Acute coronary syndrome

Question 1

ACS mechanism

Answer 1

Thrombus from atherosclerotic plaque blocking a coronary artery - made up of mostly platelets

Question 2

Types of ACS

Answer 2

Unstable angina
STEMI
NSTEMI

Question 3

ACS diagnosis

Answer 3

ECG
ST elevation / new LBBB = STEMI
No ST elevation - check troponin (serial - at baseline and 6/12hrs after onset of symptoms)

High tropoinin + ST depression/ T wave inversion/ pathological Q waves = NSTEMI
If troponin and ECG normal - unstable angina / MSK etc

Question 4

ACS sympotms

Answer 4

Central constricting chest pain
Continue at rest for more than 20 mins
Diabetics = silent MI

Question 5

Right coronary artery (RCA) supplies the…

Answer 5

Right atrium
Right ventricle
Inferior aspect of left ventricle
Posterior septal area

Question 6

Circumflex artery supplies the …

Answer 6

Left atrium
Posterior aspect of left ventricle

Question 7

Left anterior descending (LAD) supplies the…

Answer 7

Anterior aspect of left ventricle
Anterior aspect of septum

Question 8

Draw coronary arteries

Answer 8

(see zero to finals picture)

Question 9

ECG area changes to artery affected

Answer 9

Leads I, aVL, V3-6 = anterolateral = LCA
Leads V1-4 = anterior = LAD
Leads I, aVL, V5-6 = lateral = circumflex
Leads II, III, aVF = inferior = RCA

Question 10

What are troponins?

Answer 10

Proteins found in cardiac muscles

Question 11

Causes of raised troponins

Answer 11

MI
Chronic renal failure
Sepsis
Myocarditis
Aortic dissection
PE

Question 12

ACS investigations

Answer 12

Physical exam
ECG
FBC - anaemia
U&Es - prior to starting ACEi
LFTs - prior to statins
Lipid profile
Thyroid function tests
HbA1c
Fasting glucose
CXR - other causes of pain and pulmonary oedema
Echo - assess functional damage after event
CT coronary angiogram

Question 13

Acute STEMI treatment

Answer 13

Within 12 hours of onset
Primary PCI (w/in 2 hours)
Thrombolysis (if PCI unavailable) - injecting fibrinolytic medication - streptokinase, altepase and tenecteplase

Question 14

Acute NSTEMI treatment

Answer 14

BATMAN
B - beta blockers (check for contraindications)
A - aspirin 300mg stat
T - ticagrelor 180mg stat (clopidogrel if higher bleeding risk)
M - morphine titrated
A - anticoagulant - fondaparinux (unless high bleed risk)
N - nitrates - GTN
Oxygen if sats dropping

Question 15

Grace score

Answer 15

Assess for PCI in NSTEMI
6 month risk of death or repeat MI
< 5% = low, 5-10% = medium, >10% = high
Medium/high = considered for early PCI (w/in 4 days of admission)

Question 16

Complications of MI

Answer 16

DREAD
D- death
R - rupture of heart septum/papillary muscles
E - edema (heart failure)
A - arrhythmia and aneurysm
D - Dressler’s syndrome

Question 17

Dressler’s syndrome definition

Answer 17

Post MI syndrome
2-3 weeks after MI

Question 18

Dressler’s syndrome mechanism

Answer 18

Localised immune response
Causes pericarditis
Pericardial effusion (extra fluid)
Pericardial tamponade (rarely) (fluid constricts heart and prevents function)

Question 19

Dressler’s syndrome symptoms

Answer 19

Pleuritic chest pain (when breathing)
Low grade fever
Pericardial rub

Question 20

Dressler’s syndrome diagnosis

Answer 20

ECG - global ST elevation and T wave inversion)
Echocardiogram - pericardial effusion
Raised inflammatory markers - CRP and ESR

Question 21

Dressler’s syndrome managmenet

Answer 21

NSAIDs
Steroids if severe
Pericardiocentesis to remove fluid

Question 22

ACS secondary medical prevention

Answer 22

6As
Aspirin 75mg OD
Another antiplatelet (clopidogrel) for up to 12 months
Atorvastatin 80mg OD
ACE inhibitor (ramipril titrated to 10mg OD)
Atenolol
Aldosterone antagonist if clinical heart failure (eplerenone titrated to 50mg OD)

Dual anti-platelet therapy depends on PCI –> high risk of thrombus formation with different stents

Question 23

ACS secondary prevention lifestyle

Answer 23

Stop smoking
Reduce alcohol consumption
Mediterranean diet
Cardiac rehabilitation
Optimise treatment of other conditions