Acute Coronary Syndrome, Angina

Question 1

What is the description of chest pain in patients with Angina?

Answer 1

Precipitated by exertional / emotional stress, and relieved by rest. May radiate to jaw, neck, left arm

Question 2

What are the ECG changes visualised in patients with a STEMI or NSTEMI?

Answer 2

STEMI: ST elevation, Pathological Q wave

NSTEMI: ST depression, T-wave inversion

Question 3

When does Troponin initially rise after an MI? How long does it remain high for?

Answer 3

Elevates 4-6 hours after injury, and remains elevated for up to 10 days

Question 4

Why is CK-MB more useful for reinfarction than Troponin?

Answer 4

CK-MB levels deplete within 24 hours, whereas Troponin remains elevated for upto 10 days and would remain high in an infarct, masking it

Question 5

In the early stages of an MI, why are cholesterol levels lowered?

Answer 5

High catecholamines are produced in the early phases, which lower cholesterol levels

Question 6

What does the Left Anterior Descending (LAD) supply?

Answer 6

The right ventricle, left ventricle and intraventicular septum

Question 7

From what order of arteries are the MI’s commonly occluded?

Answer 7

LAD (40-50%)
RCA (30-40%)
LCX (15-20%)

Question 8

What does the Left Circumflex Artery (LCX) supply?

Answer 8

Supplies the lateral wall of the left ventricle

Question 9

What does the Right Coronary Artery (RCA) supply?

Answer 9

Supplies the right atrium, right ventricle, the inferior wall / septum / papillary muscles of the LV

Question 10

What three conditions make up Acute Coronary Syndrome?

Answer 10

NSTEMI, STEMI, Unstable Angina

Question 11

Which layer of the arterial wall becomes a site for atherosclerosis?

Answer 11

Tunica intima

Question 12

What ECG leads correspond to an MI in the LAD?

Answer 12

V1, V2, V3, V4

Question 13

What ECG leads correspond to an MI in the LCX?

Answer 13

V5, V6, LI, aVL

Question 14

What ECG leads correspond to an MI in the RCA?

Answer 14

LII, LIII, aVF

Question 15

What might a posterior infarct look like on an ECG?

Answer 15

ST depression in the anterior leads

Question 16

What is the difference between stable and unstable angina? How do each respond to GTN? What are the Troponin changes in each?

Answer 16

Stable angina - Exerted by stress, relieved by rest. Relieved by GTN. Troponin normal

Unstable angina - No particular time course. Relieved by GTN. Troponin normal

Question 17

What is Levine’s sign?

Answer 17

Patient’s using a clenched first when describing their chest pain. Predictor for myocardial ischaemia

Question 18

What are the three criteria to meet for Typical Angina? What if it meets less of the criteria?

Answer 18

• Substernal chest pain characteristic of angina
• Provoked by exertion / emotional stress
• Relieved by rest / GTN

If meets 2/3 -> Atypical angina
If meets 1/3 or 0/3 -> Non-cardiac chest pain

Question 19

What is the description for NYHA Class 1 of Heart Failure?

Answer 19

No limitation of physical activity. Ordinary activity does not cause symptoms

Question 20

What is the description for NYHA Class 2 of Heart Failure?

Answer 20

Slight limitation of physical activity. Comfortable at rest but ordinary activity results in symptoms

Question 21

What is the description for NYHA Class 3 of Heart Failure?

Answer 21

Marked limitation of physical activity. Comfortable at rest but less than ordinary activity results in symptoms

Question 22

What is the description for NYHA Class 4 of Heart Failure?

Answer 22

Severe limitation of physical activity. Discomfort at rest. Unable to perform any activities

Question 23

In a CABG, what two structures can be typically harvested?

Answer 23

Long saphenous vein from legs or

Internal mammary arteries from thorax

Question 24

What is Prinzmetal Angina?

Answer 24

Angina caused by vasospasm of the coronary arteries at rest

Question 25

What is the ECG findings associated with Pericarditis?

Answer 25

Widespread concave ST elevation PR depression

Question 26

Which artery is likely to be affected in patients who have had an MI which had then lead to complete heart block?

Answer 26

Right coronary artery

Question 27

What are the risk factors for Acute Coronary Syndrome?

Answer 27

Obesity, hypertension, smoking, family history, diabetes, male gender, hypercholesterolaemia, increasing age

Question 28

What are the first-line, simple investigations for Acute Coronary Syndrome?

Answer 28

``` 12-lead ECG Urea and electrolytes Full Blood Count Glucose Troponin Lipid profile CXR Echo Coronary angiography ```

Question 29

What is the INITIAL management of a patient with Acute Coronary Syndrome?

Answer 29

MONA Morphine, for severe pain, 5-10mg, repeat after 5 mins if necessary. Prescribe an anti-emetic alongside i.e. Metoclopramide 10mg IV or Cyclizine 50mg IV Oxygen, only if < 94% Nitrates, sublingually / IV. Caution if hypotensive Aspirin, 300mg PO

Question 30

What are some signs and symptoms of patients with Acute Coronary Syndrome?

Answer 30

- Central, left sided chest pain. May radiate to jaw, left arm. May feel heavy, constricting, "elephant on chest" - Diabetics / elderly may not feel pain - SOB, sweating, nausea, vomiting, clammy, pale - Mildly altered observations - Signs of cardiac failure

Question 31

Why should beta-blockers and verapamil NOT be used concurrently?

Answer 31

Can precipitate asystole

Question 32

How can an STEMI be diagnosed on ECG?

Answer 32

1. Clinical symptoms of ACS, lasting at least 20mins 2. Persistent ECG features in 2 leads of: a. 2.5mm ST elevation in men <40 years in V2-V3 b. 2.0mm ST elevation in men >40 years in V2-V3 c. 1.5mm ST elevation in women in V2-V3 d. 1mm ST elevation in other leads 3. New LBBB

Question 33

Outline the pathophysiology of Acute Coronary Syndrome

Answer 33

Caused by Ischaemic Heart Disease: 1. Initial endothelial dysfunction, caused by smoking, HTN, hyperglycaemia 2. Causes endothelial challenges which are pro-inflammatory, pro-oxidant, proliferative with reduced NO bioavailability 3. Fatty infiltration of subendothelial space by LDLs 4. Monocytes differentiate to macrophages, phagocytosing LDLs leading to foam cells 5. Smooth muscle proliferation from tunica media to intima, causing formation of fibrous capsule 6. Can lead to gradual narrowing and plaque rupture

Question 34

State what the two methods of managing a STEMI is?

Answer 34

Percutaneous Coronary Intervention (PCI) | Thrombolysis

Question 35

For STEMI management, using PCI a. When should it be given? b. What is the access? c. What is given to patient before PCI? d. What is given to patient during PCI?

Answer 35

a. Given if symptom duration is less than 12 hrs and can give PCI within 2 hours, or if symptoms are greater than 12 hours with evidence on ongoing ischaemia b. Radial or femoral c. Before PCI, give dual antiplatelet therapy (Aspirin + Clopidogrel (if on anticoagulant) or Aspirin + Prasugrel (if not on anticoagulant) d. During PCI, give UFH if radial access, or Bivalirudin if femoral access

Question 36

For STEMI management, using Thrombolysis a. When should it be given? b. What are examples of Thrombolysis drugs? c. What happens if it fails?

Answer 36

a. Within 12 hours of symptoms if PCI can't be offered b. Alteplase, Tenecteplase, Streptokinase c. If ECG after 90mins of Thrombolysis show failure, offer PCI

Question 37

What are contraindications for Thrombolysis in managing STEMI patients?

Answer 37

- Active internal bleeding - Recent haemorrhage, trauma, surgery - Coagulation and bleeding disorders - Intracranial neoplasm - Stroke <3 months ago - Aortic dissection - Recent head injury - Severe HTN

Question 38

Following MONA, what is the management of an NSTEMI?

Answer 38

- Aspirin 300mg PO, followed by 75mg PO - Clopidogrel 300mg PO, followed by 75mg PO (Ticagrelor is an alternative) - Anticoagulation, Fondaparinux 2.5mg PO OD (LMWH is an alternative) - Beta blockers - Nitrates - ACEI - Atorvastatin

Question 39

1. What is the mechanism of the action of statins? 2. What are the adverse events? 3. Myalgia is associated with what statins in particular? 4. What baseline tests would you do for statins in particular? 5. When would you discontinue statins with respect to LFTs? 6. Who should have a statin? 7. What are contraindications to statins? 8. How should statins be taken?

Answer 39

1. HMG-CoA reductase Inhibitor, controls the rate-limiting step of hepatic cholesterol synthesis 2. Myopathy, liver impairment, increased stroke risk in patients with previous stroke 3. Lipophillic statins, i.e. Simvastatin, Atorvastatin 4. LFTs at baseline, 3 months and 12 months 5. If AST is 3x the ULN, then discontinue 6. All patients with established CVD, or if QRISK greater than 10% 7. Pregnancy, if on current macrolides (clarithromycin, erythromycin) 8. At night

Question 40

What is the management of a patient with stable angina?

Answer 40

RAMP R - Refer to cardiology A - Advice them about diagnosis, management, when to call 999 M - Medical management a. Immediate management -> GTN b. Long term management -> BB or CCB c. Secondary management -> Aspirin, ACEI, Atorvastatin P - Procedural management a. PCI w/ Coronary Angioplasty b. CABG

Question 41

What scars may you want to look for in a patient with angina / ACS?

Answer 41

PCI scars: Femoral / radial / brachial scars | CABG scars: Midline sternotomy, long saphenous vein / internal mammary artery harvesting