Acute coronary Syndrome

Question 1

What is ACS?

Answer 1

Acute coronary syndrome: a syndrome in which there is reduced blood flow in the coronary arteries causing cardiac muscle dysfunction/ischaemia

Question 2

What is the most common presentation of ACS?

Answer 2

Central crushing chest pain, radiating up to the jaw

Question 3

How is ACS classified?

Answer 3

STEMI
NSTEMI
Unstable angina

Question 4

What are the features of STEMI?

Answer 4

• Anyone with new LBBB
• ST elevation in 2 consecutive inferior leads of more than 1mm
• ST elevation in 2 consecutive chest leads of more than 2 mm

Question 5

What are the features of NSTEMI?

Answer 5

Wide range of ECG changes that don’t fit criteria for STEMI: T wave inversion, ST depression etc
Associated with positive troponin and convincing chest pain history

Question 6

What are the features of unstable angina?

Answer 6

Chest pain at rest lasting >10 minutes

Crescendo angina

Question 7

What is crescendo angina?

Answer 7

Decrease in the distance the patient is able to walk before symptoms occur

Question 8

What is the pathophysiology of STEMI?

Answer 8

Transmural myocardial ischaemia resulting in myocardial injury or necrosis

Question 9

What may cause a STEMI?

Answer 9

Coronary plaque eruption
Erosion
Fissuring or dissection causing sudden obstructive thrombus

Question 10

What is the definitive treatment for STEMI?

Answer 10

Percutaneous coronary intervention (PCI)

Question 11

What is the initial treatment for STEMI?

Answer 11

ABCDE approach

IV access, cardiac monitor

Question 12

What are the target stats in STEMI?

Answer 12

94-98%

Question 13

Why is it important not to over oxygenate in STEMI?

Answer 13

Over oxygenation can cause free radical formation and worsen myocardial damage

Question 14

What is the timeframe for PCI?

Answer 14

<90 minutes if in PCI capable hospital

<120 minutes if transfer required

Question 15

What medication is required in treatment of STEMI?

Answer 15

Morphine and GTN for pain

Load with dual antiplatelet (aspirin and Ticagrelol)

Question 16

What are the immediate complications of STEMI?

Answer 16

Death
Ventricular arrhythmias
Pulmonary oedema
Cardiogenic shock

Question 17

What ventricular arrhythmias are ischaemic driven?

Answer 17

Ventricular fibrillation

Ventricular tachycardia

Question 18

What are the sub acute complications of STEMI?

Answer 18

Interventricular wall rupture
Acute mitral regurgitation
Ventricular free wall rupture

Question 19

What are the long term complications of STEMI?

Answer 19

Heart failure
Cardiac arrhythmias
Psychological morbidity (anxiety)

Question 20

What is NSTEMI?

Answer 20

Mismatch of myocardial oxygen demand and myocardial oxygen consumption
Often caused by artery plaque rupture

Question 21

What is the pathogenic difference between STEMI and NSTEMI?

Answer 21

NSTEMI does not have complete blockage of coronary artery blood flow
Some myocardial damage but not complete transmural damage as STEMI

Question 22

What is required to make NSTEMI diagnosis?

Answer 22

Clinical history suggestive of ACS
ECG: normal or subtle ST abnormalities, ST depression, T wave inversion
Troponin - positive

Question 23

What are the management steps for NSTEMI?

Answer 23

ABCDE approach
Cardiac monitor
Serial ECGs
Blood test: highly sensitive troponin
Involve cardiology
Admit for treatment +/- angiography

Question 24

What is the immediate medical treatment for ACS?

Answer 24

Load with dual antiplatelets

300mg Aspirin + 300mg Clopidogrel/Ticagrelol 180mg

Question 25

What medical treatment for ACS is required when in hospital?

Answer 25

Anticoagulation | Fundaparinox 2.5mg SC OD for 2-8 days until discharge or revascularisation

Question 26

What long term treatment is required after ACS?

Answer 26

Long term dual antiplatelet therapy (75mg OD Aspirin + 75mg Clopidogrel OD/Ticagrelol 90mg BD) For 1 year after STEMI or PCI If PCI then lifelong antiplatelet therapy

Question 27

What are the features of unstable angina?

Answer 27

Cardiac sounding chest pain at rest Crescendo angina No acute ECG findings Normal troponin

Question 28

Give some key features of classic cardiac chest pain history

Answer 28

``` Retrosternal heaviness/pressure Radiation to jaw or arm Intermittent or persistent Exertion exacerbates symptoms GTN will improve symptoms ```

Question 29

Give some examples of possible associated symptoms with chest pain

Answer 29

``` Autonomic features: Chest pain Sweating Dyspnoea Syncope ```

Question 30

Give some atypical presentation of chest pain

Answer 30

Epigastric pain | Isolated SoB and indigestion like symptoms - more common in elderly, diabetes, CKD and dementia

Question 31

Give some risk factors for ACS

Answer 31

``` Older age Male Smoking Family history of CAD Diabetes Hyperlipidaemia HTN CKD Peripheral vascular disease Known coronary artery disease Cocaine use ```

Question 32

What other conditions is it important to recognise cause associated raised troponin?

Answer 32

Tachyarrythmias Heart failure Hypertensive emergencies Critical illness (shock, sepsis, burns) Myocarditis Tako-Tsubo cardiomyopathy Structural heart disease (e.g. aortic stenosis) Aortic dissection Pulmonary embolism, pulmonary hypertension Renal dysfunction and associated cardiac disease

Question 33

What other conditions may cause elevated troponin?

Answer 33

- Coronary spasm - Acute neurological event (e.g. stroke or subarachnoid haemorrhage) - Cardiac contusion or cardiac procedures (CABG, PCI, ablation, pacing, cardioversion or endomyocardial biopsy - Hyper- and hypothyroidism - Infiltrative diseases (e.g. amyloidosis, haemochromatosis, sarcoidosis, scleroderma) - Myocardial drug toxicity or poisoning (e.g. doxorubicin, 5-fluorouracil, herceptin, snake venoms) - Extreme endurance efforts - Rhabdomyolysis

Question 34

What scoring systems are used for NSTEMI/unstable angina?

Answer 34

Grace ACS Risk and Mortality scoring system TIMI risk scoring HEART

Question 35

What are the features of Grace ACS Risk and Mortality scoring system?

Answer 35

``` Age HR Systolic BP Creatinine Cardiac arrest at admission ST segment deviation of ECG Abnormal cardiac enzymes Evidence of heart failure ```

Question 36

What are the features of TIMI risk scoring?

Answer 36

Age >65 >3 CAD risk factors (HTN, high cholesterol, diabetes, FH or CAD, current smoker) Known CAD (stenosis >50%) Aspirin use in past 7 days Severe angina (> 2 episodes in past 24 hrs) ECG ST changes >0/5mm Positive cardiac markers

Question 37

What are the features of HEART scoring?

Answer 37

``` History ECG Age Risk factors Troponin (initial) ```

Question 38

What secondary prevention is used after STEMI/NSTEMI?

Answer 38

Dual antiplatelets for 1 year, then lifelong aspirin ACEi Statins B blocker Good BP control Good diabetic control Lifestyle advice: smoking cessation, exercise, healthy diet

Question 39

Give cardiac DDx of chest pain

Answer 39

``` ACS Myopericarditis/cardiomyopathies Tachyarrythmias Acute heart failure Hypertensive emergencies Aortic stenosis Tako-Tsubo cardiomyopathy Coronary spasm Cardiac trauma ```

Question 40

Give some pulmonary DDx for chest pain

Answer 40

PE Pneumothorax Bronchitis/pneumonia Pleurisy

Question 41

Give vascular DDx for chest pain

Answer 41

Aortic dissection | Symptomatic AAA

Question 42

Give GI DDx for chest pain

Answer 42

Oesophagitis, reflux or spasm Peptic ulcer/gastritis Pancreatitis Cholecystitis

Question 43

Give orthopaedic DDx for chest pain

Answer 43

``` MSK disorders Chest trauma Muscle injury/inflammation Chostocondritis Cervical spine pathology ```

Question 44

Give some other DDx for chest pain

Answer 44

Anxiety disorders Herpes zoster Anaemia

Question 45

What categories may include DDx for chest pain?

Answer 45

``` Cardiac Pulmonary Vascular GI MSK ```