Acute coronary syndrome (Complete)

Question 1

What is acute coronary syndrome?

Answer 1

Umbrella term of acute presentations of ischaemic heart disease

Question 2

What are the 3 subtypes of ACS?

Answer 2

STEMI

NSTEMI

Unstable angina

Question 3

What are the main clinical features of ACS?

Answer 3

Chest pain
* Retrosternal
* ‘Crushing’/’pressure’
* Radiation to jaw/arms

Dyspnoea

Palpitations

Sweating

Nausea and vomitting

Question 4

What are the main characteristics of ACS chest pain?

Answer 4

Central crushing chest pain

Radiation to jaw or arms

Question 5

What types of patients present with atypical presentations of ACS?

Answer 5

Elderly

Diabetics

Females

Question 6

What are atypical presentations of ACS?

Answer 6

Absence of chest pain and instead:

Epigastric pain

Syncope

Acute confusion

Acute breathlessness

Diabetic hyperglycaemic crises

Question 7

What are the main investigations to consider in patients suspected of ACS?

Answer 7

Bedside:
Basic obs: Check for haemodynamic instability

ECG: Check for any changes suggestive of STEMI or NSTEMI

Bloods:

Troponin: Elevated in STEMI and NSTEMI

FBC: Check for anaemia/infection

CRP: Check for infection

Creatinine U&Es: Check for baseline kidney functions (needs to be good for PCI which uses contrast) and eGFR which is needed in GRACE score.

LFTs: Assess bleeding risk before anticoagulation

HbA1c: check for risk factor

Lipid profile: check for risk factors

Imaging:

CXR: Rule out other differentials of chest pain

Question 8

What investigation findings are suggestive of unstable angina?

Answer 8

No troponin elevation

ECG findings:
* New ST deppresion
* New T-wave inversion (due to delays in repolarisation of inner layers of heart)
* No ECG changes

Question 9

What investigation findings are suggestive of NSTEMI?

Answer 9

Elevated troponin

ECG changes:
* New ST-depression
* New T wave inversion
* Normal (1/3rd of patients)

Question 10

What investigation findings are suggestive of STEMI?

Answer 10

Elevated troponin

ECG changes:
* New ST elevation
* New Left bundle branch block (LBBB)

Question 11

What findings on ECG are suggestive of a posterior MI?

Answer 11

ST deppresion in the anterior and septal leads (V1-V4)

Peaked R waves in V1 and V2 (cell death posteriorly causes more positive depolarisation towards chest leads)

RCA or LCx commonly affected arteries in this case

Question 12

What ECG findings must be present to diagnose a patient with STEMI?

Answer 12

Must show ST elevation in 2 or more continguous leads and:

ST elevation > 1mm in limb leads

ST elevation >2 mm in precordial leads (chest leads)

Question 13

What findings must be shown to diagnose a patient with NSTEMI?

Answer 13

Patient must have signs/symptoms suggestive of ACS (N.B. Diabetics and elderly may be assymptomatic)

Elevated troponin

No ST elevation on ECG

Question 14

ST elevation in which leads is suggestive of an inferior MI?

Which artery is affected?

Answer 14

Lead II

Lead III

Lead aVF

Artery affected: RCA

Question 15

ST elevation in which leads is suggestive of an septal MI?

Which artery is affected?

Answer 15

V1

V2

Artery affected: Proximal LAD

Question 16

ST elevation in which leads is suggestive of an anterior MI?

Which artery is affected?

Answer 16

V3-V4

Artery affected: LAD

Question 17

ST elevation in which leads is suggestive of an MI in the apex?

Which artery is affected?

Answer 17

V5-V6

Potential arteries affected: Distal LAD, LCx, RCA

Question 18

ST elevation in which leads is suggestive of an MI in the lateral aspect of the heart?

Which artery is affected?

Answer 18

Lead I

Lead aVL

Artery affected: Left circumflex (Lcx)

Question 19

What is the common management for all types of ACS?

Answer 19

MONA:

Morphine

Oxygen (if sats below 94%)

Nitrates (IV or sublingual)

Aspirin (300mg)

Question 20

Administration of nitrates in management of ACS should be considered with caution in which group of patients?

Answer 20

Hypotensive patients

Question 21

What is the management plan for patients with STEMI?

Answer 21

Question 22

When is percutaneous intervention indicated in patients with STEMI?

Answer 22

Within 12 hours of onset of symptoms

PCI can be done within 120 minutes of medical contact.

PCI can be considered if still showing signs of ongoing ischaemia after 12 hours

Question 23

What mediation should be given before a PCI procedure in treatment of STEMI?

Answer 23

Dual antiplatelet therapy:

Aspirin

Prasugrel (or ticagrelor if bleeding risk)

Question 24

What medication is given during a PCI procedure with radial access?

Answer 24

Unfractioned heparin

Glycoprotein inhibitor (GPI): for bailout

Question 25

What medications are given during fibrinolysis (aka thrombolysis) of patient with STEMI?

Answer 25

Fibrinolytic drugs: Ateplase or tenecteplase Parenteral anticoagulation: (e.g. Unfractioned heparin, fondaparinux, enoxaparin) P12Y2 inhibitors: e.g.Ticagrelor (Clopidogrel if bleeding risk or on DOAC)

Question 26

What medication should be swapped in patients in need of PCI who are already on antocoagulant?

Answer 26

Swap prasugrel for clopidogrel instead (If patient is high bleeding risk but not on anticoagulant then swap for ticagrelor instead)

Question 27

If patient still experiencing signs of ischaemia after fibrinolysis, what is next management for patient?

Answer 27

Percutaneous intervention AKA Primary angioplasty

Question 28

What is the management plan for patient with NSTEMI/Unstable angina?

Answer 28

Question 29

What is the post MI management plan for patients?

Answer 29

**_Medicine_**:Should be started on 5 following drugs: Aspirin 75mg (anti-platelet) Clopidogrel 75mg or ticagrelor 90mg (second antiplatelet) Beta-blocker (Bispropolol) ACE-inhibitor High dose statin (e.g. Atorvastatin 80mg) **_Post MI investigations_**: ECHO: All patients should have one done to check for any HF Cardiac rehabilitation referral: All patients Ischaemia testing: Consider for patients who havent have an angiography to check for inducible ischaemia.

Question 30

What are some complications of MI?

Answer 30

Ventricular arrhythmia 2nd, 3rd degree heart block Recurrent ischaemia/infarction/angina Acute mitral regurgitation Congestive heart failure Cardiogenic shock Cardiac tamponade Ventricular septal defects Left ventricular thrombus/aneurysm Left/right ventricular free wall rupture Dressler's Syndrome Acute pericarditis

Question 31

How do ventricular arrythmias tend to present in patients with MI?

Answer 31

Tend to occur post MI, during cardiac catheterisation or during reperfusion. Tend to be short-lived and self resolve If they do persist however, they should be treated in accordance with advance life support protocols

Question 32

How does recuurent ischaemia/infarction/angina tend to present in patients with MI?

Answer 32

Can re-occur due to thrombosing of inserted stents. (Requires re-intervention) New infarcts can occur in new vascular territories Angina and chest pain can last for a while after an MI, especially in patients with NSTEMI

Question 33

Why are MI patients at risk of congestive heart failure?

Answer 33

Can occur as a consequence of impairment heart muscle function secondary to ischaemia. Ventricular function may improve over months as heart muscle recovers Hence why all patients require an ECHO

Question 34

Heart block most commonly occcurs in which types of MI?

Answer 34

Inferior MI This is because RCA supplies the SA node

Question 35

How is heart block post-MI managed?

Answer 35

Observation as many resolve Transcutaenous/venous pacing if symptomatic Permament pacing if failure to resolve

Question 36

How does left ventricular thrombus/aneurysm present?

Answer 36

Presents mainly in patients with anterior MI (this is because myocardium is suscpetible to stress and at risk of rupture) May present silently, cause arrythymias or embolic events (e.g. stroke, acute limb ischaemia ect). Persistent ST-elevation and signs of left ventricular failure

Question 37

How is left ventricular aneurysm/thrombosis diagnosed?

Answer 37

ECHO ECG may show persistent ST elevation

Question 38

How does left ventricular wall rupture present and how is it managed?

Answer 38

Rapid tamponade as blood fills into pericardial space. Tamponade followed by cardiac arrest/death within seconds Managed by pericardiocentesis and surgery but prognosis extremely poor

Question 39

Why can acute mitral regurgitation present in patients post MI?

Answer 39

Occurs because of papillary muscle rupture secondary to MI.

Question 40

How does acute mitral regurgitation present in patients with MI?

Answer 40

Pansystolic murmur heard best at the apex Severe and sudden heart failure Diagnosed on ECHO and requires surgical intervention

Question 41

What is ventricular septal defect?

Answer 41

Rupture in septum which seperates ventricles

Question 42

How does ventricular septal defect tend to present in patients post MI?

Answer 42

Tends to present within first week post MI Anterior MI tends to cause apical and simple ruptures Inferior MI tends to cause basal and more complex ruptures Presents with following symptoms: Shortness of breath Chest pain Heart failure Hypotension Harsh, loud pan-systolic murmur along the left sternal border. Palpable parasternal thrill.

Question 43

How is ventricular septal defect post MI managed?

Answer 43

Emergency cardiac surgery

Question 44

What is Dressler's syndrome

Answer 44

Post-infaction pericarditis

Question 45

When does Dressler's syndrome typically present post MI?

Answer 45

2-3 week to a few months after MI (Patients that get pericarditis immediately after MI is NOT considered Dresslers syndrome) N.B. Caused due to inflammatory response from ischaemic/necrotic tissue

Question 46

How is Dressler's syndrome managed?

Answer 46

High dose aspirin

Question 47

What are contraindictions to fibrinloysis/thrombolysis?

Answer 47

Active internal bleeding Recent haemorrhage, trauma or surgery (including dental extraction) Coagulation and bleeding disorders Intracranial neoplasm Stroke < 3 months Aortic dissection Recent head injury Severe hypertension

Question 48

What biochemical marker is useful in identifying possible re-infarct of a patient who had a recent MI?

Answer 48

Creatinin kinase MB as it has quicker clearance than troponin Most specific for myocardium and typically rasied 3 times above upper limit. (Troponin wont be helpful as it can be raised up to 2 weeks post MI)