ACS, angina, UA, STEMI, NSTEMI

Question 1

List the modifiable and unmodifiable RFs for ischaemic heart disease

Answer 1

Unmodifiable risk factors:
Increasing age
Male gender
Family history

Modifiable risk factors:
Smoking
Diabetes mellitus
Hypertension
Hypercholesterolaemia
Obesity

Question 2

Explain the pathophysiology of ischaemic heart disease listing some of the cells involved

Answer 2

1. ENDOTHEILIAL DYSFUNCTION triggered by smoking/HTN/DM
2. fatty infiltration of subendothelial space by LDL particles [low-density lipoproteins]
3. Monocytes migrate over from blood and differentiate into macrophages
4. Macrophafes phagocytose oxidised LDLs –> become large foam cells fomring fatty plaques. Death of macrophages increases inflammation.
5. Smooth muscle cells migrate from tunica media –> intima and form fibrous capsules around the fatty plaques
6. Plaques cause narrowing of coronay arteries (angina), and can also rupture and occlude the cornary artery (MI)

Question 3

Signs and symptoms of ACS

Answer 3

• left-sided chest pain
• radiating to jaw or left arm
• heavy, crushing
• dyspnoea
• sweating
• N+V

Question 4

Which patients may have ACS without chesy pain?

Answer 4

elderly, DM, females

Question 5

What are the 2 most important Ix for someone presenting with chest pain?

Answer 5

• ECG
• Troponin

Question 6

Which leads are associated with which territors of the heart? (HINT: visualise 3D model of heart)

Answer 6

Anterior: V1-V4

Inferior: ll. aVF, lll

Lateral: l, V5-V6, aVL

Question 7

Which leads are associated with which coronaty arteries? (HINT: visualise 3D model of heart)

Answer 7

V1-V4: left ANTERIOR descending

ll. lll. aVF: right coronary

l. V5-V^: left circumflex

Question 8

Expected Ix results for angina, unstable angina, STEMI and NSTEMI

Answer 8

Angina: changes only seen in exercise ECG

UA: ECG changes but normal trop

NSTEMI: increased trop, widespread ST depression and/or inverted T-waves

STEMI: increased trop, persistent ST elevation in leads V2-V3 + new LBBB

Question 9

Common management in all patients presenting with ACS (with key dose)

Answer 9

MONA
1. Morphine (if pt is in severe pain)
2. Oxygen (Only if sats are <94%)
3. Nitrates (cautious if Pt is hypotensive)
4. aspirin 300mg

Question 10

Drugs used in longterm Mx of pt with ACS

Answer 10

aspirin + statins for all
sublingual GTN to abort attacks

1st line: BB/CCB monotherapy
2nd line: BB/CCB combination therapy
3rd line: atypical drugs

Question 11

Which CCB should be used as monotherapy for angina and which can be used with a BB?

Answer 11

Alone: verapamil, diltiazem (will cause complete block if used with BB)

With BB: long-acting dihydropyridine like amlododipine, nifedipine

Question 12

if a patient is on monotherapy and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then consider less common antianginals like:

Answer 12

• a long-acting nitrate(isobromide mononitrate)
• ivabradine (reduced HR)
• nicorandil (vasodilator)
• ranolazine

Question 13

Mx of STEMI once confirmed by ECG

Answer 13

1. Is pt presenting with 12h of onset of symptoms?
2. Can PCI be done in 120 min?

If yes, do PCI.

If PCI cannot be done in 120 min, do fibrinolysis

Question 14

What drugs are used for fibronlysis?

Answer 14

tPA (good mortality outcomes!)e.g alteplase, streptokinase

Question 15

Drugs given to pt prior to PCI (for pts on/not on anticoag)

Answer 15

Prior: needed to do dual antiplatelet therapy (aspirin has been given already under MONA)

if the patient is not taking an oral anticoagulant: prasugrel (higher bleeding risk)

if pt is taking anticoag: clopidogrel

Question 16

Which acceess is prefered for PCI?

Answer 16

radial over femoral

Question 17

Drugs given to Pt during PCI (radial/femoral access)

Answer 17

patients undergoing PCI with radial access:
unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor (GPI) - this is the action of using a GPI during the procedure when it was not intended from the outset, e.g. because of worsening or persistent thrombus. GPI prevents platelet aggregation and thrombus formation.

patients undergoing PCI with femoral access:
bivalirudin with bailout GPI

Question 18

When would you do a CABG?

Answer 18

Mulltivessel coronary arterty disease

Question 19

What should be given along with and following fibrinolysis?

Answer 19

Along with: antithrombin (fondaparinux, edoxaban)

Following: tricagrelor (antiplatelet)

Question 20

antiplatelets vs anticoagulants

Answer 20

Both classes of medications are antithrombotic agents.

Plarelets are the primary mediators that trigger the mechanical pathway of the coagulation cascade. Platelets + fibrin (product of CC) form the clot in a vascular wall.

Anticoagulants disrupt the CC and include Vitamin K antagonists (warfarin), DOACs and LMWH.

Antiplatelets prevent platelet formation and include clopidogrel, ticagrelor, prasugrel.

Question 21

Mx once NSTEMI/UA is confirmed (including score)

Answer 21

1. Aspirin 300mg
2. Fondaparinux if no immediate PCI
3. Calculate GRACE Score

If <3% - Give tricagrelor

If >3% - coronary angiography + PCI within 72h if necessary

Question 22

What are the criteria of the GRACE Score?

Answer 22

Gold standard biomarker: troponin
Renal (serum creatinine) and cardiac (killip class) function
Age
Cardiac arrest on presentation
ECG findings

Question 23

Pt comes in with NSTEMI/UA, GRACE score <3% but hypotensive - what is the mx?

Answer 23

immediate CA + PCI

Question 24

clopidogrel vs ticagrelor - how do you decide which to use?

Answer 24

higher bleeding risk = use clopidogrel

Question 25

What are Killip classes + what are the classes?

Answer 25

Killip class - system used to stratify risk post myocardial infarction

I No clinical signs heart failure
II Lung crackles, S3
III Frank pulmonary oedema
IV Cardiogenic shock

Question 26

What is the referral criteria for a Pt who comes in with chest pain?

Answer 26

current chest pain or chest pain in the last 12 hours with an abnormal ECG: emergency admission

chest pain 12-72 hours ago: refer to hospital the same-day for assessment

chest pain > 72 hours ago: perform full assessment with ECG and troponin measurement before deciding upon further action

Question 27

Patient with suspected ACS has normal ECG, OR Pt has ECG changes but no clinical symptoms - what do you do?

Answer 27

1st line: CT coronary angiography

2nd line: non-invasive functional imaging (SPECT, sress echocardiography)

3rd line: invasive coronary angiography

Question 28

How long after an MI can PDE5 inhibitors (sildenafil/viagra) be used? When must they be avoided?

Answer 28

6 months

Pts who are on a nitrate or nicorandil

Question 29

How long after MI must dual antiplatelet therapy be followed?

Answer 29

12 months

Question 30

What class of drugs is prescribed for patients with acute MI who also have Sx of HF/LVF? When is it started?

Answer 30

Aldosterone antagonist (like eplerenone, spironolactone). Start 3-14 days after MI, after ACE-I.

Question 31

How do you manage a patient with ACS who is also having hyperglycaemia?

Answer 31

dose-adjusted insulin infusion with regular monitoring of blood glucose levels to glucose below 11.0 mmol/l

Question 32

G ive tw o cardiac enzym es th at com m only rise follow ing cardiac
dam age

Answer 32

Troponin (I/T), CK-MB, CK, AST, LDH.

Question 33

Man hasSTEMI - tw o abnorm alities th a t
m ay be seen on his E C G p rio r to discharge

Answer 33

Inverted T waves, pathological Q waves.

Question 34

safe for pt to drive after STEMI?

Answer 34

Not allowed to drive for 4 weeks, can drive from then on so long
as not otherwise disqualified, DVLA do not need to be informed.