Acute Coronary Syndromes

Question 1

name what happens when there is spontaneous plaque rupture and local thrombosis with degrees of occlusion

Answer 1

acute coronary syndromes

Question 2

give four examples of acute coronary syndrome

Answer 2

> unstable angina
non-ST elevation myocardial infarction
ST elevation myocardial infarction
sudden cardiac death

Question 3

describe the character of the patients chest pain

Answer 3

> site: retrosternal
> character: tight band
> radiation: neck, jaw, down the arms
> aggravating: exertion, motional stress
> relieving factors: incomplete improvement with GTN or physical rest

Question 4

name some modifiable risk factors associated with ACS

Answer 4

> smoking
> diabetes mellitus
> hyperlipidaemia
> hypertension
> lifestyle

Question 5

what would the typical history for unstable angina/ NSTEMI be?

Answer 5

progressive angina with increasing frequency and severity

NSTEMI there will often be myocardial ischaemic symptoms occurring during rest

Question 6

what would you expect to see on the examination for an unstable angina/NSTEMI?

Answer 6

look unwell or completely fine and there are often no specific features to be found

Question 7

what investigations should you carry out for an unstable angina or STEMI?

Answer 7

ECG

biomarkers

Question 8

what would you expect to see on an ECG of an unstable angina or NSTEMI?

Answer 8

they may be normal but there is commonly a st-segment depression, transient st-segment elevation or a t wave inversion.
in unstable anginas the changes resolve after pain but in NSTEMI they tend to persist

Question 9

what is used as a biomarker in acute coronary syndromes?

Answer 9

cardiac troponin

Question 10

what would an elevated cTn suggest?

Answer 10

a high risk of adverse events

Question 11

when are cTn levels elevated?

Answer 11

when there is compromise to myocyte intergrity

Question 12

what is the MONA treatment?

Answer 12

Morphine
Oxygen
Nitro-glycerine
Aspirin

Question 13

what anti-platelet therapy should all acute coronary syndrome patients receive?

Answer 13

both aspirin and ADP receptors blocker:
> clopidogrel
> prasugrel
> ticagrelor

Question 14

name the anti-thrombotic therapy that acute coronary syndrome patients can be put on?

Answer 14

> intravenous in-fractured heparin

> low molecular weight heparin

Question 15

what are the contraindications for using beta-blockers to treat acute coronary syndrome?

Answer 15

> asthma
acute left ventricular dysfunction
impaired atrioventricular nodal conduction

Question 16

when are angiotensin converting enzyme inhibitors given in acute coronary syndromes?

Answer 16

if there is left ventricular dysfunction

Question 17

what non-medical therapy can be given to treat acute coronary syndrome?

Answer 17

coronary angiography and revascularisation by PCI or CABG

Question 18

what can plaque rupture lead to?

Answer 18

more complete thrombotic occlusion or coronary lumen and infarction of distal myocardium

Question 19

how can you increase the amount of myocardium that can be salvaged after a ST-elevated myocardial infarction?

Answer 19

by dissolving/removing the occlusive thrombus quickly

Question 20

what has been proven to be a superior treatment of ST-elevated myocardial infarction and why?

Answer 20

primary PCI (over fibrinolytic therapy) for al cause, cardiac mortality, recurrent MI and reduced risk of haemorrhagic stroke

Question 21

how quickly should you aim to begin fibrinolysis for a STEMI?

Answer 21

> 90 minutes from the patient calling for help

> 30 mins of hospital arrival

Question 22

how can the call to needle time of fibrinolysis be reduced?

Answer 22

pre-hospital fibrinolysis

Question 23

what can increase the risk of intra-cranial haemorrhage from fibrinolytic therapy?

Answer 23

> over 75 years
> female
> previous stroke
> low body weight
> SBP >160mmHg
> chronic kidney disease

Question 24

in what scenario is primary PCI the best course of treatment for a STEMI?

Answer 24

> door to balloon time = less than 90 mins
> less than three hr symptom onset
> cardiac shock
> high bleeding risk
> uncertain diagnosis

Question 25

in what situation will thrombolysis the best course of treatment in a STEMI?

Answer 25

> door to balloon time is more than 90 mins

> less than a 3hr symptom onset

Question 26

what treatment is used for secondary prevention after a STEMI?

Answer 26

> change in lifestyle
> control co-morbidities
> aspirin and clopidogrel for 1 year
> beta-blockers
> statins
> angiotensin converting enzyme inhibitor

Question 27

what in-patient investigations would be carried out for a STEMI?

Answer 27

> echo for myocardial dysfunction

> LV ejection fraction

Question 28

what would you be looking for in an echo for myocardial dysfunction in a STEMI?

Answer 28

> size of wall motion abnormality
> hypokinetic or akinetic
> overall contractility
> presence and degree of overall mitral regurgitation
> presence of mural thrombus

Question 29

how can an acute coronary syndrome lead to sudden cardiac death?

Answer 29

the atherthrombotic event causes acute myocardial ischemia and subsequent sufficient electrical disturbance to cause ventricular arrhythmia

Question 30

describe ventricular fibrillation

Answer 30

it tends to rapidly deteriorate into asystole which is more difficult to restore cardiac output. defibrillation is the only effective treatment

Question 31

how quickly does the chance of resuscitation success reduce?

Answer 31

it reduces 7-10% every minute