Acute Coronary Syndrome

Question 1

Pathophysiology of ACS

Answer 1

Result of a thrombus from an atherosclerotic plaque blocking a coronary artery.

Question 2

What does the right coronary artery supply

Answer 2

Right atrium and ventricle, inferior aspect of LV and posterior septal area

Question 3

What does the circumflex artery supply

Answer 3

Left atrium and posterior aspect of LV

Question 4

What does the left anterior descending artery supply

Answer 4

Anterior aspect of LV and Anterior aspect of septum

Question 5

Three types of ACS

Answer 5

Unstable angina, STEMI and NSTEMI

Question 6

Symptoms of ACS

Answer 6

Central constricting chest pain
N&V
Sweating or clammy
Impending doom
SOB
Palpitations
Pain radiating to arm or jaw

Question 7

Which group of patients might experience a ‘silent MI’

Answer 7

Diabetics may not experience the typical chest pain during ACS

Question 8

ECG changes in STEMI

Answer 8

ST segment elevation and new left bundle branch block

Question 9

ECG changes in NSTEMI

Answer 9

ST segment depression, deep T wave inversion and pathological Q waves

Question 10

Anterolateral ECG lead

Answer 10

I, aVL, V3-V6

Question 11

Anterior ECG lead

Answer 11

V1-V4

Question 12

Lateral ECG leads

Answer 12

I, aVL, V5-V6

Question 13

Inferior ECG lead

Answer 13

II, III, aVF

Question 14

What is a marker of ACS

Answer 14

Serial troponins (baseline and 6-12 hours after onset of symptoms

Question 15

Alternative causes of raised troponins

Answer 15

Chronic renal failure, sepsis, myocarditis, aortic dissection, pulmonary embolism

Question 16

Investigations when someone presents with ACS symptoms

Answer 16

Physical exam, ECG, FBC, U&Es, LFTs, Lipid profile, TFTs, HbA1c and fasting glucose

Question 17

Acute STEMI treatment

Answer 17

Primary PCI within 2 hours of presentation, thrombolysis if PCI not available

Question 18

Acute NSTEMI treatment (BATMAN)

Answer 18

Beta blockers
Aspirin 300mg stat
Ticagrelor 180mg stat
Morphine titrated
Anticoagulant - Fondaparinux
Nitrates - GTN

Question 19

When would you give clopidogrel instead of ticagrelor in acute NSTEMI treatment

Answer 19

If the patient is at a higher bleeding risk

Question 20

When you would you not give fondaparinux for acute NSTEMI treatment

Answer 20

Unless high bleeding risk

Question 21

What is the GRACE score?

Answer 21

It assesses the need for PCI in NSTEMI

Question 22

Complications of MI

Answer 22

Death, rupture of heart septum or papillary muscles, Oedema, arrythmia and aneurysm, dressler’s syndrome

Question 23

What is Dressler’s syndrome

Answer 23

Post MI, there is a localised immune response which causes pericarditis

Question 24

Presentation of Dressler’s syndrome

Answer 24

Pleuritic chest pain, low grade fever and pericardial rub, pericardial effusion

Question 25

Management of Dressler’s syndrome

Answer 25

NSAIDs, more severe cases steroids, may need pericardiocentesis

Question 26

Secondary prevention medical management

Answer 26

Aspirin 75mg once daily, another antiplatelet, atorvastatin, ACEI, betablocker

Question 27

What secondary prevention medication is added for someone with clinical heart failure

Answer 27

Aldosterone antagonist - such as eplerenone