ACS

Question 1

Anterior
Inferior
Lateral
Posterior leads

Answer 1

Anterior - V1-4. LAD artery.
Inferior - aVF, II and III. Right coronary artery.
Lateral - aVL, I, V5, V6. Left circumflex artery.
Posterior - Reciprocal changes in V1-4.

Question 2

Initial management of ACS?

Answer 2

Aspirin 300mg,
Oxygen - only if sats < 94%.
Morphine - only if in severe pain.
Nitrates - sublingual or IV. Caution if hypotensive.

Question 3

ECG criteria for a STEMI

Answer 3

1mm ST elevation in any lead except V2-3.
2.5mm elevation in V2-3 if male and under 40 years old.
2mm elevation in V2-3 if male and over 40 years old.
1.5mm elevation in V2-3 if female.
New LBBB

Question 4

What is the management of a STEMI?

Answer 4

PCI if available within 120mins otherwise fibrinolysis.

Question 5

Describe features of PCI

Answer 5

Further antiplatelet prior to PCI - Prasugrel, ticareglor if high bleeding risk and clopidogrel if already taking anticoagulant.
Radial access (preferred) - Give unfractionated heparin with bailout glycoprotein IIb/IIIa
Femoral access - Bivalirudin with bailout GPI
Use drug alluding stent instead of metal stent.

Question 6

Describe features of fibrinolysis

Answer 6

Give teectoplase/Alteplase along with antithrombin (enoxiparin). Start ticagrelor after PCI.
Repeat ECG after 60-90mins, if ongoing ST elevation then perform PCI

Question 7

Explain the management of NSTEMI

Answer 7

Aspirin and fondaparniux if no PCI planned, otherwise just aspirin.
If GRACE < 3% then start ticagrelor (high risk of bleeding then swap).
If GRACE > 3% and unstable then immediate PCI.
If GRACE > 3% and not unstable then PCI within 72 hours and start on aspirin, prasugrel, and unfractionated heparin.

Question 8

What are the poor prognostic factors for ACS?

Answer 8

Age,
Heart failure or development of heart failure,
Peripheral vascular disease,
Reduced systolic BP,
Killip class,
Elevated creatinine,
Elevated cardiac markers
Cardiac arrest on admission,
ST deviation

Question 9

Describe features of the Killip class

Answer 9

I - No clinical signs of heart failure,
II - Lung crackles, S3.
III - frank pulmonary oedema,
IV - cardiogenic shock

Question 10

What is the secondary prevention following an MI?

Answer 10

All patients are offered: SAAB - statin, aspirin (and second agent which gets stopped after 12 months), ACE inhibitor, beta blocker.
Aldosterone antagonists - if signs of heart failure and left ventricular systolic dysfunction.

Question 11

Definition of unstable angina vs NSTEMI?

Answer 11

Unstable angina - chest pain at rest with ECG changes (ST depression or T wave inversion) and NO troponin rise.
NSTEMI - Chest pain at rest with ECG changes (ST depression or T wave inversion) and rise in troponin

Question 12

Contraindications for thrombolysis in MI?

Answer 12

Remembered with mneumonic AGAINST:
Aortic dissection,
GI bleed,
Allergic reaction,
Iatrogenic (recent surgery),
Neurological disease (recent stroke, malignancy),
Severe HTN (>200/120),
Trauma