ACS

Question 1

Myocardial infarction (MI)

Answer 1

necrosis of myocardial tissue following occlusion of a coronary artery and subsequent ischaemia.

Question 2

Initial Mx on suspicion of ACS

Answer 2

GTN 1-2 puffs 400-800mcg ( repeat every 5min pro, caution ifs <90SBP)
Aspirin 300mg stat

Question 3

STEMI

Answer 3

completely occluded coronary artery
- Chest pain at rest or minimal exertion, lasting >15 minutes
- ECG changes (new ST-elevation or left bundle branch block)
- Rise in troponin: myocardial necrosis

Question 4

Diagnosis of STEMI

Answer 4

• new ST-segment elevation in 2 or more contiguous leads.
• The ST elevation should be ≥2mm in the precordial leads or ≥1mm in the limb leads.

Question 5

Treatment of STEMI

Answer 5

MMONAC 
Morphine 1-1-mg IV if pain 
Metoclopramide 10mg IV
Oxygen (if sats <94%)
Nitrates (GTN spray)
Aspirin 300 mg (stat)
Clopidogrel 300 mg (Although, in practice, other similar drugs such as Ticagrelor 180mg are increasingly being used)

Question 6

Percutaneous Coronary Intervention (PCI) for STEMI can be considered if

Answer 6

• patients present within 12 hours of symptom onset and within 2 hours/120minutes of medical contact.
• They should be haemodynamically stable.

Question 7

Drug therapy during PCI

Answer 7

heparin (unfractionated)
glycoprotein IIb/IIIa inhibitor (GPI)

Question 8

Thrombolysis offered if

Answer 8

Patients present within 12 hours of symptom onset but after 2 hours of medical contact

provided they are stable and have no contraindications to its use, If there are contraindications PCI can be done

Question 9

Contraindications to thrombolysis

Answer 9

Aortic Dissection
GI bleed
Allergic reaction
Iatrogenic: recent surgery
Neurological disease: recent stroke (within 3 months), malignancy
Severe HTN (>200/120)
Trauma, including recent CPR

Question 10

NSTEMI

Answer 10

partially occluded coronary artery
- Chest pain at rest or minimal exertion lasting >15 minutes
- ECG changes (new ST-depression of T wave inversion)
- Rise in troponin: myocardial necrosis

Question 11

Diagnosis NSTEMI

Answer 11

• typical symptoms of an ACS
• no ST segment elevation on ECG
• raised cardiac biomarkers.

Question 12

NSTEMI stratification systems

Answer 12

Thrombolysis in Myocardial Infarction (TIMI) score or GRACE model

Question 13

Global Registry of Acute Coronary Events (GRACE)

Answer 13

age
heart rate, blood pressure
cardiac (Killip class) and renal function (serum creatinine)
cardiac arrest on presentation
ECG findings
troponin levels

Question 14

Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)?

Answer 14

immediate: patient who are clinically unstable (e.g. hypotensive)
within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk
coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission

Question 15

NSTEMI low risk Mx

Answer 15

conservatively with medications.
Antithrombin therapy with fondaparinux sodium (2.5mg OD) should also be offered, Heparin (unfractionated) if renal impaired

Question 16

Post ACS secondary prevention advice

Answer 16

cardiac rehabilitation programme including advice for lifestyle changes, stress management and health education.
Lifestyle-specific interventions to reduce their cardiovascular risk should include
- healthy eating
- reducing alcohol consumption,
- regular physical exercise(at least 150 min/week)
- smoking cessation
- weight management

Question 17

ALL patients post-MI patients should be started on the following 5 drugs:

Answer 17

Dual antiplatelet therapy -aspirin (75mg) plus clopidogrel (75mg) /ticagrelor (90mg) usually given
Statin
Beta blocker
ACEi

Question 18

Unstable angina

Answer 18

critical narrowing of coronary artery causing ischaemia
- Chest pain at rest or minimal exertion lasting >15 minutes
- ECG changes (new ST-depression or T wave inversion)
- NO rise in troponin: no myocardial necrosis

Question 19

Unstable angina Mx

Answer 19

Treated same way as NSTEMI

Question 20

Possible complications following a myocardial infarction (MI) include:

Answer 20

Acute/chronic heart failure
Post-infarction angina
Stroke
Depression
Anxiety disorders
Anxiety disorders
Sudden death

Question 21

Angina

Answer 21

chest pain (or constricting discomfort) caused by an insufficient blood supply to the myocardium
occurs predictably with physical exertion or emotional stress, and is relieved within minutes of rest, or with a dose of sublingual glyceryl trinitrate

Question 22

Angina Mx

Answer 22

Conservative: explain dx & mx, modify lifestyle/RF, when to call 999
Medical
GTN spray
primary
1. B blocker to slow down heart ( bisoprolol) or Ca blocker to reduce vessel constriction and BP ( Amlodipine)
2. long-acting nitrate (for example isosorbide mononitrate), nicorandil, ivabradine, or ranolazine.
Secondary prevention
1. antiplatelet (aspirin)
2. ACEi if comorbidities
3. statin if high lipids