S9 Investigation and Management of ACS

Question 1

What is the most common acute coronary syndrome? What are two rarer pathologies?

Answer 1

• atheromatous plaque rupture
• coronary dissection
• coronary spasm

Question 2

What is a type 1 MI?

Answer 2

• atherosclerotic plaque rupture/ulceration/fissure/erosion/dissection
• results in thrombus in one or more coronary arteries
• decreased myocardial blood flow and or distal embolisation
• myocardial necrosis

Question 3

What is critical information to get from a history when assessing a patient for MI/angina?

Answer 3

• is there any radiation?
• is the pain dull with central tightness?
• is the pain relieved with GTN spray and how long does it take to have an affect?
• is the pain getting worse?
• is it pleuritic pain?
• does the patient have any risk factors e.g. smoking, family history, hypertension, high cholesterol, thrombophilia?

Question 4

What would you assess on examination of a patient with a possibility of acute chest syndrome?

Answer 4

• BP (systolic pressure of below 90mmHg)
• tachycardia or bradycardia (heart block?)
• auscultation of the lungs - clear or wet?
• any unusual heart sounds e.g. murmurs
• does the patient have cool peripheries?
• check the JVP

Question 5

Which ECG leads look at the lateral aspect of heart?

Answer 5

Lead I, aVL, V5 and V6

Question 6

What are the major coronary arteries?

Answer 6

• right coronary artery

* left main coronary artery - circumflex artery and left anterior descending artery/interventricular anterior artery

Question 7

Which ECG leads look at the inferior aspect of heart?

Answer 7

Leads II, III and aVF

Question 8

Which ECG leads look at the anteroseptal aspect of heart?

Answer 8

V1, V2, V3, V4

Question 9

If an infarct is in the septal aspect which leads will be abnormal?

Answer 9

V1 and V2

Question 10

If an infarct is in the anterior aspect which leads will be abnormal?

Answer 10

V1 to V6

Question 11

If an infarct is in the lateral aspect which leads will be abnormal?

Answer 11

V5 and V6

Question 12

If an infarct is in the anteroseptal aspect which leads will be abnormal?

Answer 12

V1-V4

Question 13

If an infarct is in the anterolateral aspect which leads will be abnormal?

Answer 13

V3-V6

Question 14

If an infarct is in the inferior aspect which leads will be abnormal?

Answer 14

II, III and aVF

Question 15

If an infarct is in the high lateral aspect which leads will be abnormal?

Answer 15

I and aVL

Question 16

What does ST elevation imply?

Answer 16

Sudden occlusion

Long term it is a mark of left ventricular aneurysm

Question 17

What does ST depression imply?

Answer 17

Under supply of blood to the myocardium but no sudden coronary occlusion

If in anterior leads can be due to a sudden occlusion of a vessel at the back of the heart (posterior STEMI)

Non-ischaemic causes as well

Question 18

What does T wave inversion imply?

Answer 18

Under supply of blood to the myocardium but no sudden coronary occlusion

Can be a non-ischaemic cause

Question 19

What is the immediate response if a patient has ST elevation?

Answer 19

Patient straight to cath lab for emergency percutaneous coronary intervention (PCI)

Question 20

What does an ECG look like for someone with NSTEMI?

Answer 20

• can be normal
  Or
• T wave inversion
• ST depression

Question 21

What blood tests do you do to determine if someone has NSTEMI?

Answer 21

• Hb
• test renal function
• cholesterol
• HBA1c
• troponin

Question 22

What is troponin measured using?

Answer 22

Immunoassay

Question 23

How long do troponin levels stay raised for?

Answer 23

2 or more weeks

Question 24

What is the pathway for STEMI management?

Answer 24

1. Give 300mg aspirin (antiplatelet drug)
2. Ticagrelor 180mg/Prasugrel 60mg (second antiplatelet drug)
3. Morphine 5-10mg IV with metoclopramide 10mg IV (for pain and nausea symptoms of morphine)
4. Nitrate (GNT) 2 puffs under tongue (reduced BP)
5. Oxygen if oxygen saturation below 92%
6. Direct transfer to cardiac catheter labs for PCI

Question 25

What is the management for a NSTEMI?

Answer 25

* antiplatelet and antithrombotic drugs - aspirin/clopidogrel and enoxaparin (LMWH) * anti-ischaemics - bisopolol/GTN infusion * secondary prevention - statin and ACE inhibitors

Question 26

If a patient has NSTEMI but has dynamic ECG changes or develops arrhythmia with compromise what should you do?

Answer 26

An urgent PCI

Question 27

Why do you do an invasive coronary angiogram?

Answer 27

To establish the type of lesion and its location

Question 28

Into which artery do you do an invasive coronary angiogram?

Answer 28

Radial or femoral artery

Question 29

How can you manage someone post MI/stent insertion?

Answer 29

* lifestyle changes - low fat diet, regular exercise and low salt * dual antiplatelets for 12 months then aspirin for life * statins * bisoporol * ACE inhibitor