chapter 4

Question 1

what are the specific group of people that present with angina uncharacteristically ?

Answer 1

no chest pain just breathlessness - diabetics , females , elderly

Question 2

angina usually gets misdiagnosed as what?

Answer 2

in digestion

Question 3

what is crescendo angina ?

Answer 3

a form of unstable angina -
angina on exertion , occuring with increasing frequency , provoked by progressively less exertion

Question 4

unstable angina characteristic ?

Answer 4

angina like pain occurring recurrently and unpredictably without exercise provocation

may settle spontaneously and relieved for short term by GTN sublingual

Question 5

the categories of ACS?

Answer 5

STEMI - ST elevation or new LBBB

Non ST segment elevation ACS :
NSTEMI (High troponin)
unstable angina (no ECG CHANGES OR NO HIGH TROPONIN)

Question 6

unstable angina ECG ?

Answer 6

normal
show evidence of acute myocardial ischemia -ST depression
non specific abnormalities - T wave inversion

Question 7

in unstable angina - when there are no ecg changes and troponin levels are normal = GRACE SCORE LOW what can be done ?

Answer 7

further risk assessment test = exercise testing
non invasive imaging

Question 8

NSTEMI angina characteristic ?

Answer 8

pain >20 mins
nausea and vomiting
sweating
belching

Question 9

NSTEMI in vascular sense ?

Answer 9

partial or intermittent occlusion

Question 10

treatmnet for NSTEMI and unstable angina is the same ?

Answer 10

yes
unlike STEMI - needing immediate reperfusion

Question 11

what does the development of q waves mean in STEMI ?

Answer 11

damage to the myocardium in the area where the artery is occluded - causing iMPAIRED VENTRICULAR FUNCTION

Question 12

during acute phase of STEMI there is substantial risk of what ?

Answer 12

tach and vfib

Question 13

DD for angina in STEMI ?

Answer 13

PE and aortic dissection

Question 14

suspect aortic dissection when ?

Answer 14

acute chest pain - radiating to the back
marked hypotension
loss of peripheral pulse
asymmetry f pulse in the upper limbs

Question 15

does a single normal ECG exclude ACS?

Answer 15

no - should be repeated in intervals

Question 16

what needs to be established if PPCI is not given within 20 mins?

Answer 16

fibrinolytic

Question 17

symptoms of PE

Answer 17

sudden hypoxia

Question 18

how to detect anterior or anteroseptal infraction on ECG

Answer 18

change in leads V1-V4
by LAD artery - left anterior descending

if V5-V6 involved , lead 1 and AVL = anterolateral

Question 19

which infraction has the worst prognosis ?

Answer 19

anterior infract causes most damage on left ventricle function - worst prognosis

Question 20

how to detect inferior infraction ?

Answer 20

lead 2,3 and avF

right coronary artery

Question 21

how to detect lateral infraction ?

Answer 21

lead V5 V6
or
lead 1 and aVL

Question 22

how to detect posterior infraction ?

Answer 22

ST segment depression V3-V4 (anterior leads)

dominant r wave in v1-v2- reflects posterior q wave development

= right coronary artery occlusion

confirmed with repeating ecg with posterior leads v7-v10

Question 23

one third of patients with inferior and posterior STEMI May also have ?

Answer 23

right ventricular infraction

st elevation in v1
and inferior posteriori STEMI

Question 24

are ST segment depression and t wave inversion in the ecg lead related to where the damage occurred in the heart ?

Answer 24

no

Question 25

other causes pf st elevation ?

Answer 25

SAH TBI brigade syndrome - ST elevation in V1 -V2 takotsubo cardiomyopathy

Question 26

pe ecg changes ?

Answer 26

t wave inversion v1-v4

Question 27

other causes for high troponin ?

Answer 27

PE aortic dissection myocarditis heart failure chronic renal failure sepsis

Question 28

what is the GRACE SCORE BASED ON ?

Answer 28

age troponin levels ecg changes signs of heart failure HR serum creation BP cardiac arrest

Question 29

treatmnet for ACS

Answer 29

ACS protocol cardiac monitor loading 300mg aspirin GTN oxygen pain relief - opiate analgesia - morphine anti metic clopidrogel - 300mg /600 prasugrel - 60mg ticagrelor - 180mg

Question 30

when does PCI not become useful ?

Answer 30

after 12 hour of symptom onset however should be considered if in ecg shows ongoing ischemia

Question 31

some setting PCI is used with what adjuncts ?

Answer 31

glycoprotein 2b/3a inhibitors

Question 32

benefits of PCI to fibrinolytic ?

Answer 32

lower risk of bleeding into the brain and bleeding in general

Question 33

contra for PCI?

Answer 33

previous hemorrhagic stroke schema stroke last 6 months recent major injury or trauma active bleeding non or suspected aortic dissection known bleeding disorder

Question 34

if patient getting fibrinolytic do they need additional antithmbotic therapy ? if so what

Answer 34

yes = aspirin 300mg and clop 300= if high bleeding risk / or ticagrelor =180mg + antithrombin therapy LMWH/ UFH / fondaparinoux

Question 35

indication for fibrinolytic ?

Answer 35

more tha 12 hr since symptom onsert and PCI not possible within 120 min AND ST segment elevation in 2 adjacent chest leads of 0.2mv or more or 2 or more peripheral limb leads of 0.1mv or more or dominant r waves and st depression in v1-v3 or new onset LBBB

Question 36

after successful thrmbolysiswith fibrinolytic what should be considered ?

Answer 36

angiography with or without PCI

Question 37

how do you know fibrinolytic therapy has failed ?

Answer 37

cardiac monitoring continuously 12 lead ecg recored 60-90 mins after fibrinlitics failure of st elevation to depress in more than 50 percent compared to pre treatmnet ECG or no reperfusion arrythmia - accelerated idioventriuclar rythm - NOT in all cases and might not be witnessed symptoms unreliable guide for reperfusion

Question 38

treatmnet for NSTEMI ?

Answer 38

immediate treatmnet object - prevent new thrombus formation , reduce myocardial oxygen demand = further thrombus prevention fondaparinoux aspirin loading and daily maintenance prasugrel 60mg (contra >75 and hx of bleeding) then 10 mg or clop 300mg then 75mg or ticagrelor 180mg then 90 mg reduce myocardial oxygen demand = beta blockers bb contra = diltiazem avoid DCCB such as nifedipine consider Nitrate infusion if angina persist pr reoccurs after sublingual nitrate consider early ACE

Question 39

long term therapy for ACS?

Answer 39

cardiac rehab - reduce hospital admission begins from he cardiac unit tot he community long term anticoagulant if PCI minimum of one year if atrial fib as complication - DOAC or warfarin ACEI - reduce the remodelling that contributes to left ventricular dilation reduce risk of HF and future MI for first few days if low LVEF (<40) - aldosterone antagonist ECHO examination of LVF BB - shown to reduce mortality cardioprotective effect prevent future arrythmia statins - reduce risk of future coronary event stop smoking anti hypertensives

Question 40

NSTEMI CONSIDERED cause of cardiac arrest ?

Answer 40

immediate coronary angiography and PCI if needed

Question 41

if an arrythmia occurs within 24-48 hr after an ACS has happened what is the management ?

Answer 41

ICD is not indicated unless persistently severe LV function at least 4 weeks post ACS also check for other factors that might have predisposed the arrythmia - hypokalaemia

Question 42

if there is sustained ventricular arrythmia after 48 hr of ACS ?

Answer 42

ICD unless arrythmia associated with ischemia which can be reversed with revascularisation

Question 43

who are at most risk for cardiac arrest as late complication

Answer 43

those who develop Vf and tach - should be seen by a cardiologist for an ICD

Question 44

what indicates poor prognosis in relation to myocardial infraction and arrythmia ?

Answer 44

AV block - extensive myocardial injury usually slow and hesitant to atropine temporary cardiac pacing is usually needed

Question 45

if cardiac arrest occurs in the contact of MI what should happen

Answer 45

if esp in cardiac lab - mECHANICAL DECOMPRESSION - AND START PCI or extracorporeal CPR