Acute Coronary Syndrome

Question 1

What does ACS include?

Answer 1

-Unstable angina
-MI

Question 2

What is unstable angina?

Answer 2

-New-onset or rapidly worsening angina (crescendo angina), angina on minimal exertion or angina at rest in the absence of myocardial injury

Question 3

Criteria for diagnosis of acute MI

Answer 3

-Clinical evidence of acute myocardial ischaemia and rise/ fall of cardiac troponin values with at least one value above the 99th centile upper reference limit

+

-Symptoms of myocardial ischaemia
-New ischaemic ECG changes
-Development of pathological Q waves
-Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischaemic aetiology
-Identification of a coronary thrombus by angiography or autopsy

Question 4

Risk markers indicative of poor prognosis for ACS

Answer 4

-Recurrent ischaemia
-Extensive ECG changes at rest or during pain
-Raised plasma troponin I or T concentrations
-Arrhythmias and haemodynamic complications (hypotension, mitral regurgitation) during episodes of ischaemia

Question 5

Clinical symptoms of ACS

Answer 5

-Prolonged cardiac pain: chest, throat, arms, epigastrium, back
-Anxiety and fear of impending death
-Nausea and vomiting
-Breathlessness
-Collapse/syncope

Question 5

Clinical signs of ACS

Answer 5

-Sympathetic activation: pallor, sweating, tachycardia
-Vagal activation: vomiting, bradycardia (inferior)
-Impaired function: hypotension, oliguria, cold peripheries, narrow pulse pressure, raised JVP, third HS, quiet 1st HS, diffuse apical impulse, lung crepitations

Question 6

Complications of ACS

Answer 6

-Arrhythmia
-Recurrent angina (coronary A, IV glycoprotein)
-Acute Heart Failure
-Pericarditis (avoid NSAIDs)
-Dressler syndrome (persistent fever, pericarditis, pleurisy- autoimmunity?)
-Papillary muscle rupture (acute pulmonary oedema, severe mitral regurgitation)
-Ventricular septal rupture (Pansystolic murmur radiating to right sternal border)
-Ventricular rupture= cardiac tamponade
-Embolism

Question 7

ACS investigations

Answer 7

-ECG
-ECHO
-X-ray (pulmonary oedema, cardiomegaly)
-Coronary angiography

Question 8

Management of ACS

Answer 8

-PCI, thrombolysis (STEMI within 12 hours)
-Coronary angiography
-Aspirin
-Clopidogrel
-LMW heparin
-statin
-beta-blocker
-ACEi
-Analgesia (morphine sulphate)
-Anti-emetic

Question 9

Relative contraindications to thrombolytic therapy

Answer 9

-Active internal bleeding
-Previous subarachnoid or intracerebral haemorrhage
-Uncontrolled hypertension
-Recent surgery (within 1 month)
-Recent trauma (including traumatic resuscitation)
-High probability of active peptic ulcer
-Pregnancy