Myocardial ischaemia, dyspnoeic and sudden cardiac death

Question 1

Treatments NSTEACS according to risk stratification

Answer 1

High: aggressive medical management AND coronary angiography AND revascularisation

Medium: further observation and risk stratification then restratification into high or low risk

Low: discharge on upgraded medical therapy WITH urgent cardiac follow up

Question 2

What acute coronary syndrome does not have confirmed myonecrosis?

Answer 2

Unstable angina

Question 3

Medications that cause cough (2)

Answer 3

ACE inhibitors
Beta blockers

Question 4

What patients are likely to present without chest pain (who have acute coronary syndrome)?

Answer 4

Diabetics
Elderly (delerium and fatigue common)
Pain is absent in ~ 20% patients
May be complicated by cardiac failure, arrhythmias and shock.

Question 5

WWWTK acute dyspnoea + no fever

Answer 5

chest pain?

No - wheezing?

Yes - pleuritic?

Question 6

Physical exam: inspection of head and neck of dyspnoeic patient (5)

Answer 6

1 nasal flaring
2 pursed lip breathing
3 mouth vs nose breathing
4 evidence of trauma
5 tracheal position

Question 7

Patient Hx - MI likelihood decreased if presenting with (4):

Answer 7

Pleuritic chest pain
Produced by palpation
Sharp or stabbing pain
Position chest pain

Question 8

What investigations should be performed early for presentation of chest pain?

Answer 8

ECG and blood tests specifically for myonecrosis (troponin)

Question 9

List factors involved in the risk stratification of NSTEACS

Answer 9

clinical features, complications, age, number of risk factors, high risk background including diabetics and renal failure, elevated troponins and ECG changes

Question 10

Patient Hx - MI likelihood increased if presenting with (4):

Answer 10

SOCRATES
- radiating pain
Sweating
Nausea/vomiting
History of MI

Question 11

ECG evolution during MI (5)

Answer 11

1 ST elevation
2 R drops and Q develops
3 T wave inversion and Q wave begins
4 ST normalizes and T wave inverted
5 ST and T normal, Q persists

Question 12

Dx acute dyspnoea + fever

Answer 12

pneumonia

Question 13

Relevant past MHx for dyspnoeic patient

Answer 13

Lung & heart disease and severity
GIT as well as causes of anaemia
Hx thromboembolism
Hx malignancy
Hx rheumatic disease

Question 14

DDX acute dyspnoea + no fever + pleuritic chest pain (3)

Answer 14

Spontaneous pneumothorax
PE
Pericarditis

Question 15

Medications that cause interstitial lung disease (4)

Answer 15

Amiodarone
Hydralazine
Bleomycine
Methotrexate

Question 16

What is the typical presentation of ACS?

Answer 16

chest pain

Question 17

Besides diagnostic value, what else is troponin good for?

Answer 17

Prognostic indicator

• pt. with elevated troponin but normal CK and CK-MB levels = develop adverse outcome
• the higher the troponin, the poorer the higher risk of adverse event

Question 18

Medication Hx for ACS (6)?

Answer 18

Nitrates, beta blockers, aspirin, ACE inhibitors

Drugs for:
hypertension hypercholesterolaemia

Question 19

Important DDX for troponin elevation? (6)

Answer 19

MI
Chronic or acute renal dysfunction
Hypertensive crisis
Tachy- or bradyarrhythmias
PE
Myocarditis

Question 20

First thing to differentiate in symptom presentation of dyspnoea

Answer 20

acute vs chronic

Question 21

STEMI symptom onset - time before hospital presentation - AND intervention

Answer 21

<1hr - PCI within 1hr otherwise fibrinolysis

1-3hrs - PCI within 90min otherwise fibrinolysis

3-12hrs - PCI within 90min (onsite) or 2hr (offsite) otherwise fibrinolysis

Question 22

Categories in the assessment of severity of dyspnoea

Answer 22

Class I
- disease present bu no dyspnoea or only on exertion
Class II
- dyspnoea on moderate exercise
Class III
- dyspnoea on minimal exercise
Class IV
- dyspnoea at light rest

Question 23

DDX acute dyspnoea + no fever + no chest pain + wheeze (4)

Answer 23

asthma
anaphylaxis
aspiration
COPD

Question 24

ECG criteria (mm for leads) for diagnosis of acute STEMI (<40M, >40M and F all ages)

Answer 24

ST elevation…

<40 male
- V2/V3: >2.5mm
- all other leads: >1mm

> 40 male
- V2/V3: >2mm
- all other leads: >1mm

All ages female
- V2/V3: >1.5mm
- all other leads: >1mm

Question 25

List 3 non cardiorespiratory causes of dyspnoea

Answer 25

Psychogenic Acidosis Hypothalamic lesion

Question 26

Primary investigation of dyspnoeic patient (4)

Answer 26

Vitals - all, SaO2 required on pts presenting with respiratory distress GCS BSL on known diabetics and pts on steroids ECG if cardiac involvement suspected

Question 27

Define stable angina

Answer 27

Acute pain resulting from an increased demand for oxygen and a decreased ability to provide it. - fixed stenosis Chest pain is usually short lived (<10 min), provoked by exercise and relieved by rest and/or glycerol nitrate (GTN).

Question 28

Physical exam: general inspection of dyspnoeic patient (5)

Answer 28

1 level of consciousness 2 level of anxiety 3 speech 4 skin colour 5 body position

Question 29

DDX chronic dyspnoea + no cough (5)

Answer 29

Pulmonary hypertension Cardiomyopthay Deconditioning Anaemia Neuromuscular disease

Question 30

List causes of type II MI (5)

Answer 30

1 Artherosclerosis 2 Vasospasm 3 Microvascular dysfunction 4 Non-artherosclerotic coronary dissection 5 Oxygen supply/demand imabalance alone

Question 31

Define dyspnoea

Answer 31

Subjective feeling of breathlessness or effort in breathing. Multidimensional, not a single sensation. 1 work/effort 2 tightness 3 air hunger

Question 32

List some alternate causes of chest pain to cardiac

Answer 32

Psychogenic Reflux Musculoskeletal Respiratory Vascular Abdominal Neurological

Question 33

List 3 types of chest pain

Answer 33

Chest wall Pleuritic Visceral

Question 34

DDX acute dyspnoea + no fever + no chest pain + no wheeze (2)

Answer 34

acidosis respiratory muscle weakness

Question 35

List 4 categories of respiratory disease responsible for dyspnoea and an example for each

Answer 35

1 airways disease - asthma, COPD 2 parenchymal disease - interstitial lung disease 3 pulmonary circulation - PE 4 chest wall and pleura - pneumothorax

Question 36

DDX chronic dyspnoea + cough + wheeze (2)

Answer 36

Asthma Chronic obstructive pulmonary disease

Question 37

DDX acute dyspnoea + no fever + non pleuritic chest pain (2)

Answer 37

Myocardial ischaemia Pericardial effusion / cardiac tamponade

Question 38

How to assess severity of dyspnoea

Answer 38

Amount of exertion to generate dyspnoea - distance walked - number of steps that can be climbed - duration - variability (progressive deterioration / fluctuation)

Question 39

Medications that cause wheeze (4)

Answer 39

Beta blockers Aspirin and NSAIDs Morphine Tamoxifen

Question 40

Past medical Hx ACS

Answer 40

Hx of angina, MI or other cardiac disease Risk factors in young patient (<65yo)? Hx angioplasties, coronary artery bypass, previous thrombolysis? Diabetes mellitus or chronic renal failure?

Question 41

List 3 main systems/conditions responsible for dyspnoea

Answer 41

Cardiac Respiratory Anaemia

Question 42

Signs in dypsnoeic patient requiring immediate treatment (7)

Answer 42

1 Evidence of airway obstruction or compromise 2 Severe respiratory effort and marked accessory muscle use 3 Tachypnoea > 30, single words only 4 Pallor or cyanosis 5 Hypoxia despite oxygen therapy 6 Decreased air entry 7 Altered level of consciousness

Question 43

Differentiate MI type I and II.

Answer 43

I - plaque rupture or thrombus II - oxygen supply/demand imbalance

Question 44

Typical vs atypical pain symptoms?

Answer 44

Typical = chest pain - radiating pain, sweating, nausea, SOB Atypical = chest pain - not central (jaw/arms) - burning quality, lethargy, delerium

Question 45

What diagnosis results from non ST elevated acute coronary syndrome + confirmed myonecrosis?

Answer 45

nonSTEMI

Question 46

How long within arrival time should an ECG be performed on presentation with chest pain?

Answer 46

10 minutes

Question 47

Medications that cause PE (2)

Answer 47

Oestrogens Tamoxifen

Question 48

List 3 conditions present under the umbrella term acute coronary syndrome

Answer 48

1 Unstable angina 2 STEMI 3 nonSTEMI

Question 49

Troponin elevation timeline?

Answer 49

Delayed by 4-6 hours

Question 50

ACS treatment

Answer 50

Revascularization = reperfusion - percutaneous coronary intervention - fibrinolysis

Question 51

What does pulse oximetry measure?

Answer 51

Amount of Hb bound with oxygen

Question 52

DDX chronic dyspnoea + cough + no wheeze (4)

Answer 52

Interstitial lung disease Malignancy Chronic pneumonia Pleural effusion

Question 53

What differentiates nonSTEMI and unstable angina?

Answer 53

Myonecrosis confirmed = rise/fall troponin ECG can be similar

Question 54

Initial management of NSTEACS presentations

Answer 54

All patients with NSTEACS should be given aspirin, unless contraindicated Risk stratification: high, medium, low

Question 55

Define unstable angina

Answer 55

Pain that occurs when the heart doesn't receive enough oxygen. Unpredictable symptoms occurring during exertion and at rest. - dynamic stenosis Chest pain is prolonged or atypical presentation of known angina without ECG or laboratory findings of MI.

Question 56

What is ECG able to differentiate between and allow for what immediate treatment?

Answer 56

STEMI vs NSTEACS Immediate reperfusion

Question 57

Adjunctive treatments of STEMI

Answer 57

Antiplatelets Anticoagulants Direct thrombin inhibitors Oxygen Nitrates Antiemetics Analgesics

Question 58

DDX of patient with dyspnoea... 1 central chest pain 2 pleuritic chest pain

Answer 58

central - AMI, acute pulmonary edoema pleuritic - PE, pneumothorax, pleural disease

Question 59

List 5 cardiac conditions leading to dyspnoea

Answer 59

LV failure Ischaemia Valvular disease Cardiomyopathy Pericardial effusion