Acute Coronary Syndrome

Question 1

What is the initial management of an NSTEMI?

Answer 1

1. Aspirin 300mg STAT
2. If GRACE score equal to or below 3 = conservative management with ticagrelor + fondaparinux
   If GRACE above 3 and unstable = PCI immediately
   If GRACE above 3 and stable = PCI within 72 hours + fondaparinux

Question 2

What are the findings on an ECG for an NSTEMI?

Answer 2

ST depression
or T-wave inversion

Question 3

What’s the purpose of a GRACE score

Answer 3

To calculate 6 month mortality risk and therefore need for a PCI or not

Question 4

What is acute coronary syndrome?

Answer 4

Set of signs and symptoms caused by reduced blood flow to the heart

Question 5

Diagnosis of an NSTEMI?

Answer 5

History: chest pain at rest

ECG: normal/ST depression/T wave inversion

Troponin: raises between 1-4h after presentation

Question 6

Diagnosis of a STEMI?

Answer 6

History: chest pain at rest
ECG: ST elevation and new LBBB
Troponin is irrelevant if ECG indicates a STEMI

Question 7

Diagnosis of Unstable Angina

Answer 7

History: chest pain
ECG: normal
Troponin: normal

Question 8

Initial management of a STEMI if the onset is under 12 hours?

Answer 8

300mg Aspirin STAT
If PCI possible within 120 minutes -> give PCI, prasugrel
If not possible -> fibrinolysis + antithrombin until PCI possible.

Question 9

How to decide whether to use clopidogrel or ticagrelor?

Answer 9

Clopidogrel = high bleeding risk
Ticagrelor = no bleeding risk

Question 10

What is the secondary prevention of NSTEMI?

Answer 10

AAABC mnemonic

Aspirin 75mg
Clopidogrel 75mg/Ticagrelor 90mg
ACEi
Atorvastatin 80mg
Beta blockers e.g. bisoprolol

Echocardiogram to assess for systolic function and HF
Referral to cardiac rehabilitation

Question 11

What is indicated by a harsh, loud pansystolic murmur heard best on the left sternal border and palpable parasternal thrill?

Answer 11

Ventricular septal defect - complication of MI

Question 12

When does Dressler’s syndrome occur after an MI?

What are the symptoms?

What is the management?

Answer 12

2-3 weeks or few months after an MI

Pleuritic chest pain and fever

High dose aspirin

Question 13

What is the cause of left ventricular aneurysm?

Answer 13

Anterior MI, as the myocardium is particularly vulnerable to wall stress there

Question 14

What is the management of ventricular free wall rupture?

Answer 14

Pericardiocentesis and surgery

Question 15

What MI commonly causes acute mitral regurgitation?

Answer 15

Infero-posterior MI

Question 16

What is the DVLA advice following a PCI?

Answer 16

If driving private vehicle e.g. car -> don’t drive for 4 weeks after, don’t need to notify DVLA

If lorry/bus driver -> don’t drive for 6 weeks after and notify DVLA