ACS

Question 1

What three conditions does acute coronary syndrome involve?

Answer 1

STEMI, NSTEMI and unstable angina

Question 2

What is the common underlying pathology in ACS?

Answer 2

Plaque rupture, thrombosis and inflammation

Question 3

What would rupture of a fibrous plaque lead to?

Answer 3

Platelet aggregation and adhesion, thrombosis, vasoconstriction and distal thrombus embolism.

Question 4

What is the difference in the vessel occlusion in unstable angina and myocardial infarction

Answer 4

Unstable angina is partial occlusion whereas myocardial infarction is total occlusion.

Question 5

What is the similarity in the plaques in unstable angina and myocardial infarction

Answer 5

Both have a necrotic centre and an ulcerated cap

Question 6

Is unstable angina reversible?

Answer 6

Yes

Question 7

What would you see on the ECG in unstable angina?

Answer 7

Normal or ST depression

Question 8

What would cardiac markers show in unstable angina?

Answer 8

They would be normal

Question 9

Are cardiac markers raised in NSTEMI and STEMI?

Answer 9

Yes

Question 10

What is the different in the ECG trace between STEMI and NSTEMI

Answer 10

STEMI is ST elevation and NSTEMI is ST depression

Question 11

What are the risk factors for acute coronary syndrome?

Answer 11

Mnemonic ABCDEF:

Age, Blood pressure, Cholesterol, Diabetes, Exercise, Fags/Fat/Family History

Question 12

What is a silent myocardial infarction?

Answer 12

Acute coronary syndrome with chest pain. (Seen most often in elderly diabetic patients)

Question 13

What are the symptoms of ACS?

Answer 13

• Central chest pain lasting >20 mins
• Nausea
• Sweatiness
• Dyspnea - shortness of breath
• Palpitations

Question 14

What are the signs of ACS?

Answer 14

• Distress and anxiety
• Pallor
• Sweating
• Pulse high or low
• BP high or low
• 4th heart sound
• May be signs of heart failure (Raised JVP, 3rd heart sound, basal crepitations(crackles at the base of lungs))
• May hear a pansystolic murmur

Question 15

What signs other than ST elevation would you maybe see in the ECG in a STEMI?

Answer 15

• Pathological Q waves

- New left bundle branch block

Question 16

What signs other than ST depression would be maybe see in the ECG in a NSTEMI?

Answer 16

T wave inversion

Question 17

What are troponins?

Answer 17

Protein complex that regulates actin and myosin contraction. They are released when myocardial cells are damaged

Question 18

When do troponin levels rise?

Answer 18

About 3 - 12 hours after chest pain

Question 19

What would you look for on a chest x-ray in acute coronary syndrome?

Answer 19

Cardiomegaly, pulmonary oedema or a widened mediastinum

Question 20

What is the treatment for myocardial infarction (MONA)?

Answer 20

M - Morphine
O - Oxygen
N - Nitrates (GTN spray)
A - Aspirin (anti- coagulatant)

Question 21

What is used in conjunction with aspirin as a dual antiplatelet therapy?

Answer 21

P2Y12 inhibitors e.g Clopidogrel, Ticagrelor

Question 22

What is the surgical treatment for acute coronary syndrome?

Answer 22

PCI - Percutaneous coronary intervention

Question 23

What is the criteria for stenting?

Answer 23

1. STEMI
   - 1 mm elevation in 2 contiguous limb leads
   - 2 mm elevation in 2 contiguous precordial leads
2. New onset LBBB
3. Posterior MI
   CABG (coronary artery bypass graft) - Done in patients with multivessel disease

Question 24

What is the nature of the chest pain seen in unstable angina?

Answer 24

During exercise and rest

Question 25

What is the difference in vessel occlusion between NSTEMI and STEMI?

Answer 25

NSTEMI = complete occlusion of a MINOR or a partial occlusion of a major coronary artery
STEMI = Complete occlusion of a major coronary artery