Acute Coronary Syndromes

Question 1

Three types of acute coronary syndrome?

Answer 1

unstable angina/ STEMI/ NSTEMI

Question 2

What is acute coronary syndrome?

Answer 2

thrombus forming from rupture of atherosclerotic plaque blocking coronary artery

Question 3

Presentation of acute coronary syndrome?

Answer 3

central constricting chest pain with:

Pain radiating to the jaw or arms
Nausea and vomiting
Sweating and clamminess
A feeling of impending doom
Shortness of breath
Palpitations

Question 4

How long do symptoms occur for?

Answer 4

more than 15 mins at rest

Question 5

What is a silent myocardial infarction and who are at highest risk?

Answer 5

no typical chest pain
diabetics at high risk

Question 6

ECG changes for STEMI?

Answer 6

ST-segment elevation
New left bundle branch block

Question 7

ECG changes for NSTEMI

Answer 7

ST segment depression
T wave inversion

Question 8

What are pathological Q waves?

Answer 8

suggest deep infarction of full thickness of heart muscle
appear 6 hours or more after symptoms

Question 9

What is troponin?

Answer 9

protein from damaged myocardial infarction raised in blood

for diagnosis of NSTEMI

Question 10

Dangers of interpreting a troponin result?

Answer 10

Troponin is non-specific

raised also due to:

Chronic kidney disease
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism

Question 11

How to avoid incorrect interpretation of troponin?

Answer 11

repeat troponin 3hrs after baseline
high or rising troponin = NSTEMI

Question 12

Investigations for acute coronary syndrome?

Answer 12

Baseline bloods: FBC, U&E, LFT, lipids and glucose
Chest x-ray
Echocardiogram

Question 13

How to classify and diagnose a STEMI?

Answer 13

ST elevation and new LBBB

Question 14

How to classify and diagnose a NSTEMI?

Answer 14

raised troponin
normal ECG or other changes (ST depression/ T wave inversion)

Question 15

How to classify and diagnose a unstable angina?

Answer 15

normal troponin
normal ECG or other changes (ST depression/ T wave inversion)

Question 16

Initial management for acute coronary syndrome?

Answer 16

CPAIN

C – Call an ambulance
P – Perform an ECG
A – Aspirin 300mg
I – Intravenous morphine for pain if required (with an antiemetic, e.g., metoclopramide)
N – Nitrate (GTN)

Question 17

If patient is pain free but chest pain was within last 72 hours, how to manage?

Answer 17

refer to same day assessment unit

Question 18

How to manage a STEMI?

Answer 18

PCI and angioplasty
thrombolysisH

Question 19

How to manage NSTEMI?

Answer 19

BATMAN

B – Base the decision about angiography and PCI on the GRACE score
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M – Morphine titrated to control pain
A – Antithrombin therapy with fondaparinux (unless high bleeding risk or immediate angiography)
N – Nitrate (GTN)

Question 20

Do you give oxygen to manage an MI?

Answer 20

NO - only if sats drop below 95% (non-COPD pts)

Question 21

How to determine if a NSTEMI is for immediate angiography?

Answer 21

if unstable –> GRACE score (6 month probability of death after having NSTEMI)

<3% - low risk
>3% med to high risk

Question 22

3 main ways for ongoing management for ACS?

Answer 22

Echo
Cardiac rehab
secondary prevention

Question 23

What is the secondary prevention with someone with ACS?

Answer 23

6As

Aspirin 75mg once daily indefinitely
Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril) titrated as high as tolerated
Atenolol (or another beta blocker – usually bisoprolol) titrated as high as tolerated
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)

Question 24

What must you monitor when patients are on ACE inhibitors or aldosterone antagonists?

Answer 24

bloods for potassium
can cause hyperkalaemia (can be fatal)

Question 25

Complications of MI?

Answer 25

DReAD

D – Death
R – Rupture of the heart septum or papillary muscles
E – “oEdema” (heart failure)
A – Arrhythmia and Aneurysm
D – Dressler’s Syndrome

Question 26

What is dressslers syndrome? plus presentation, investigation, management?

Answer 26

pericarditis post MI ( 2-3 weeks)

pleuritic chest pain, low fever, pericardial rub

ST elevation and T wave inversion

NSAIDS or pericardiocentesis to drain pericardial effusion

Question 27

What are the four types of MI?

Answer 27

Type 1: Traditional MI due to an acute coronary event
Type 2: Ischaemia secondary to increased demand or reduced supply of oxygen (e.g. secondary to severe anaemia, tachycardia or hypotension)
Type 3: Sudden cardiac death or cardiac arrest suggestive of an ischaemic event
Type 4: MI associated with procedures such as PCI, coronary stenting and CABG

Type 1: A – ACS-type MI
Type 2: C – Can’t cope MI
Type 3: D – Dead by MI
Type 4: C – Caused by us MI