acute coronary syndrome

Question 1

unstable angina

Answer 1

ischaemic sx suggestive of ACS but no elevation in troponins or ECG changes

treated the same until troponin result is known
- trop takes hours to come back
- used to distinguish between NSTEMI

Question 2

modifiable and unmodifiable risk factors for ACS

Answer 2

unmodifiable
- increasing age
- male gender
- fam history

modifiable
- smoking, obesity
- diabetes
- hypertension
- hypercholesterolaemia

Question 3

which patients may not experience chest pain/have atypical presentation during an MI

Answer 3

diabetics
elderly
women

Question 4

ST elevation in V1-4

Answer 4

anterior
Left anterior descending (LAD)

Question 5

ST elevation in II, III, aVF

Answer 5

inferior - right coronary artery

Question 6

ST elevation in I, V5-6

Answer 6

lateral - left circumflex

Question 7

if a patient presents with an NSTEMI which risk stratification scoring tool is used

Answer 7

GRACE
- to decide futher management
- high risk/unstable -> coronary angio
- lower risk - coronary angio at later date

Question 8

secondary prevention of ACS

Answer 8

5 A’s
- Aspirin
- Another antiplatelet - clopidogrel
- Atorvastatin (or statin)
- ACEi
- Atenolol or bisoprolol (beta blocker)

Question 9

pathological Q wave

Answer 9

appears 6 or more hours after onset of symptoms

suggests a deep infarction involving the full thickness of the hear murcle (transmural)

Question 10

common initial management for all patients with ACS

Answer 10

MONA

morphine (only if in severe pain)

oxygen - only if sats <94%

nitrates - caution if hypotensive

apirin 300mg

Question 11

simplified STEMI mx

Answer 11

aspirin 300mg

<12hrs of onset sx + can give within 120 mins = PCI
- radial access (preferred to femoral) + drug-eluting stents

no PCI in 120 mins = fibrinolysis
–> if ongoing ischaemia -> consider PCI

Question 12

what drug changes should be made in STEMI prior to PCI

Answer 12

dual antiplatelet therapy required - (aspirin + another)

if not already taking anticoagulant = prasugrel

if current taking oral anticoag = clopidogrel

Question 13

drug therapy for STEMI during a PCI

Answer 13

PCI with radial access
- unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI)

with femoral access
- bivalirudin with bailout GPI

Question 14

what drug should a patient be given at the same time as fibrinolysis

Answer 14

antithrombin ! (Fondaparinux)
- prevents formation of new clots

• repeat ECG after 60-90mins, persistent MI -> PCI

Question 15

management of NSTEMI

Answer 15

aspirin 300mg
if not high risk + no immediate PCI planned = Fondaparinux
PCI planned or creatinine >265 = unfractionated heparin

GRACE score for 6 month mortality
- low risk (<=3%) = conservative mx (DAPT)
- high risk (>3%) = PCI (immediate or 72hrs)

Question 16

Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary) and within what time frame?

Answer 16

immediate = patients who are clinically unstable - e.g hypotensive

within 72hrs = patients with a GRACE score >3% (those at higher risk)

Question 17

drug therapy in PCI for NSTEMI/unstable angina

Answer 17

prior = DAPT
- NOT on anticoag = prasugrel or ticagrelor
- taking anticoag = clopidogrel

during = unfractionated heparin (regardless of fonaparinux or not)

Question 18

conservative mx of NSTEMI/unstable angina

Answer 18

dual antiplatelet therapy - aspirin + …

patient NOT at high risk of bleeding = ticagrelor

high risk of bleeding = clopidogrel

Question 19

poor prognostic factors of ACS

Answer 19

age
development/hx of heart failure
peripheral vascular disease
reduced systolic BP
Killip class

initial serum creatinine
elevated initial cardiac markers
arrest on admission
ST segment deviation

Question 20

Killip class

Answer 20

system used to stratify risk post myocardial infarction giving a % 30 day mortality

class I = no sign of heart failure - 3%

II - lung crackles, S3 - 17%
III - frank pulmonary oedema - 38%

IV - cardiogenic shock - 81%
–> the poorest prognostic indicator

Question 21

posterior infarction

Answer 21

rarely isolated, occurs in context of lateral or inferior STEMIs

= V1-V3
- ST DEPRESSION
- upright T waves
- dominant R wave in V2

posterior infarction is confirmed by ST elevation + Q waves in posterior leads (V7-9)

Question 22

what can a new left bundle branch block indicate

Answer 22

acute coronary syndrome!

Question 23

why should metformin be stopped in MI

Answer 23

due to risk of lactic acidosis
- introduced back later
- control by insulin/dextrose infusion

Question 24

ECG reveals ST-segment depression in leads I, aVL, and V5-6 - diagnosis?

Answer 24

NSTEMI

Question 25

ECG findings in NSTEMI/unstable angina

Answer 25

ST depression or T wave inversion - partial thickness damage due to partial/transient blockage STEMI = FULL thickness, transmural heart damage due to complete coronary artery blockage

Question 26

what does Global T wave inversion indicate

Answer 26

think non-cardiac cause brain herniation = cushings triad - hypertensive - bradycardic - tachypnoeic with signs if Cheyne-stokes breathing

Question 27

in what cases is fondaparinux offered

Answer 27

NSTEMI patient who are; - NOT at high risk of bleeding - NOT having angiography immediately give alongside DAPT