ACS

Question 1

Define:

Answer 1

This refers to NSTEMI, STEMI and unstable angina (angina at rest)

Question 2

Define IHD:

Answer 2

chronic process of atherosclerosis in the coronary arteries

Question 3

Aetiology:

Answer 3

Due to demand exceeding supply usually due to atherosclerosis (endothelial damage that leads to plaque formation)

Question 4

Risk factors:

Answer 4

male
diabetes mellitus 
smoking 
sedentary lifestyle 
cocaine use - leads to coronary artery spasm 
obesity 
family history 
hypertension 
hyperlipidemia

Question 5

epidemiology:

Answer 5

common

> 2% prevelance

more common in males than females

~5/1000 incidence in the uk

Question 6

symptoms:

Answer 6

CENTRAL CRUSHNG CHEST PAIN

Lasting >20 minutes

radiates to the arm, back, jaw or epigastrium

Associated with: breathlessness, sweating, palpitations, nausea and vomiting.

Silent infarcts: these are in the elderly or diabetics (they do not have chest pain) –> syncope, pulmonary oedema, epigastric pain, and vomiting

Question 7

Signs:

Answer 7

there are no clinical signs of ACS

Pale

sweating

low grade pyrexia

arrhythmia

restless

distress

BP disturbances

check radial pulses for aortic dissection rule out

new heart murmurs

signs of complications

signs of HF (JVP raised, peripheral oedema, 3rd HS)

pericardial friction rub

Question 8

Investigations:

Answer 8

ECG Changes (ST elevation or new LBBB) = STEMI

No –> Rise in troponin (NSTEMI) no rise = UA

UA and NSTEMI may show ST depression or T wave inversion

Bloods - FBC, U+E’s, TFTs, amylase (pancreatitis may present similar), cardiac enzymes (troponin, creatine kinase, LSH and AST) , lipid profile, glucose, CRP

Exercise ECG

pharmacological stress test

cardiac catheterisation/angiogram

rMPI

Echo

coronary calcium scoring

Question 9

Management:

Answer 9

MONABASH

Morphine (pain)/ metoclopramide (nausea)
Oxygen 
Nitrates (GTN spray)
Anticoagulants (aspirin and clopidogrel)
Beta blockers 
ACEi
Beta blockers 
statins 
heparin (LMWH)

May have a percutaneous coronary intervention

or CABG

STEMI - Clopidogrel and aspirin + PCI

NSTEMI - Aspirin and clopidogrel and fondoparinex.

Question 10

Complications:

Answer 10

DARTH VADER

death 
arrhythmias 
rupture
tamponade 
heart failure
Valve disease
Aneurysm 
Dressler's syndrome (autoimmune pericarditis 2-5 weeks post MI)
Emboli
Reinfarction

Question 11

prognosis:

Answer 11

TIMI - risk of stratification

KILIP - evidence of HF