ACS c ST elevation

Question 1

What are the different types of Acute Coronary Syndrome?

Which of these is a common medial emergency?

Answer 1

• Unstable angina
• STEMI
• NSTEMI
• STEMI

Question 2

What are the sx for ACS?

Answer 2

• Central, crushing chest pain
• Nausea and vomiting
• Sweating and clamminess
• Feeling of impending doom
• Shortness of breath
• Palpitations
• Pain radiating to jaw or arms

Question 3

What are the ECG criteria for STEMI?

Answer 3

STEMI

• ST elevation >1mm in 2 or more adjacent limb leads or
• ST elevation >2mm in 2 or more adjacent chest leads

LBBB

• QRS equal to or more than 120ms
• Broad R wave in 1, aVL, V6
• lack of septal q wave in 1 and V6

Question 4

What Ix would you order for MI?

Answer 4

• Bedside
  
  • ECG
  • heart sounds
• Bloods
  
  • Troponins & CK-MB
  • FBC
  • U&E
  • glucose
  • Lipid profile
• Imaging
  
  • CXR
  • echocardiogram
  • CT coronary angiogram

Question 5

What is the nature of troponin raise in MI?

Answer 5

• Serum level increase within 3-12 hrs from onset of chest pain
• Peak at 24-48 hrs
• Return to baseline at 5-14 days

Question 6

Why is troponin not specific to MI?

Answer 6

Troponin can be raised in

• Chronic renal failure
• Sepsis
• Myocarditis
• Aortic dissection
• Pulmonary embolism

Question 7

What will be the initial treatment for STEMI?

Answer 7

1. Aspirin 300mg PO
2. Reperfusion therapy (PCI or Fibrinolysis)
   
   • Fibrinolysis if PCI x be offered in 120mins
   • PCI if can be offered in 120mins and pt presenting in 12hr of sx
   • Drugs for PCI
     
     • Prasugrel (if pt not on anticoag)
     • Clopidogrel (if pt on anticoag)
3. If reperfusion unable, then medication therapy
   
   • Ticagrelor or
   • Prasugrel (if pt high bleeding risk)
4. Secondary prevention

Question 8

When should you offer primary PCI?

Answer 8

• pt presenting c 12 hr of sx onset c STEMI or
• can be trasnferred to PCI centre within 120mins of first medical contact

Question 9

When to offer thrombolysis?

Answer 9

• If PCI cannot be offered in 120minutes

Question 10

Thrombolysis involves using fibrinolytic agents. What are the examples

Answer 10

• streptokinase
• alteplase
• tenecteplase

Question 12

What are the Cx for MI?

*use mnemonic DREAD

+ other anatiomical cx

Answer 12

Dressler’s syndrome

• present after weeks of first episode
• raise dinflammatory markers

Cardiac arrest (most common)

• leads to death

Cardiogenic shock

• large part of the ventricular myocardium is damaged > EF of heart decrease

Chronic HF

Tachyarrythmias

• VF

Bradyarrythmias

• AV block due to inferior MI

Pericarditis

• First 48hrs after STEMI (common)

Papillary muscle rupture

• present hours to days after first ep
• new murmur of mitral regurgitation

Ventricular aneurysm

Pericardial tamponade

• raised JVP
• muffled heart sounds

Question 14

What are the secondary pharmacological preventions for MI?

*mnemonic 6As

Answer 14

• Aspirin 75mg once daily
• Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months
• Atorvastatin 80mg once daily
• ACE inhibitors (e.g. ramipril titrated as tolerated to 10mg once daily)
• Atenolol (or other beta blocker titrated as high as tolerated)
• Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)

Question 15

What secondary prevention lifestyle advise can you give to a patient after MI?

Answer 15

• Stop smoking
• Reduce alcohol consumption
• Mediterranean diet
• Cardiac rehabilitation (a specific exercise regime for patients post MI)
• Optimise treatment of other medical conditions (e.g. diabetes and hypertension)

Question 16

What is Dressler’s syndrome?

Answer 16

• autoimmune response mounted by the body after injury to myocardium or pericardium
• occurs between 2 -3 weeks after the initial injury, but can also present a few months later

Question 17

What is the blood test monitoring like for pt on statins?

Answer 17

• LFTs at baseline, 3months and 12 months