Angina/Acute Coronary Syndrome

Question 1

What comprises IHD?

Answer 1

1. ACS (unstable angina, NSTEMI and ST)
2. Stable angina

Question 2

When does maximum coronary blood flow occur?

Answer 2

Diastole

Question 3

Which area of the heart is most vulnerable to ischemia?

Answer 3

Subendocardial area

Myocardial wall pressure is greatest in this area which is closest to LV cavity

Question 4

In which direction is the hear perfused?

Answer 4

Epicardial to Endocardial

Question 5

In which direction is the heart depolarised?

Answer 5

Endocardium to Epicardium

Question 6

List the 4 types of MI

Answer 6

• Type 1: Traditional MI due to acute coronary event
• Type 2: Ischaemia 2^o to increased demand or reduced supply of oxygen (eg. 2^o to severe anaemia, tachycardia or hypotension)
• Type 3: Sudden cardiac death or cardiac arrest suggestive of an ischaemic event
• Type 4: MI associated with PCI / coronary stunting / CABG

Question 7

List 2 non-modifiable risk factors for IHD

Answer 7

1. Increasing age
2. Male; females catch up after menopause
3. FxH of premature (<60 years) CAD

Question 8

List 2 modifiable risk factors for IHD

Answer 8

1. Smoking
2. Hyperlipidaemia
3. Diabetes - doubles risk
4. Hypertension

Question 9

What is Angina?

Answer 9

Narrowing of coronary arteries reduces blood flow to the myocardium during times of high demand (ie. exercise)

Results in insufficient supply to meet demand

Question 10

How does Angina present?

Answer 10

Constricting chest pain with or without radiation to jaw or arms

Question 11

What defines ‘stable’ angina?

Answer 11

Chest pain typical of angina is defined by:

1. Constriction like pain in chest/neck/arm/jaw
2. Brought on by physical activity
3. Alleviated by rest or GTN within minutes

2/3 features indicate atypical angina pain

Question 12

What defines ‘unstable’ angina?

Answer 12

When the symptoms come on randomly whilst at rest

Question 13

What is the First line investigation for angina?

Answer 13

CT Coronary Angiography (CTCA) - Gold Standard

Involves injecting contrast and taking CT images to highlight any narrowing

Question 14

When is CTCA indicated for Angina?

Answer 14

For atypical or typical angina pain or

ECG shows ischaemic changes in chest pain with < 2 angina features

Question 15

List the second and third line investigations for stable Angina

Answer 15

2nd line: non-invasive functional imaging

3rd line: invasive coronary angiography

Question 16

List 3 examples of Non-invasive functional imaging

Answer 16

1. Myocardial perfusion scintigraphy with SPECT
2. Stress ECHO
3. MRI for regional wall motion abnormalities

Question 17

List 4 other baseline investigations for Angina

Answer 17

1. Physical Examination
2. ECG
3. FBC (check for anaemia)
4. U&Es (prior to ACEi and other meds)
5. LFTs (prior to statins)
6. Lipid profile
7. TFTs
8. HbA1C and fasting glucose

Question 18

What are the 4 principals of Angina management (RAMP)

Answer 18

1. Refer to cardiology (urgently if unstable)
2. Advise patient about diagnosis, management and when to call an ambulance
3. Medical treatment
4. Procedural or surgical interventions

Question 19

First line treatment for stable Angina?

Answer 19

Beta blocker or rate limiting CCB

If not tolerated or symptoms not controlled, try switching to the other from above

Question 20

Second line treatment of stable angina?

Answer 20

Beta blocker + long-acting dihydropyridine CCB

Question 21

Third line treatment for Stable Angina?

Answer 21

Monotherapy with one of the following anti-anginals:

1. Ivabradine
2. Nicorandil
3. Ranolazine
4. Isosorbide mononitrate

Question 22

What procedure may patients with stable angina be eligible for?

What is the criteria for this

Answer 22

Re-vascularisation (with CABG or PCI) if:

• symptoms are not controlled on optimal medical treatment AND
• there is complex 3 vessel disease or
• there is significant left main stem stenosis

Question 23

What causes ACS?

Answer 23

Thrombus from an atherosclerotic plaque blocking a coronary artery

Question 24

How is a diagnosis of ACS made?

Answer 24

ECG + serial troponins

Question 25

How is a diagnosis of STEMI made?

Answer 25

If there is ST elevation or new left bundle branch block on ECG Must be in 2 consecutive leads (2 in chest, 1 limb)

Question 26

How is a diagnosis of NSTEMI made?

Answer 26

Raised troponin levels and/or Other ECG changes (ST depression or T wave inversion or pathological Q waves)

Question 27

List 2 possible diagnosis if there are normal troponin levels and normal ECG

Answer 27

1. Unstable angina 2. Musculoskeletal chest pain

Question 28

How does ACS present?

Answer 28

Central, constricting chest pain associated with: * Nausea and vomiting * Sweating and clamminess * Feeling of impending doom * SOB * Palpitations * Pain radiating to jaw or arms

Question 29

What duration must symptoms persist to be regarded as ACS?

Answer 29

\> 20 minutes

Question 30

Which patient group may not experience typical chest pain

Answer 30

Diabetics - “Silent MI”

Question 31

List 2 ECG changes seen in STEMI

Answer 31

1. ST elevation in leads consistent with an area of ischaemia 2. New Left Bundle Branch Block

Question 32

List 3 ECG changes which may be seen in an NSTEMI

Answer 32

* ST segment depression * Deep T Wave Inversion * Pathological Q Waves (suggests deep infarct - late sign)

Question 33

State which artery supplies each heart area and which are the corresponding ECG leads

Answer 33

Question 34

List 5 investigations for ACS (not bloods)

Answer 34

1. **ECG** 2. **CTCA -** assess CAD 3. **Chest xray** - for ddx 4. Physical Examination

Question 35

List 4 things to investigate on bloods for ACS

Answer 35

* FBC (check for anaemia) * U&Es (prior to ACEi and other meds) * LFTs (prior to statins) * Lipid profile * TFTs * HbA1C and fasting glucose

Question 36

List 2 other causes of raised troponins (not ACS)

Answer 36

1. Chronic renal failure 2. Sepsis 3. Myocarditis 4. Aortic dissection 5. Pulmonary embolism

Question 37

What is the definitive treatment for an acute STEMI

Answer 37

Presenting within 12hrs of onset * **Primary PCI** (if available within 2 hours of presentation) * **Thrombolysis** (if PCI not available within 2 hours)

Question 38

What is PCI?

Answer 38

Catheter inserted via brachial or femoral artery into coronary arteries under xray guidance. Contrast injected to identify blockage Treated with balloons to widen the gap or devices to remove or aspirate the blockage Usually stent is put in to keep the artery open

Question 39

What is Thrombolysis? What is the risk

Answer 39

Use of fibrinolytic medication that rapidly dissolves clots Significant risk of bleeding

Question 40

List 2 examples of Thrombolysis

Answer 40

1. Streptokinase 2. Alteplase 3. Tenecteplase

Question 41

What is the treatment of an Acute NSEMI?

Answer 41

MONA * Grace score ≤ 3 → Ticagralor and Fondapainux * Grace score \> 3 → PCI (give Prasugrel or Clopidogrel prior)

Question 42

Should O2 be routinely given in NSTEMI treatment?

Answer 42

NO, only if O2 sats are dropping (ie. \<95%).

Question 43

What score is used to assess for PCI in NSTEMI

Answer 43

**GRACE Score** Gives a 6-month risk of death or repeat MI after having an NSTEMI

Question 44

Interpret the GRACE score and state who is eligible for PCI?

Answer 44

* \<5% Low Risk * 5-10% Medium Risk * \>10% High Risk Medium or high risk are considered for early PCI (within 4d of admission) for underlying CAD

Question 45

List 4 complications of an MI (DREAD)

Answer 45

1. **D**eath 2. **R**upture of the heart septum or papillary muscles 3. “**E**dema” (***Heart Failure***) 4. **A**rrhythmia and **A**neurysm 5. **D**ressler’s Syndrome

Question 46

What is Dressler’s Syndrome? (ie. post MI syndrome) How does it present?

Answer 46

Pericarditis which occurs 2-3 wks post MI Presents with pleuritic chest pain, low grade fever and a pericardial rub on auscultation

Question 47

List 2 complications of Dressler's syndrome

Answer 47

pericardial effusion and pericardial tamponade

Question 48

How is a diagnosis of Dressler's syndrome made?

Answer 48

1. ECG (global ST elevation and T wave inversion), 2. Echocardiogram (pericardial effusion) 3. Raised inflammatory markers (CRP and ESR)

Question 49

Management of Dressler's syndrome

Answer 49

NSAIDs (aspirin / ibuprofen), more severe require steroids (prednisolone) May need pericardiocentesis to remove fluid

Question 50

List the 6 secondary prevention medical managements for ACS (6A's)

Answer 50

* **A**spirin * **A**nother antiplatelet: eg. clopidogrel or ticagrelor * **A**torvastatin * **A**CEi * **A**tenolol (or other BB) * **A**ldosterone antagonist

Question 51

List 4 secondary lifestyle prevention measures

Answer 51

1. Stop smoking 2. Reduce alcohol consumption 3. Mediterranean diet 4. Cardiac rehabilitation 5. Optimise treatment of other medical conditions (e.g. diabetes and hypertension)