Acute Coronary Syndrome

Question 1

What are the three types of ACS?

Answer 1

Unstable angina
STEMI
NSTEMI

Question 2

How can you differentiate between the three types of ACS?

Answer 2

If ECG shows ST elevation of new LBBB then it is STEMI

If ECG shows no changes then do troponin

If troponin raised or other ECG changes (ST depression and T wave inversion or Q waves) then NSTEMI

If no ECG changes and normal troponin then Unstable angina or musculoskeletal cause

Question 3

What are the symptoms of ACS?

Answer 3

Central crushing chest pain
Nausea and vomiting 
Sweating and clamminess 
Feeling of impending doom
SOB
Palpitations 
Pain radiating to the jaw or arms

Symptoms should continue for more than 20 mins. If not then consider angina. Diabetics may not have these symptoms (silent MI)

Question 4

What leads have changes in an anterolateral MI?

Answer 4

1, AVL, V3-V6

Question 5

What leads have changes in an anterior MI?

Answer 5

V1-V4

Question 6

What leads have changes in a lateral MI?

Answer 6

1, AVL, V5-V6

Question 7

What leads have changes in an inferior MI?

Answer 7

2, 3, AVF

Question 8

What coronary artery is affected if there are changes in 1, AVL, V5-V6?

Answer 8

Circumflex

Question 9

What artery is affected by changes in leads 1, AVL, V3-V6?

Answer 9

Left Coronary

Question 10

What coronary artery is affected by changes in leads V1-V4

Answer 10

LAD

Question 11

What artery is affected by changes in leads 2, 3, AVF?

Answer 11

Right coronary

Question 12

What are the alternative causes for raised troponin?

Answer 12

Chronic renal failure 
Sepsis 
Myocarditis
Aortic dissection 
PE

Question 13

What additional scans can you perform when suspecting MI?

Answer 13

CXR- to investigate for other causes of chest pain and pulmonologist oedema

Echo- after the MI to assess functional damage

CT coronary angiogram- to assess for coronary artery disease

Question 14

How long after presenting with a STEMI should be the cutoff for having PCI?

Answer 14

2 hours

Question 15

What is the management of an NSTEMI?

Answer 15

BATMAN

B-Beta blockers (unless contraindicated)
A-Aspirin
T-Ticagrelor or clopidogrel
M-Morphine
A-Anticoagulant (LMWH)
N-Nitrates 

Give oxygen if sats are dropping

Question 16

What scoring system is used for assessing if an NSTEMI patient needs PCI, and what is the threshold?

Answer 16

GRACE score

5-10% is medium risk
Over 10% high risk

Medium risk or higher should have PCI within 4 days of admission

Score gives 6 month predicted risk of death or repeat MI after having an NSTEMI

Question 17

What are the complications of an MI?

Answer 17

DREAD

D-Death
R-Rupture of the heart septum or papillary muscles
E-“Edema” (heart failure)
A-Arrhythmias and aneurysm 
D-Dressler’s Syndrome

Question 18

What heart condition does Dressler’s syndrome cause, which is categorised by global ST elevation and T wave inversion on an ECG?

Answer 18

Pericarditis

Treatment is with aspirin/ibuprofen. Severe cases use prednisolone. May need pericardiocentesis to remove fluid if tamponade.

Question 19

What is the secondary prevention of MI?

Answer 19

6 A’s

Aspirin
Another Antiplatelet (e.g clopidogrel/tricagrelor)
Atorvastatin
ACE inhibitors
Atenolol
Aldosterone antagonist for those with heart failure I.e eplerenone

Question 20

What is the lifestyle advice for secondary prevention of MI?

Answer 20

Stop smoking 
Reduce alcohol 
Mediterranean diet
Cardiac rehabilitation 
Optimise treatment of other medical conditions e.g diabetes, hypertension