Acute coronary syndrome

Question 1

Differentiating between ACS spectrum of conditions

Answer 1

If there is ST elevation or new LBBB = STEMI

If no ST elevation look at the troponin:

• Raised troponin or other ECG changes = NSTEMI
• No ischaemic ECG changes and troponin normal - Unstable angina or other cause of chest pain

Question 2

Symptoms to ask about in suspected ACS

Answer 2

Nausea and vomiting

Sweating and clamminess

Feeling of impending doom

SOB

Palpitations

Pain radiating to jaw/arms

Question 3

NSTEMI possible ECG changes

Answer 3

ST segment depression in a region

Deep T Wave Inversion

Pathological Q Waves (suggesting a deep infarct – a late sign)

Question 4

I, aVL, V3-6 ECG changes

Answer 4

LCA territory

Question 5

V1-4 ECG changes

Answer 5

LAD territory infarct - Anterior MI

Question 6

I, aVL, V5-6 ECG changes

Answer 6

Circumflex territory infarct - Lateral MI

Question 7

II, III, aVF ECG changes

Answer 7

RCA territory infarct - inferior MI

Question 8

What ECG changes may be seen in a posterior infarct?

Answer 8

ST depression in the anteroseptal leads (V1-3)

Most commonly you see combination of inferior ST elevation with “posterior extension” - ST depression in V1-3

Question 9

What can caused raised troponin?

Answer 9

ACS
CKD
Sepsis
Myocarditis
Aortic dissection
PE

It rises in myocardial ischaemia but is non specific for ACS

Question 10

Investigations in suspected ACS

Answer 10

ECG

BLOODS:
FBC (check for anaemia)
U&Es (prior to ACEi and other meds)
LFTs (prior to statins)
Lipid profile
Thyroid function tests (check for hypo / hyper thyroid)
HbA1C and fasting glucose (for diabetes)

CXR
Echo
CT coronary angiogram

Question 11

Acute STEMI management

Answer 11

Primary PCI with stent

Thrombolysis if PCI not available within 2h of presentation

Aspirin 300mg
Clopidogrel 300mg 
Morphine
GTN spray or infusion
Oxygen if required
Anti-emetic if required

Question 12

Acute NSTEMI treatment

Answer 12

BATMAN mnemonic

Beta-blockers
Aspirin 300mg
Ticagrelor 180mg stat dose (or clopidogrel 300mg)
Morphine
Anticoagulant - fondaparinux
Nitrates

Oxygen only if O2 sats low

May need PCI if medium or high risk

Question 13

How can you risk stratify NSTEMI patients?

Answer 13

GRACE score - 6m risk of death or repeat MI

<5% low risk
5-10% medium
>10% high

If medium or high risk, considered for an early PCI

Question 14

Complications of MI

Answer 14

Death

Rupture of heart septum or papillary muscles

Heart failure

Arrythmia

Aneurysm

Dressler’s syndrome

Question 15

What is Dressler’s syndrome?

Answer 15

It is caused by a localised immune response and causes pericarditis

Causes pleuritic chest pain, low fever, pericardial rub on auscultation

Can cause pericardial effusion and rarely tamponade

Question 16

How is Dressler’s syndrome managed?

Answer 16

NSAIDs

In more severe cases steroids (prednisolone)

May need pericardiocentesis to remove fluid from around the heart.

Question 17

Long term secondary prevention following MI

Answer 17

6As

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 18

Conservative long term management of MI

Answer 18

Stop smoking

Reduce alcohol

Optimise treatment of comorbidities