Acute Coronary Syndromes Presentation and Management

Question 1

Acute coronary syndrome

Answer 1

A sudden collection of symptoms suspected or proven to be related to a problem with the coronary arteries

Question 2

Acute coronary syndrome can result in

Answer 2

Myocardial ischaemia anf infarction

Question 3

Myocardial infarction

Answer 3

Cell death due to prolonged ischaemia

Question 4

Chronic ischaemic heart disease

Answer 4

Stable angina

Question 5

Acute coronary syndromes

Answer 5

Unstable angina

MI - STEMI and NSTEMI

Question 6

Complete coronary occlusion initial ECG

Answer 6

ST elevation

Question 7

Complete coronary occlusion ECG at 3 days

Answer 7

Q waves

Question 8

Partial coronary occlusion initial ECG

Answer 8

No ST elevation

Question 9

Partial coronary occlusion ECG at 3 days

Answer 9

No Q waves

Question 10

STEMI

Answer 10

ST elevation MI

Question 11

NSTEMI

Answer 11

Non-ST elevation MI

Question 12

Diagnosis of MI is based on

Answer 12

Detection of cell death/injury via biomarkers and one of:

ECG changes, symptoms of ischaemia, coronary problem evidence via angiogram autopsy or other test

Question 13

Cardiac biomarkers

Answer 13

Myoglobin
Troponin
CK-MB

Question 14

Most important cardiac biomarker

Answer 14

Troponin

Question 15

Troponin levels are significantly higher in which MI

Answer 15

Large infarction - STEMI

Question 16

Non-coronary causes of troponin rise

Answer 16

Arrhythmia
Pulmonary embolism
Cardiac contusion
Sepsis
Renal failure

Question 17

Coronary problems that can lead to MI

Answer 17

Atherosclerosis 
Coronary vasospasm
Coronary dissection
Embolism in coronary artery
Inflammation of coronary arteries (vasculitis)

Question 18

MI type 1

Answer 18

Plaque rupture with thrombus

Question 19

MI type 2

Answer 19

Vasospasm or endothelial dysfunction
Fixed atherosclerosis and supply-demand imbalance
Supply-demand imbalance alone

Question 20

Chest pain associated with MI

Answer 20

Radiation to left arm and neck
Discomfort more than pain
Severe but not agony

Question 21

Symptoms of MI

Answer 21

Chest pain
Nausea
Sweating
Breathlessness

Question 22

Cardiac risk factors

Answer 22

Male
Age
Known heart disease
Hypertension
High cholesterol
Diabetes
Smoker
Family history

Question 23

Examination of MI

Answer 23

Heart rate
Blood pressure
Auscultation - murmurs or crackles
May look fine or unwell (STEMI)

Question 24

Key investigations for MI

Answer 24

ECG

Bloods - troponin, haemoglobin, kidney function, cholesterol

Question 25

Different ECG findings associated with MI

Answer 25

``` ST elevation - emergency No ST elevation ST depression T wave inversion Normal ```

Question 26

Coronary artery involved in inferior MI

Answer 26

Right coronary artery

Question 27

Coronary artery involved with anterior MI

Answer 27

Left anterior descending coronary artery

Question 28

Coronary artery involved with posterior MI

Answer 28

Circumflex coronary artery

Question 29

Posterior MI ECG presentation

Answer 29

Opposite changes in the leads opposite those looking at that area (V1-V2)

Question 30

Treatment of STEMI (reperfusion therapy)

Answer 30

Mechanical - primary PCI, bypass | Pharmacological - thrombolysis

Question 31

Primary PCI

Answer 31

Percutaneous coronary intervention = angioplasty and stenting

Question 32

Thrombolysis

Answer 32

Tenecteplase (TNK)

Question 33

Action of thrombolysis

Answer 33

Dissolves blood clot in coronary artery

Question 34

Risk of thrombolysis

Answer 34

Bleeding

Question 35

Be cautious of thrombolysis if

Answer 35

Had recent stroke or previous intracranial bleed Had recent surgery On warfarin Have severe hypertension

Question 36

Thrombolysis vs Cath lab

Answer 36

Cath lab as no risk of bleeding but waiting time is important. If long wait give thrombolysis and then transfer

Question 37

Signs that unstable angina and not MI

Answer 37

Rapidly worsening Occurs at rest ECG may be normal or abnormal Troponin not raised

Question 38

Reason behind raised troponin

Answer 38

Myocardial cell death

Question 39

Management of suspected acute coronary syndrome

Answer 39

Admit to hopsital Cardiac monitor IV access Give oxygen if levels low

Question 40

Treatment of acute coronary syndrome

Answer 40

``` Glycerol trinitrate (GTN) Opiates - morphine Anti-platelet - aspirin Anti-coagulant - heparin Beta blocker Statin ACE inhibitor ```

Question 41

Glycerol trinitrate (GTN)

Answer 41

Vasodilator - opens up coronary arteries

Question 42

Opiates function

Answer 42

Painkillers | Also relieve anxiety and help venodilate

Question 43

Anti-platelet and anti-coagulant drugs function

Answer 43

Anti-thrombotic - stop platelets sticking together to prevent thrombosis

Question 44

Beta blockers function

Answer 44

Reduce work heart has to do

Question 45

Statin function

Answer 45

Lowers cholesterol levels

Question 46

Ace inhibitor function

Answer 46

Helps heart muscle recover

Question 47

Risks of coronary angiogram and PCI

Answer 47

``` Bleeding Blood vessel damage MI Coronary perforation Stroke Dye affecting kidney function ```

Question 48

Post-operation management

Answer 48

``` Monitor heart Echocardiogram Auscultate for murmurs and signs of heart failure Start drugs Look out for complications ```

Question 49

Mechanical complications of operation

Answer 49

Myocardial rupture - cardiac tamponade Acute ventricular septal defect Mitral valve dysfunction due to papillary muscle rupture

Question 50

Cardiac tamponade

Answer 50

Accumulation of fluid in pericardial space

Question 51

Pre-discharge management

Answer 51

``` Check medications Address risk factors Smoking cessation Arrange cardiac rehabilitation Make plans for follow-up ```

Question 52

Longer term concerns most MI

Answer 52

Higher risk of bleeding and further MI/death Cardiac failure Late arrhythmias related to scar