ACS

Question 1

Definition of ACS

Answer 1

ST - segment acute coronary syndrome (STEACS) : STEMI, New on set of LBBB or STEMI in presence of LBBB
Non - ST segment acute coronary syndrome (NSTEACS) : NonSTEMI and unstable angina (UA)

Question 2

Atherosclerosis

Answer 2

Progressive disease process leading to thickening and hardening of arterial wall due to accumulation of lipid laden macrophages leading to development of plaque
Due to an inflammatory process
Both innate and adaptive immune response involved

Question 3

Myocardial infarction

Answer 3

Myocardial cell death due to prolonged ischemia
10-15 mins - diminished glycogen stores, relaxed myofibrils and sarcolemmal disruption and mitochondria abnormalities.
Necrosis process

Question 4

Bio marker detection

Answer 4

Cardiac trips in I and T
Elevated levels 1-3 hrs after MI may take up to 12 hrs
Remain elevated for up to 14 days

Question 5

Anterior MI

Answer 5

Blockage in the LAD - ECG changes in V1-V4
The artery supplies the anterior septum, left ventricle and apex of heart
Myocardium becomes ischaemic

Question 6

Anterior MI symptoms

Answer 6

Reduction in left ventricular function which can lead to: arrhythmias (VT, VF, AF, SVT)
Tachycardia
Hypotension
Pts will often have severe chest pain

Question 7

Inferior MI

Answer 7

Blockage occurs in RCA (ECG changes to II, III, AVF)
Symptoms l:
Chest pain, weakness, nausea, vomiting, hypotension, cold and diaphoretic

Question 8

Inferior MI can result in..

Answer 8

Bradycardia and AV block

Question 9

Inferior/RV MI

Answer 9

Inferior infarcts can involve damage to the right ventricle
Physiological findings: distended neck veins, elevated jugular venous pressure, clear lung fields
Treatment: VT/VF can occur if RCA has a large LV supply

Question 10

Lateral MI

Answer 10

Involves leads I, aVL, V5, V6
Blockage of the left circumflex artery
Can develop cardiogenic shock if circumflex has large LV supply

Question 11

Posterior MI

Answer 11

Usually supplied by posterior descending artery (PDA)

May observe ST depression in V1-V3 which indicates that you need to complete a posterior lead ECG (V7-V9)

Question 12

Pathological Q waves

Answer 12

Irreversible myocardial necrosis produces pathological Q waves.
Q waves are considered pathological if
> 0.4 sec (1mm) wide
> 25% of depth of QRS complex

Question 13

Consider fibrinolytics if

Answer 13

PCI unavailable

Pt presents within 60-120 minutes after Sx onset with an expected delay of >90min

Question 14

Adjunct pharmacotherapy when administering fibrinolytics

Answer 14

Enoxaparin or infractioned heparin
Clopidogrel 300-600 loading dose or ticagrelor 180 or prasugrel 60mg
* PCI with in 24hts is recommended for pts who received fibrinolytics
* Rescue PCI recommended if <50% ST segement recover at 60-90 min post fibrinolytics

Question 15

Additional assessment information required for MI presentation

Answer 15

Do we need a right sided or posterior ECG?
Time of onset
BGL
NOK details
Allergies
Last oral intake
PQRST assessment 
Medications 
Chest X-ray 
Pathology (hs trop) 
Ensure 2 x IVC inserted

Question 16

Reperfusion contraindications

Answer 16

BP > 180/110
Recent trauma/surgery 
GIT bleed with in last 2 weeks
Stroke/TIA last 12 months
Prior ICH
Current anticoagulation or warfarin diathesis