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Cardiovascular Medicine > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

1
Q

… are the gold-standard test for the investigation for myocardial necrosis. They are now the only recognised biomarker that should be used in the diagnostic work-up of ACS. They begin to rise hours after the event.

A

Troponins (T or I) are the gold-standard test for the investigation for myocardial necrosis. They are now the only recognised biomarker that should be used in the diagnostic work-up of ACS. They begin to rise hours after the event.

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2
Q

Traditionally, troponin was measured 6-12 hours following a suspected myocardial infarction. However, with the use of newer ‘high-sensitivity’ troponin assays, results can be achieved within .. hours of patient presentation to emergency services. Troponin has an important role in ruling out ACS in patients with possible NSTEMI/UA. The negative predictive value for exclusion of acute MI with troponin is >95%, which increases to almost 100% with a second troponin at 3 hours. Hospitals will have local guidelines on the use of troponin as part of a diagnostic algorithm to rule in or rule out ACS.

A

Traditionally, troponin was measured 6-12 hours following a suspected myocardial infarction. However, with the use of newer ‘high-sensitivity’ troponin assays, results can be achieved within 4 hours of patient presentation to emergency services. Troponin has an important role in ruling out ACS in patients with possible NSTEMI/UA. The negative predictive value for exclusion of acute MI with troponin is >95%, which increases to almost 100% with a second troponin at 3 hours. Hospitals will have local guidelines on the use of troponin as part of a diagnostic algorithm to rule in or rule out ACS.

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3
Q

Cardiac enzymes (e.g. troponin) are biomarkers of myocardial …

A

Cardiac enzymes (e.g. troponin) are biomarkers of myocardial necrosis.

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4
Q

This gentleman is suffering from an ST-elevation myocardial infarction (STEMI). The ST-elevation in leads II, III and aVF is suggestive of an … MI.

A

This gentleman is suffering from an ST-elevation myocardial infarction (STEMI). The ST-elevation in leads II, III and aVF is suggestive of an inferior MI.

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5
Q

The right coronary artery (RCA) usually supplies the territory affected in an … MI (80% of cases). The RCA gives rise to the posterior descending artery (PDA) that runs within the posterior interventricular groove. The RCA supplies blood to both ventricles, the right atrium and the atrioventricular node. Therefore, patients with RCA occlusion are at risk of complete heart block.

A

The right coronary artery (RCA) usually supplies the territory affected in an inferior MI (80% of cases). The RCA gives rise to the posterior descending artery (PDA) that runs within the posterior interventricular groove. The RCA supplies blood to both ventricles, the right atrium and the atrioventricular node. Therefore, patients with RCA occlusion are at risk of complete heart block.

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6
Q

Occlusion of the left circumflex (LCx) artery is responsible for the remaining …% of inferior MIs.

A

Occlusion of the left circumflex (LCx) artery is responsible for the remaining 20% of inferior MIs.

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7
Q

Left main stem occlusion causes widespread ST depression and ST elevation in …

A

Left main stem occlusion causes widespread ST depression and ST elevation in aVR.

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8
Q

Left anterior descending (LAD) occlusion causes anterior ST elevation in …

A

Left anterior descending (LAD) occlusion causes anterior ST elevation in V1-V4.

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9
Q

Circumflex artery (Cx) occlusion most commonly causes lateral ST elevation in aVL and …. In 20% of cases, it causes inferior changes (discussed above).

A

Circumflex artery (Cx) occlusion most commonly causes lateral ST elevation in aVL and V6. In 20% of cases, it causes inferior changes (discussed above).

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10
Q

Which of the following is not a potential complication of an acute myocardial infarction?

A    Pericarditis 
B	Mitral regurgitation
C	Complete heart block
D    Mitral stenosis
E	Ventricular tachycardia
A

All of the above are complications of an acute myocardial infarction (MI), except mitral stenosis.

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11
Q

Which of the following medications works by relaxing vascular smooth muscle that leads to increased coronary blood flow?

A    Glyceryl trinitrate
B	Ivabradine
C	Amlodipine
D	Ranolazine
E	Bisoprolol
A

A

Nitrates (e.g. Glyceryl trinitrate) work by causing vascular smooth muscle relaxation, which improves coronary blood flow.

A short-acting nitrate should be given to patients to relieve episodes of angina. Major side-effects include headache and dizziness due to low blood pressure. Patients should be advised to spray 1 to 2 doses under the tongue for an attack of angina. If pain has not subsided in 5 minutes they should repeat the dose. If the pain is ongoing after 10 minutes they should call for an ambulance.

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12
Q

The management of patients with NSTEMI or UA can be remembered using the mnemonic ‘BATMAN’:

A

B - Beta-blockers (unless contraindicated)
A - Aspirin (300 mg loading, then 75 mg once daily)
T - Ticagrelor (180 mg loading, then 90 mg twice daily), alternatively clopidogrel if high bleeding risk
M - Morphine (titrate for analgesia)
A - Antithrombotic agent (Fondaparinux 2.5 mg subcutaneous unless contraindicated)
N - Nitrates (sublingual nitrates to relieve pain - consider infusion if ongoing pain)

If there is ongoing chest pain despite nitrates and morphine, they need discussion with cardiology regarding urgent revascularisation.

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13
Q

The … score is a risk stratification tool used to group patients with NSTEMI/UA into high, intermediate, low or lowest risk to help determine the need for further intervention (e.g. PCI). It should not guide initial prescribing.

A

The GRACE score is a risk stratification tool used to group patients with NSTEMI/UA into high, intermediate, low or lowest risk to help determine the need for further intervention (e.g. PCI). It should not guide initial prescribing.

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14
Q

Which of the following is not a recognised adverse-effect of amiodarone?

A
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15
Q

The presentation of acute chest pain in a patient with cardiovascular risk factors should always raise the concern for acute coronary syndrome (ACS). ACS is an umbrella term for STEMI, NSTEMI, and unstable angina (UA). ACS is typically due to rupture of an atheromatous plaque that develops due to coronary artery disease. This occludes the coronary artery leading to ischaemia that causes characteristic features of chest pain, ECG changes, and troponin rise.

We can use the combination of these findings to differentiate the three conditions:

A

STEMI: total occlusion, ST segment elevation on ECG, troponin rise
NSTEMI: incomplete occlusion, other ischaemic changes (or none) on ECG, troponin rise
UA: incomplete occlusion, other ischaemic changes (or none) on ECG, troponin normal

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16
Q

UA is characterised by typical cardiac chest pain but an absent .. rise

A

C: UA is characterised by typical cardiac chest pain but an absent troponin rise

17
Q

Which of the following is not a potential complication of an acute myocardial infarction?

A	Pericarditis
B	Mitral regurgitation
C	Complete heart block
D    Mitral stenosis
E	Ventricular tachycardia
A

All of the above are complications of an acute myocardial infarction (MI), except mitral stenosis.

Mitral stenosis is usually a chronic condition occurring secondary to rheumatic heart disease. Mitral regurgitation may occur secondary to ischaemia and rupture of a papillary muscle. Pericarditis may occur acutely following an MI, or several weeks later as part of an autoimmune phenomenon termed Dressler’s syndrome. Post-MI patients are at high risk of tachyarrhythmias. If the right coronary artery is occluded then patients may develop complete heart block due to ischaemia of the atrioventricular node.

18
Q

A 64-year-old female is currently an inpatient awaiting a femoral-popliteal bypass graft. She has a past medical history of diabetes mellitus and hypertension. She is now complaining of central crushing chest pain, which came on after walking to the bathroom 3 minutes ago. The pain quickly improved with rest. You ask the nurse to perform observations and an ECG.

Observations are normal, the ECG is normal.

What is the single most appropriate treatment to help with this patient’s pain?

A	Dispersible aspirin 300 mg
B	Intravenous morphine 5 mg STAT
C	Oxygen 15 L/min non-rebreathe mask
D	Sublingual GTN spray
E	Subcutaneous fondaparinux 2.5 mg once only
A

This patient has probable underlying ischaemic heart disease and developed an episode of angina. The use of a short-acting nitrate to improve coronary blood flow is appropriate to help with the pain.

This lady has a number of cardiovascular risk factors and is currently awaiting a femoral-popliteal bypass for peripheral vascular disease. This makes the cause of her chest pain likely to be ischaemic heart disease (IHD). The fact that her symptoms developed on exertion, and the absence ECG changes with normal observations, makes the diagnosis of angina pectoris the most likely. Blood should still be taken for cardiac enzymes such as troponin to assess for any myocardial damage.

19
Q

You are asked to see a 76-year-old patient on the acute medical unit who is complaining of central chest tightness. He was admitted with community-acquired pneumonia and has a background of hypertension and diabetes mellitus. An ECG shows new T wave inversion in the anterior leads (V1-V5).

The patient’s initial troponin I at the onset of chest tightness was 16 (< 14 ug/L) and repeat troponin I at 3 hours was raised at 219 (< 14 ug/L).

Which of the following is the most likely diagnosis?

A Angina pectoris
B Unstable angina
C ST-elevation myocardial infarction (STEMI)
D Non-ST-elevation myocardial infarction (NSTEMI)
E Pleural effusion

A

The presence of new T-wave inversion on the ECG and a troponin rise confirms the diagnosis of non-ST-elevation myocardial infarction (NSTEMI).

20
Q

A 62-year-old is admitted to the acute medical unit with chest pain. There is evidence of ST depression in the inferior leads. They are given glyceryl trinitrate spray that helps to relieve the chest pain. Initial blood tests show a troponin of 345 (< 14 ug/L). PMH: nil. SH: smoker 10 cigarettes per day.

What is the most appropriate treatment?

A Discharge and review for outpatient echocardiogram
B Prescribe aspirin 300 mg, ticagrelor 180 mg and fondaparinux if no contraindications
C Immediate transfer to a coronary care unit
D Prescribe aspirin 75 mg, clopidogrel 75 mg and unfractionated heparin if no contraindications
E Complete the GRACE score and only prescribe anti-platelets if high risk

A

B

This patient has a non-ST-elevation myocardial infarction that requires urgent treatment with anti-platelets and antithrombotic agents.

The management of patients with NSTEMI or UA can be remembered using the mnemonic ‘BATMAN’:

B - Beta-blockers (unless contraindicated)
A - Aspirin (300 mg loading, then 75 mg once daily)
T - Ticagrelor (180 mg loading, then 90 mg twice daily), alternatively clopidogrel if high bleeding risk
M - Morphine (titrate for analgesia)
A - Antithrombotic agent (Fondaparinux 2.5 mg subcutaneous unless contraindicated)
N - Nitrates (sublingual nitrates to relieve pain - consider infusion if ongoing pain)

21
Q

The management of patients with NSTEMI or UA can be remembered using the mnemonic ‘BATMAN’:

A

B - Beta-blockers (unless contraindicated)
A - Aspirin (300 mg loading, then 75 mg once daily)
T - Ticagrelor (180 mg loading, then 90 mg twice daily), alternatively clopidogrel if high bleeding risk
M - Morphine (titrate for analgesia)
A - Antithrombotic agent (Fondaparinux 2.5 mg subcutaneous unless contraindicated)
N - Nitrates (sublingual nitrates to relieve pain - consider infusion if ongoing pain)

22
Q

GRACE socre

A

The GRACE score is a risk stratification tool used to group patients with NSTEMI/UA into high, intermediate, low or lowest risk to help determine the need for further intervention (e.g. PCI). It should not guide initial prescribing.

23
Q

Which of the following is correct regarding atherosclerosis?

A It occurs in the capillary beds
B Thinning of the tunica intima is the predominant feature
C It only affects the coronary vessels
D Raised HDL is associated with atherosclerosis
E Foam cells are lipid-laden macrophages

A

E

Atherosclerosis is the predominant pathophysiological process leading to ischaemic heart disease (IHD).

24
Q

Aspirin is commonly used in patients with, or at risk, of ischaemic heart disease. It works through irreversible inhibition of ….

A

Aspirin is commonly used in patients with, or at risk, of ischaemic heart disease. It works through irreversible inhibition of cyclooxygenase.

25
Q

INHIBITION of the adenosine diphosphate (ADP) receptor. …

A

Inhibition of the adenosine diphosphate (ADP) receptor. Clopidogrel

26
Q

Direct inhibition of thrombin. …

A

Direct inhibition of thrombin. Dabigatran

27
Q

Potentiates the action of anti-thrombin III to inhibit factor Xa. …

A

Potentiates the action of anti-thrombin III to inhibit factor Xa. Low molecular weight heparin.

28
Q

A 65-year-old man is bought in by ambulance with central crushing chest pain. There is evidence of ST elevation in the anterior leads of the ECG. He undergoes urgent coronary angiography that shows complete occlusion of the left anterior descending artery. He successfully undergoes percutaneous coronary intervention. He has multiple cardiac risk factors including being a current smoker, obese, hypertensive and diabetic.

Which of the following terms would best describe this presentation?

A	Myocardial infarction
B	Type 2 myocardial infarction
C	STEMI
D	Type 5 myocardial infarction
E	Unstable angina
A

C

This patient presented with acute coronary syndrome, which is an umbrella term for three condition: STEMI, NSTEMI and UA.

29
Q

A 54-year-old man presents to accident and emergency with acute chest pain. The team are concerned about acute coronary syndrome (ACS).

Which of the following blood tests is most commonly used to assess for cardiomyocyte necrosis?

A	Full blood count
B	Urea & electrolytes
C	Creatinine kinase
D	Myoglobin
E	Troponin I
A

Cardiac enzymes (e.g. troponin) are biomarkers of myocardial necrosis.

30
Q

A 58-year-old gentleman is transferred for percutaneous coronary intervention following an ST-elevation myocardial infarction (STEMI). He has a past medical history of hypertension, diabetes mellitus and hypercholesterolaemia. He is found to have ST-elevation in leads II, III, and aVF on a standard 12-lead ECG.

Which coronary vessel is most likely to be affected?

A	Left main stem
B	Left anterior descending (LAD)
C	Circumflex artery (Cx)
D	Right coronary artery (RCA)
E	Coronary sinus
A

D

Cardiovascular Medicine (28 decks)

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