ACS

Question 1

How is acute NSTEMI treated?

Answer 1

BATMAN
Beta-blockers unless contraindicated
Aspirin 300mg stat dose
Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk)
Morphine titrated to control pain
Anticoagulant: Fondaparinux (unless high bleeding risk)
Nitrates (e.g. GTN) to relieve coronary artery spasm

O2 if needed

Question 2

What is the GRACE score?

Answer 2

This scoring system gives a 6-month risk of death or repeat MI after having an NSTEMI:
<5% Low Risk
5-10% Medium Risk
>10% High Risk
If they are medium or high risk they are considered for early PCI

Question 3

What are the complications of heart failure?

Answer 3

DREAD:
Death
Rupture of the heart septum or papillary muscles
oEdema
Arrhythmia and Aneurysm
Dressler’s Syndrome

Question 4

What is Dressler’s syndrome?

Answer 4

Post-myocardial infarction syndrome. Usually occurs around 2-3 weeks after an MI.
Caused by a localised immune response and causes pericarditis

Question 5

How does Dressler’s syndrome present?

Answer 5

Pleuritic chest pain, low grade fever and a pericardial rub on auscultation. It can cause a pericardial effusion and rarely a pericardial tamponade.

Question 6

How is Dressler’s syndrome treated?

Answer 6

NSAIDs (aspirin / ibuprofen) and in more severe cases steroids (prednisolone)

Question 7

What secondary prevention is given in ACS?

Answer 7

6 A’s:
Aspirin 75mg once daily
Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months
Atorvastatin 80mg once daily
ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily)
Atenolol (or other beta blocker titrated as high as tolerated)
Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)

Question 8

What lifestyle advice is given as secondary prevention?

Answer 8

Stop smoking
Reduce alcohol consumption
Mediterranean diet
Cardiac rehabilitation (a specific exercise regime for patients post MI)
Optimise treatment of other medical conditions (e.g. diabetes and hypertension)

Question 9

What area of the heart and corresponding coronary artery is affected in an abnormality in leads I, aVL, V3-6?

Answer 9

Anterolateral

LCA

Question 10

What area of the heart and corresponding coronary artery is affected in an abnormality in leads V1-4?

Answer 10

Anterior

LAD

Question 11

What area of the heart and corresponding coronary artery is affected in an abnormality in leads I, aVL, V5-6?

Answer 11

Lateral

Circumflex

Question 12

What area of the heart and corresponding coronary artery is affected in an abnormality in leads II, III, aVF?

Answer 12

Inferior

RCA

Question 13

How is a STEMI treated?

Answer 13

MONA
Morphine- vasodilation, decreases sympathetic drive and thus demand on heart
Oxygen- support non infarcted heart
Nitrates- sublingual nitroglycerides or GTN spray
ASA- aspirin

Question 14

What is given after resolution of an ACS event?

Answer 14

Statin
B blocker
ACEi

Question 15

What reperfusion strategies are available?

Answer 15

PCI

Thrombolysis

Question 16

What is primary PCI?

Answer 16

Putting a catheter into the patient’s brachial or femoral artery, feeding that up to the coronary arteries under x-ray guidance and injecting contrast to identify the area of blockage.
This can then be treated using balloons to widen the gap or devices to remove or aspirate the blockage.
Usually a stent is put in to keep the artery open.

Question 17

What is thrombolysis?

Answer 17

Injecting a fibrinolytic medication (they break down fibrin) that rapidly dissolves clots. There is a significant risk of bleeding which can make it dangerous.
E.g. streptokinase, alteplase, tenecteplase