Acute Coronary Syndrome

Question 1

What is acute coronary syndrome?

Answer 1

Where a thrombus grows on top of an atherosclerotic plaque leading to vessel occlusion

Question 2

What are the symptoms?

Answer 2

Central crushing chest pain
Radiating to left arm/neck/jaw
Tachypnoea
Palpitations
Sweating
Feeling of impending doom

Question 3

What are the signs?

Answer 3

Tachycardia
Tachypnoea
HTN
Can be bradycardic and vomiting
Wide pulse pressure
Raised JVP
Bibasal crepitations
Mild pyrexia

Question 4

What investigations should be done?

Answer 4

BP
ECG
Bloods
-troponin= raised
-LFTs= pre statin
-FBC
-U&Es= pre ACEI
-TFTs
-HbA1c
-Coag

CXR
-cardiomegaly or pulmonary oedema

ECHO
-look for abnormalities

CT coronary angiogram
-look for occlusion

Question 5

What ECG changes are seen in an STEMI?

Answer 5

ST elevation or new LBBB

Question 6

What ST changes are seen in a STEMI?

Answer 6

Anterior MI

• ST elevation in leads V1-4
• affects left anterior descending artery

Lateral MI

• ST elevation in leads I, aVL, V5/6
• affects left circumflex artery

Inferior MI

• ST elevation in leads II, III, avF
• affects right coronary artery

Anterolateral STEMI= affects left coronary artery

If ST depression consider posterior STEMI

Question 7

What ECG changes are seen in an NSTEMI?

Answer 7

ST segment depression
T wave inversion
Pathological Q waves (late sign)

Question 8

What is the initial management of a STEMI?

Answer 8

Aspirin 300mg
Then give morphine/nitrates/oxygen as appropriate

If patient presents within 12hrs symptom onset and PCI can be done within 120mins then PCI is indicated

If PCI >120mins away then thrombolysis with altepase indicated

If >12hrs but still signs of ischaemia then PCR indicated

Question 9

What is the initial management of nSTEMI?

Answer 9

Aspirin 300mg
Then give morphine/nitrates/oxygen as appropriate
Need to trop them
Give fondaparinux if no immediate PCI planned

Do risk score
<3% then commence ticagrelor
>3% then PCI immediately if unstable or within 72hrs if stable

Question 10

What is the long term management of ACS?

Answer 10

Aspirin 75mg od
Another platelet e.g. clopidogrel for 12months
Atorvastatin 80mg od
ACEi (titrate up to 10mg)
Atenolol or another beta blocker (titrate dose up)
Aldosterone antagonist if HF present

Question 11

What are complications of ACS?

Answer 11

Death
Rupture of heart septum/papillary muscles
-leads to right to left shunt
oEdema- pulmonary
Aneurysm or Arrhythmia
Dressler syndrome
-pericarditis with chest pain worse on exertion and lying down