ACS

Question 1

what does acs include?

Answer 1

Includes unstable angina and myocardial infarctions

Question 2

what is the common underlying pathology for ACS?

Answer 2

Plaque rupture, thrombosis and inflammation in coronary artery
–Rarely due to emboli, coronary spasm or vasculitis

Question 3

what is a MI and how is it recognised?

Answer 3

Myocardial cell death, releasing cardiac troponin with ischaemia
–ST-segment elevation (STEMI) and non-ST-segment elevations
(NSTEMI) on 12 lead ECG
STEMI: complete obstruction; NSTEMI: incomplete obstruction

Question 4

what is unstable angina?

Answer 4

–Similar clinical presentation as NSTEMI without significant rise in
cardiac troponin

Question 5

what are modifiable risk factors for ACS?

Answer 5

–Smoking
–Diabetes
–Hypertension
–Dyslipidaemia
–Obesity
–Lack of exercise
–Cocaine use

Question 6

what are the symptoms of ACS?

Answer 6

–Acute chest discomfort >15 mins/ or in past 12 hours
*Dull, central and/or crushing. Not relieved by rest. May radiate
–Associated symptoms: anxiety, nausea, pallor sweatiness, dyspnoea,
palpitations.

Question 7

what are the signs of ACS?

Answer 7

–Associated with haemodynaic instability (systolic BP <90 mmHG)
*Tachycardia and sweating- sympathetic activation
*Bradycardia, nausea and vomiting- vagal activation
–4th heart sound, low grade fever
–Signs of heart failure (3rd heart sound, increased JVP, basal crepitations

Question 8

what cardiac issues can cause chest pain?

Answer 8

Stable angina, dissecting thoracic aneurysm, pericarditis, cardiac tamponade, myocarditis, acute congestive cardiac failure, or
arrhythmias.

Question 9

what non-cardiac issues can cause chest pain?

Answer 9

Respiratory (PE, pneumothorax, CAP, asthma pleural effusion)
–Other: acute pancreatitis, GORD, oesophagitis; rib fracture, spinal
disorders, cancer; psychogenic
–Non-specific chest pain (16% of people)

Question 10

what is the suspected ACS initial management?

Answer 10

*999
*Aspirin 300mg STAT
*Pain relief:
–GTN and/ or opioid (IV diamorphine 2.5mg-5mg
over 5 minutes
*12-lead ECG (should not delay hospital
transfer)
*Oxygen: only if hypoxic

Question 11

how do you diagnose ACS?

Answer 11

*Cardiac history (clinical skills)
*CV examination (clinical skills)
*Investigations
–12 lead ECG
*Pathological Q waves, left bundle branch block, ST changes
–Blood sample for high sensitivity troponin I or T
–BP, HR, oxygen saturation
–Chest x-ray
*Signs of HF, pulmonary causes
–Other: FBC, u+e, lipid, lft, TFT, HbA1c, CRP, ESR

Question 12

nb need to learn off- what is the universal definition of MI?

Answer 12

Acute myocardial injury with evidence of acute myocardial ischaemia and detection of a rise of the cardiac troponin levels with at least one value above the 99th percentile and at
least one of the following:
–Symptoms of myocardial ischaemia;
–New ischaemic ECG changes;
–Development of pathological Q waves on the ECG;
–Imaging evidence of new loss of viable myocardium or new regional
wall motion abnormalities in a pattern consistent with ischaemic
aetiology;
–Identification of coronary thrombus by angiography or auto

Question 13

what is PPCI?

Answer 13

*Angiography first
*Access via the radial or femoral artery
*X-ray guided insertion through the aorta and into the
affected coronary artery
*Insertion of a balloon which is inflated and a stent to
restore blood flow

Question 14

what is dual antiplatelet therapy?

Answer 14

–Aspirin lifelong and P2Y12 inhibitor for 12 months
*Prasugrel or
*Clopidogrel (if high bleed risk or on anticoagulant)

Question 15

what is the purpose of fibrinolytics?

Answer 15

–Activates plasminogen to form plasmin, degrades fibrin and breaks up thrombi
–Streptokinase, alteplase, tenecteplase

Question 16

when are antithrombins used?

Answer 16

–Unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor. Bivalirudin
if femoral access needed
–With antiplatelet therapy

Question 17

when is STEMi management not suitable?

Answer 17

–Not suitable for PCI or fibrinolysis
–Aspirin and ticagrelor (or clopidogrel if high bleed risk)

Question 18

what is initial antithrombin therapy?

Answer 18

Fondaparinaux: binds antithrombin III, neutralizing factor Xa,
interrupts clotting cascade

Question 19

what is DAPT?

Answer 19

–Aspirin +
–Prasugrel (if PCI intended) or
–Ticagrelor (no PCI) or
–Clopidogrel (high bleed risk/ anticoagulant)

Question 20

what post MI assessments should be done?

Answer 20

*Left ventricular function assessment
–Covered in HF lecture
*Bleeding risk

Question 21

what secondary prevention should be given?

Answer 21

ACEi/ bb/ DAPT/ statin/ aldosterone antagonist

Question 22

when should ACEi be given?

Answer 22

as secondary prevention
–As soon as haemodynamically stable. Continue indefinitely
–Titrate upwards every 12-24 hours, complete titration within 6 weeks
to max tolerated dose.
–Monitor: renal function, U+E, BP before stating and every 2-4 weeks

Question 23

when should BB be given?

Answer 23

as secondary prevention
–As soon as haemodynamically stable
–Titrate slowly up to max tolerated dose.
–Monitor HR and BP
–12 months all patients, lifelong if HF with reduced LVEF

Question 24

what statin should be given for secondary prevention?

Answer 24

–Atorvastatin 80mg
–Monitor liver enzymes, cholesterol HbA1c at 3 months then annually.
CK if persistent muscle pain. TFT and Hba1c before starting

Question 25

how should an aldosterone be given in secondary prevention?

Answer 25

–HF with reduced LVEF.
–Initiate after ACEi, within 14 days of MI
–Monitor renal function and U+E