ACS

Question 1

Give the differential diagnosis for ACS. (Positive troponin)

Answer 1

Plaque rupture
Prinzmental’s angina
Cocaine use
Vasculitis-(kawasaki’s, takayasu’s, PAN, Churg Strauss, SLE, RA)
Aortic dissection with retrograde extension (Usually RCA/inferior infarct)
Coronary artery embolism- endocarditis, prosthetic valve, mural thrombus, myxoma.
Fixed CAD with demand ischemia ( anemia/tachycardia/AS)
Myocarditis

Question 2

What are Sgarbossa criteria for ACS in LBBB?

Answer 2

> 1mm ST elevation in concordant QRS deflection (Sen 20%, spec 98%).
5mm ST elevation in discordant elevation (Sen 41% Spec 85%).
ST segment depression >1mm in leads V1,V2, or V3.

Question 3

Name physical exam findings which suggest ACS.

Answer 3

Signs of ischemia: New S4, paradoxical S2, new MR murmur from papillary dysfunction.
Signs of Heart failure: S3, pulmonary edema/crackles, increased JVP, if right sided possibly clear lungs + kussmaul’s sign

Question 4

What are non-ACS causes of increased troponin?

Answer 4

Mayocarditis, toxic CMP, severe CHF, PE, severe respiratory distress, SAH, demand ischemia, renal failure (decreased trop clearance).

Question 5

Name the 4 pillar treatments of ACS.

Answer 5

1. Anti-ischemia: Nitrates, beta-blockers (or CCB ), Morphine, Oxygen.
2. Antiplatelet: Aspirin, P2Y12 inhibitor, GP IIb/IIIa inhibitor.
3. Anticoagulation: UFH, LMWH (enoxaparin), direct thrombin inhibitor (bivalirudin), Xa inhibitor (fondaparinux)
4. Reprofusion: thrombolytics, PCI, CABG.