Question 20

Name complications : acute MI (6)

Answer 20

• ventricular tachycardia and ventricular fibrillation (sudden death) are the most frequently encountered complications in the ED and prehospital setting, occurring in approximately 10% of cases.
• Bradyarrhythmias : heart block from irreversible damage to the His-Purkinje system after an anterior MI or arteriovenous (AV) node dysfunction from an inferior MI. Emergent pacemaker placement may be necessary.
• Left ventricular dysfunction that occurs with anterior MI usually causes** pulmonary edema** or cardiogenic shock.
• Right ventricular infarction

Question 21

Name late complications of MI (5)

Answer 21

that tend to occur several hours to days after presentation include left ventricular free wall rupture causing
* tamponade
* ventricular septal defect
* pericarditis
* left ventricular aneurysm
* thromboembolism.

Question 22

Name iatrogenic complications of MI therapy (3)

Answer 22

• Heparin and antiplatelet therapies lead to significant bleeding in up to 10% of patients.
• Intracranial hemorrhage occurs in 0.5% to 0.7% of patients who receive thrombolytics for STEMI.
• These bleeds are often fatal.