ACS - cardio booklet

Question 1

When do TnI levels rise in MI?

Answer 1

Begin to rise 3-4hrs post myocardial damage
Stay elevated for up to 2 weeks

Question 2

What else (blood wise) should be measured in STEMI pts?

Answer 2

CK

Question 3

Levels for male and female suggesting MI

Answer 3

Male - greater than 34 ng/L
Female - greater than 16ng/L

Question 4

What does rising and falling cardiac troponin mean?

Answer 4

• Could mean chronic cardiomyocyte damage
• But if higher chnage - rise of more than 5ng/L could suggest ACS

Question 5

When to test hs-TnI?

Answer 5

• On admission
• 1hr after admission
• If symptoms onset was 3 hours or more ago then only 1 level is needed

Question 6

What can cause false positive troponin elevation?

Answer 6

• Advanced renal failure
• Large PE
• Severe congestive cardiac failure
• Myositis
• Prolonged tachyarrythmias
• Aortic dissection, stenosis
• Hypertrophic cardiomyopathy
• Malignancy
• Stroke
• Severe sepsis

Question 7

What should all patients have routinely done if suspect STEMI?

Answer 7

Posterior and right ventricular leads recorded on or soon after admission
Esp those with inferior STEMI
Diagnostic changes may be transient
ST elevation in RV4 = highly sensitive for RV infarction

Question 8

Conditions which can mimic STEMI on ECG

Answer 8

• Early repolarisation = upsloping of ST segment (esp V1, V2 and sometimes V3) present in younger, athletic patients, sometimes African Caribbean patients
• Pericarditis - concave ST elevation, widespread
• Brugada syndrome
• Takotsubo cardiomyopathy

Question 9

Difference between STEMI and NSTEMI

Answer 9

NSTEMI - partial occlusion so not full thickness ischaemia
STEMI - full occlusion, full thickness

Question 10

Management STEMI

Answer 10

• IV access
• Pain relief - morphine and antiemetic
• Oxygenation if hypoxic (aim above 94%)
• Aspirin 300mg (then 75mg OD for life)
• Prasugrel if PCI

Question 11

Who can have Prasugrel?

Answer 11

• If having PCI
• Under age 75
• Weigh more than 60kg
• Not had prior TIA or stroke

Question 12

When is Clopidogrel/Ticagrelor used instead of Prasugrel?

Answer 12

• Clopidogrel 600mg loading dose if not fulfil criteria for Prasugrel
• Ticagrelor first choice in NSTEMI or if cant have prasugrel

Question 13

What should all patients with STEMI have on admission?

Answer 13

• Full biochemical screen
• Lipid profile
• Random glucose
• HbA1C
• FBC

Question 14

Medications post STEMI

Answer 14

• Bisprolol
• ACEi/ARB
• Statin
• Control diabetes, hypertension, smoking cessation

Question 15

What happens if someone with AF has MI?

Answer 15

May then be on 3 anticoagulants
Limit time on these 3 drugs and give PPI

Question 16

Complication post STEMI treatment

Answer 16

• Heart failure - diuretics
• Shock - inotropes, intra-aortic balloon pump
• Valve damage/septal defect –> surgery?

Question 17

Management NSTEMI

Answer 17

• Pain relief - Morphine and anti-emetic
• Aspirin 300mg loading dose
• LMWH - Enoxaparin for 48hrs based on weight and Crt
• Repeat ECG
• GRACE score risk assessment
• Ticagrelor if risk more than 3% 180mg loading and 90mg BD
• Inpatient angiogram

Question 18

What to consider while patient waiting for inpatient angio post NSTEMI?

Answer 18

• Nitrates
• Ranolazine
• CCBs

Question 19

Management stable angina

Answer 19

• Aspirin 75mg OD (if intolerant, Clopidogrel 75mg)
• Sublingual GTN spray
• Beta blockers or CCB alone - symptom control
• or then both if not responsive - BB + CCB (amlodipine)

or if still not responsive add:
* Long acting nitrates (isosorbide mononitrate)
* K+ channel opening drugs (Nicorandil)
* ranolazine
* ivabradine (dont use with verapamil or diltiazem)

Question 20

Non-cardiac chest pain

Answer 20

• Costochondritis
• GORD
• PE
• Pneumonia
• Pneumothorax
• Psychogenic/psychosomatic