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Finals: Medicine > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

1
Q

Acute coronary syndrome (ACS) is an umbrella term for which three conditions?

A
  • Unstable angina (UA)
  • Non-ST elevation myocardial infarction (NSTEMI)
  • ST elevation myocardial infarction (STEMI)
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2
Q

What does angina refer to?

A

Chest pain

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3
Q

What is the difference between stable and unstable angina

A

Stable angina - is chest pain on exertion as the demands of oxygen by the heart increases. Pain goes away at rest.

Unstable angina - is chest pain even at rest.

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4
Q

What is the key characteristic of acute coronary syndrome?

A

ACS is characteristed by the occlusion or reduction in blood supply through a coronary artery to myocardial tissue

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5
Q

How occluded are the coronary arteries for ST elevation myocardial infaraction (STEMI) to occur?

A

Total occlusion of a coronary artery

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6
Q

What occludes the coronary arteries in ST elevation myocardial infaraction (STEMI)?

A

A thrombus

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7
Q

What has to happen for a thrombus to form?

A

Thrombus is formed when an atherosclerotic plaque rupture

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8
Q

What is the difference between Ischaemia and Infarction?

A

Ischaemia: refers to the reduction/lack of blood flow to the tissue, which can cause angina type symptoms

Infarction: refers to the cellular changes that can occur as a result of reduced/no perfusion to the tissue.

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9
Q

Define Bundle branch block

A

Bundle branch block is when electrical impulses travel through the ventricles is slower than is normal because of a block in the coronary arteries.

This causes slower depolarisation of the ventricles.

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10
Q

When a thrombus totally occludes the coronary artery which is the features that may be evident on an ECG?

A

ST elevation

OR

New left bundle branch block (LBBB)

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11
Q

What are the two key features that are indicative of ST elevation myocardial infarction (STEMI)?

A

ST elevation on ECG or new LBBB

AND

Rise in troponin levels

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12
Q

When does troponin rise?

A

Troponin is an indicator of cardiac tissue damage.

Rises when there is ischaemic present

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13
Q

When a thrombus forms in a fast flowing artery it is made up mostly of what?

A

Platelets.

Hence anti-platelet medications such as aspirin, clopidogrel and ticagrelor are the mainstay of treatment.

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14
Q

How occluded are the coronary arteries for non ST elevation myocardial infaraction (NSTEMI) to occur?

A

Occurs when there is partial occlusion of a coronary artery causing ischaemia and infarction

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15
Q

What are the ECG changes associated with heart tissue ischaemia?

A

T waves and/or ST changes

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16
Q

What are the modifiable risk factors associated with the developing of atherosclerosis?

A
  • ​High cholesterol
  • Hypertension
  • Smoking
  • Diabetes
  • Obesity
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17
Q

What are the non-modifiable risk factors associated with the developing of atherosclerosis?

A
  • Age
  • Family history
  • Male sex
  • Premature menopause
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18
Q

Fill in the blanks

A
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19
Q

What are the clinical features of acute coronary syndrome

A

Symptoms

  • Chest pain > 15 minutes: central crushing or pressing pain +/- radiation to neck and/or left arm
  • Shortness of breath
  • Sweating
  • Nausea and vomiting
  • Palpitations

Signs

  • Pale
  • Clammy
  • Tachycardia
  • Cardiac failure (e.g. pulmonary oedema, hypotension)
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20
Q

Define a silent MI?

A

This is the presence of an MI without any signs or symptoms

This typically occurs in elderly patients or those with significant co-morbidities e.g. diabetes mellitus

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21
Q

What are the ECG changes associated with ST elevation myocardial infarction (STEMI)?

A

ST segment elevation in leads consistent with an area of ischaemia

ANR / OR

New Left Bundle Branch Block

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22
Q

What are the ECG changes associated with non-ST elevation myocardial infarction (NSTEMI)?

A

ST segment depression in a region

Deep T Wave inversion

Pathological Q Waves

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23
Q

Name the inferior leads of an ECG?

A

Leads II, III and aVF

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24
Q

What leads are associated with the Anterolateral area of the heart?

A

Leads:

I

aVL

V3-6

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25
Q

What leads are associated with the anterior aspect of the heart?

A

Leads V1-4

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26
Q

What leads are associated with the lateral aspect of the heart?

A

Leads I, aVL, V5-6

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27
Q

What leads are associated with the inferior aspect of the heart?

A

II, III, aVF

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28
Q

Leads II, III and avF is associated with which kind of MI?

A

Inferior MI

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29
Q

Leads V1-4 is associated with which kind of MI?

A

Anteroseptal MI

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30
Q

Leads I, avL and V5-6 are assoicated with which kind of MI?

A

Lateral MI

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31
Q

Which artery is usually affected in an inferior MI

A

Typically the right coronary artery that is affected.

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32
Q

Which leads are associated with a Posterior MI

A

No ST elevation on routine ECG

However may be seen as ST depression

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33
Q

Which artery is usually affected in an Anteroseptal MI

A

Left anterior descending artery

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34
Q

Which artery is usually affected in an Lateral MI

A

The left circumflex artery

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35
Q

For Inferior MI which:

a) Artery is affected?
b) Which leads will have the ECG changes present?

A

a) Right coronary artery
b) Leads II, III and avF

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36
Q

For Anteroseptal MI which:

a) Artery is affected?
b) Which leads will have the ECG changes present?

A

a) Left anterior descending artery (LAD)
b) V1- V4

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37
Q

For Lateral MI which:

a) Artery is affected?
b) Which leads will have the ECG changes present?

A

a) Left circumflex artery
b) Leads I, avL, V5 and V6)

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38
Q

Which artery supplies the inferior wall of the heart?

A

Right coronary artery

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39
Q

Which artery supplies the anterior wall and septum?

A

Left anterior descending artery

40
Q

Which artery supplies the lateral wall of the left ventricle, posterior surface and sometimes the inferior wall?

A

Left circumflex artery

41
Q

Which ECG change is a sign of previous myocardial infarction?

A

Pathologic Q waves

42
Q

Define reciprocal changes on an ECG?

A

Reciprocal changes refers to ST depression in the leads opposite those with ST elevation

43
Q

What is the name given to this kind of change seen on an ECG?

A

ST elevation

44
Q

What is the name given to this kind of change seen on an ECG?

A

ST depression

45
Q

What is the name given to this kind of change seen on an ECG?

A

T wave inversion

46
Q

Complete heart block i.e. 3rd degree heart block, may occur as a complication following an acute myocardial infarction

Which MI are the most at risk of causing complete heart block?

A

Inferior MI

47
Q

Why is the inferior MI the most likely to cause a complete heart block

A

This is because the right coronary artery, the artery causing inferior MI, supplies the tissue that surrounds the AV node system.

The infarction of the tissue surrounding the AV node causes the AV node to no longer works

The result is firing lower down in the conduction system, which is independent from SA node i.e. complete disassociation between the P waves (atria depolarisation) and QRS complex (ventricular depolarisation)

48
Q

What are the ECG features of a complete heart block

A

No observable relationship between P waves and QRS complexe

P waves are normal because the atria are conducting normally

QRS rate is slow

49
Q

Name the three mainstay investigations for ACS

A

Clinical features

ECG

Serum troponin

50
Q

What are Troponins

A

They are proteins found in cardiac muscle.

51
Q

Why is a rise in troponin is consistent with myocardial ischaemia

A

A rise in troponin is consistent with myocardial ischaemia as the proteins are released from the ischaemic muscle.

52
Q

Troponins are non-specific. What does this mean?

A

It means that although a raised troponin is suggestive for ACS it is not specific for it and is raised for other reasons too e.g. stress

53
Q

In unstable angina, there is no detectable rise in troponi. How is the diagnosis made?

A

The diagnosis is made on the basis of the clinical history and ECG changes.

54
Q

Name other conditions in which troponin is raised (other than MI)?

A

Congestive heart failure

Pulmonary embolism

Sepsis

55
Q

Describe how coronary angiogram works?

A

X-ray image using contrast dye. A catheter is inserted into the aorta via the femoral artery. The contrast dye is injected into the coronary arteries and x-ray-based imaging is then used to visualise the coronary arteries showing any blockage that may be present.

56
Q

What is the immediate management of suspected ACS

A

Mnemonic MONA

M: Morphine - administeredwith an anti-emetic to relieve chest pain

O: Oxygen - should be reserved if saturations <94% or if <88% in patients at risk of hypercapnic respiratory failure (target in these patients is 88-92%). Limited benefit in patients with preserved oxygen saturations (94% or greater), and may indeed be harmful

N: Nitrates - Sublingual GTN

A: Aspirin - loading dose i.e. 300mg

57
Q

Patients diagnosed with STEMI should be referred for emergency coronary angiography +/- primary percutaneous coronary intervention (PCI) if they present with how many hours from:

a) onset of chest pain?
b) diagnosis of STEMI?

A

a) Within 12 hours of onset of chest pain
b) Within 2 hours of diagnosis of STEMI

58
Q

What is involved in coronary angiography?

A

Coronary angiography involves insertion of a catheter via the femoral artery or radial artery.

From here, the catheter can be passed to the coronary artery vessels with x-rays for guidance and contrast injected.

The injection of contrast allows visualisation of the coronary anatomy.

During the procedure a balloon catheter can be inserted to open up a blockage.

A stent can be then be inserted into the blocked artery.

59
Q

If PCI is unable to be performed what should be considered instead?

A

Fibrinolysis with fibrinolytic agents e.g. alteplase while arranging transfer to a PCI centre.

Coronary angiography +/- PCI should be performed in the following 2-24 hours after fibrinolysis

60
Q

Describe the Dual anti-platelet therapy (DAPT) in the management of STEMI?

A

Combination of aspirin and a second anti-platelet agent

Should be initiated prior to PCI

Usually ticagrelor however clopidogrel could be used particularly if there is a high bleeding risk

61
Q

How long should dual anti-platelet therapy continue after coronary angiogram +/- PCI?

A

Minimum 12 months after

62
Q

Whe nis antithrombotic agents usually given in the management of STEMI?

A

Usually given at the time of PCI.

63
Q

When would Glycoprotein IIb/IIIa inhibitors be useful in the mangement of STEMI?

A

Can be given at the time of PCI if there is high thrombus burden

64
Q

Give an example of a Glycoprotein IIb/IIIa inhibitors

A

Tirofibanmay

65
Q

Give an example of a Antithrombotic agents

A

Unfractionated heparin

Low molecular weight heparin (LWMH)

66
Q

Fill in the blanks of the initial management of acute coronary syndrome

67
Q

Fill in the blanks of the definitive management of STEMI

68
Q

Which scoring system is used to estimate the six-month mortality risk in patients with NSTEMI / UA

A

GRACE Score

69
Q

GRACE Score categories patients in various groups. Name these groups and what is the management of each?

A

Low risk: discharge on medical treatment

Intermediate risk: PCI within 96 hours

High risk: PCI within 2 hours

70
Q

What are the two principle pharmacological agents to treat NSTEMI / unstable angina?

A

Additional antiplatelet agent e.g. clopidogrel, ticargrelor

Antithrombotic agent e.g. fondaparinux, unfractionated heparin

71
Q

Following an MI, several medications should be initiated to help in the secondary prevention of major cardiovascular events.

Name these agents?

A

The 6As:

1) Aspirin 75mg once daily

2) Another antiplatelet: e.g. clopidogrel or ticagrelor for up to 12 months

3) Atorvastatin or another high dose statin

4) ACE inhibitors or Angiotensin receptor blocker can be an alternative if side-effects or intolerant to ACE inhibitor

5) Atenolol or other beta blocker

6) Aldosterone antagonist i.e. mineralocorticoid antagonist, for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)

72
Q

Following an MI, mineralocorticoid antagonist could be considered for which kind of patients?

A

Patients with LV dysfunction i.e. heart failure

73
Q

Atorvastatin is an example of which kind of drug class?

74
Q

Why is it important to continue dual anti-platelet therapy for 12 months folloiwng a coronary stent at PCI?

A

Prevents stent thrombosis

75
Q

What is the acute NSTEMI management?

A

Mnemonic BATMAN:

B – Beta-blockers unless contraindicated

A – Aspirin 300mg stat dose

T – Ticagrelor 180mg stat dose (clopidogrel 300mg is an alternative if higher bleeding risk)

M – Morphine titrated to control pain

A – Anticoagulant: Fondaparinux (unless high bleeding risk)

N – Nitrates (e.g. GTN) to relieve coronary artery spasm

Give oxygen only if their oxygen saturations are dropping (i.e. <95%).

76
Q

Name the complications of MI?

A

Mnemonic DREAD:

D – Death

R – Rupture of the heart septum or papillary muscles

E – “oEdema” (Heart Failure)

A – Arrhythmia and Aneurysm

D – Dressler’s Syndrome

77
Q

Describe Dressler’s Syndrome

A

Also known as post-myocardial infarction syndrome

Usually occurs around 2-3 weeks after an MI

Caused by a localised immune response and causes pericarditis (inflammation of the pericardium around the heart)

78
Q

What are the clinical features of Dressler’s Syndrome

A

Presents with:

  • Pleuritic chest pain
  • Low grade fever
  • Pericardial rub on auscultation.

It can cause a pericardial effusion and rarely a pericardial tamponade

79
Q

How is Dressler’s Syndrome diagnosed?

A

A diagnosis can be made with an:

  1. ECG (global ST elevation and T wave inversion)
  2. Echocardiogram (pericardial effusion)
  3. Raised inflammatory markers (CRP and ESR)
80
Q

What is the management of Dressler’s Syndrome?

A

NSAIDs (aspirin / ibuprofen)

In more severe cases steroids e.g. prednisolone

They may need pericardiocentesis to remove fluid from around the heart.

81
Q

Name some of the secondary prevention lifestyle modifications a patient can make following acute coronary syndrome?

A

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)

82
Q

Right Coronary Artery (RCA) supplies which parts of the heart?

A

Right atrium

Right ventricle

Inferior aspect of left ventricle

Posterior septal area

83
Q

Circumflex Artery supplies which parts of the heart?

A

Left atrium

Posterior aspect of left ventricle

84
Q

Left Anterior Descending (LAD) supplies which part of the heart

A

Anterior aspect of left ventricle

Anterior aspect of septum

85
Q

What is the Acute NSTEMI treatment

A

BATMAN

B – Beta blockers unless contraindicated

A – Aspirin 300mg stat dose

T – Ticagrelor 180mg stat dose

M – Morphine titrated to control pain

A – Anticoagulant: Low Molecular Weight Heparin (LMWH) at treatment dose (e.g. enoxaparin 1mg/kg twice daily for 2-8 days)

N – Nitrates (e.g. GTN) to relieve coronary artery spasm

86
Q

When does troponin start to rise in ACS (STEMI and NSTEMI)

A

Levels start to elevate within 2-3 hours after the onset of chest pain

87
Q

Which type of STEMI is associated with ECG changes in V1-V4

A

Anteroseptal MI

88
Q

Which type of STEMI is associated with ECG changes in II, III, aVF

A

Inferior MI

89
Q

Which type of STEMI is associated with ECG changes in V4-6, I, aVL

A

Anterolateral MI

90
Q

Which type of STEMI is associated with ECG changes in I, aVL, V5-6

A

Lateral MI

91
Q

For anteroseptal MI, name the:

i) ECG changes
ii) Coronary artery commonly affect

A

i) V1-V4
ii) Left anterior descending

92
Q

For inferior MI, name the:

i) ECG changes
ii) Coronary artery commonly affect

A

i) II, III, avF
ii) Right coronary

93
Q

For anterolateral MI, name the:

i) ECG changes
ii) Coronary artery commonly affect

A

i) V4-6, I, aVL
ii) Left anterior descending or left circumflex

94
Q

For lateral MI, name the:

i) ECG changes
ii) Coronary artery commonly affect

A

i) I, aVL +/- V5-6
ii) Left circumflex

95
Q

For posterior MI, name the:

i) ECG changes
ii) Coronary artery commonly affect

A

i) Reciprocal changes in anterior leads (V1-4)
ii) Usually left circumflex but also can be right coronary artery

Finals: Medicine (91 decks)

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