Acute Coronary Syndrome

Question 1

When does ACS occur

Answer 1

When a thrombus blocks a Coronary artery

Question 2

What are the three types of ACS

Answer 2

Unstable Angina
NSTEMI
STEMI

Question 3

What is the difference between MI and Angina

Answer 3

MI is referred to the death of myocardium whereas angina is the underperfusion

Question 4

What are the non modifiable risk factors for ACS

Answer 4

Age
Male
Family history
South Asian

Question 5

What are the modifiable risk factors for ACS

Answer 5

Smoking
HTN
Hyperlipidaemia
Obesity
Diabetes
Sedentary Lifestyle

Question 6

What is the difference between STEMI and NSTEMI

Answer 6

STEMI= complete occlusion
NSTEMI = Severe occlusion

Question 7

When can NSTEMIs occur n a non occlusive setting

Answer 7

Severe sepsis
Hypotension
Hypovolemia
Coronary Artery Spasm

Question 8

What is the presentation of ACS

Answer 8

Central CRUSHING Chest pain
Radiates to neck jaw and arms
Present with N+V, sweating, SOB or syncope

Question 9

What are some non MI causes of Chest pain

Answer 9

C- Myocarditis/Pericarditis
C- Cardiomyopathy
C -Valvular disease
C- Aortic Dissection
P- PE
P- Pneumonia
P- Pneumothorax
R- Costochondritis
R- Herpes
G- Oesophageal spasm
G- Cholecystitis
G-Pancreatitis

Question 10

Describe Troponin levels in unstable angina, STEMI and NSTEMI

Answer 10

Unstable= normal troponin
NSTEMI= Raised troponin
STEMI= Raised troponin

Question 11

Describe the ECG Changes for Unstable, STEMI and NSTEMI

Answer 11

UNSTABLE =NORMAL/ST DEPRESSION
NSTEMI = NORMAL/ST DEPRESSION
STEMI = ST ELEVATION/LBBB

Question 12

How would you diagnose a STEMI

Answer 12

ST elevation
->2mm in chest lead
->1mm in limb leads
LBBB with chest pain

Question 13

How would you diagnose NSTEMI

Answer 13

Raised troponin
Chest pain
Abnormal ECG

Question 14

What is the initial investigation of ACS

Answer 14

ECG

STEMI= urgent referral

Question 15

After ECG what should you investigate

Answer 15

Bloods
Troponin (3hrs after pain starts)
FBC and CRP (Infection?)
D-Dimer (PE?)
Chest X ray (pulmonary oedema?)

Question 16

An RCA STEMI would be present on what leads and myocardium area

Answer 16

II, III and aVF

Inferior myocardium

Question 17

A LAD STEMI would be found on what leads and area

Answer 17

V1-V6
(V1-V2 = Poximal LAD at septal)
(V3-V4 = LAD at Anterior)
V5-V6 =Distal LAD at Apex)

Question 18

An LCx STEMI would be found on what leads and area

Answer 18

I, aVL

Lateral Myocardium

Question 19

An RCA/LCx STEMI would be found on what leads and area

Answer 19

V7-V9 with ST depression at V1-V3

Posterolateral myocardium

Question 20

What is Troponin

Answer 20

A protein marker of dead cardiomyocytes which raise 3hrs after MI

Question 21

What are some non ACS causes of raised Troponin

Answer 21

Myocarditis and Pericarditis
Arrythmia
Heart Fail
Type A Aortic Dissection
Sepsis
Strenuous Exercise

Question 22

What is the managment for ACS

Answer 22

"What's HAPON"
H- Hospital (PCI IMMEDIATE if STEMI)
A- Aspirin w/ Clopidogrel
P- Pain relief (morphine)
O- Oxygen
N- NItrates

Question 23

What is the management for STEMI

Answer 23

ACS Management then ......
Before PCI
-Prasugrel (not on anti-coag) 
-Clopidogrel (on anti coag)
PCI (<2hr of medical contact)
Thrombolysis (>12hr of symptoms)

Question 24

Why may you choose clopidogrel over prasugrel

Answer 24

Clopidogrel should be used if the patient is on anticoagulation already

Question 25

What is the management of NSTEMI

Answer 25

``` Oxygen >90 Aspirin with GRACE score if low risk = prasugrel/ticragelor if high risk = clopidogrel GTN for symptom relief IV morphine (decrease preload) Start LMWH or Fondaparinux ```

Question 26

What is the Post MI management

Answer 26

``` Aspirin 75mg with clopidogrel 75 mg (Anti Platelet) Bisoprolol (BB) Ramipril (CCB) Atorvastatin -do ECHO = heart fail? -do cardiac rehab ```

Question 27

What are the main complications of MI

Answer 27

``` Heart fail -Ventricular fibrillation -Mitral Incompetence -LV rupture -Cardio shock Dressler's ```

Question 28

How does ECG change after an MI

Answer 28

Hyperacute T wave Deep Q wave LBBB

Question 29

What is the difference between T1 and T2 MI

Answer 29

T1- IHD | T2 - Demand / Vasospasm

Question 30

How does occlusion change between unstable, NSTEMI and STEMI

Answer 30

``` Unstable = Minor NSTEMI = Major STEMI = Total ```

Question 31

How does infarction change between unstable, NSTEMI and STEMI

Answer 31

``` Unstable = Only ISCHEMIA NSTEMI = Sub endo infarction STEMI = Transmural infarction ```

Question 32

What investigation shows the extent of occlusion

Answer 32

CT Coronary Angiogram

Question 33

Why is alteplase used in thrmobolysis of a STEMI

Answer 33

Clot buster | -Activates plasmin which decreases fibrin

Question 34

What is the long term prevention of ACS

Answer 34

Beat Blocker Aspirin (300mg load then 75mg) w/ Clopidogrel Atorvastatin ACE inhibitor