Acute Coronary Syndrome

Question 1

What is a thrombus usually made up of?

Answer 1

Platelets hence antiplatelet medication

Question 2

How to diagnose between STEMI, NSTEMI and unstable angina?

Answer 2

STEMI- ECG ST elevation or new left bundle branch block
NSTEMI- No ST elevation BUT Inverted t waves, ST depression or pathological Q waves or elevated troponin.
Unstable angina- normal troponin and ECG

Question 3

Symptoms of ACS?

Answer 3

Central or left sided pain
Pain radiating to jaw or arms/ heavy constricting
Sob
Sweating clamminess
Nausea vomiting
Palpitation
Feeling of impending doom

Symptoms should continue at rest for more than 20 minutes
Diabetics may experience a silent MI

Question 4

What do pathological Q waves suggest?

Answer 4

Deep infarct- late sign

Question 5

Right coronary artery refers to?

Answer 5

Inferior, II, III and AVF

Question 6

Circumflex supplies?

Answer 6

Lateral- I, AVL, V5-6

Question 7

LAD supplies?

Answer 7

Anterior- V1 to 4

Question 8

Left coronary artery supplies?

Answer 8

Anterolateral- I aVL, V3-6

Question 9

Alternative causes for raised troponin?

Answer 9

CAMPS
Chronic renal failure
Aortic dissection
Myocarditis
PE
Sepsis

Question 10

If patients present with STEMI within 12 hours treatment would be?

Answer 10

Primary PCI (2 hours), or thrombolysis

Question 11

Acute NSTEMI treatment?

Answer 11

BATMAN
Base decision of angiography/PCI on GRACE score
Aspirin 300mg stat dose
Ticagrelor 180 mg stat dose (clopidogrel 300mg alternative if higher bleeding risk)
Morphine
Antithrombin Fondaparinux
Nitrates GTN

Oxygen only if sats dropping below 95%

Question 12

What is the GRACE score?

Answer 12

6 month death or repeat MI after having NSTEMI:

less than 3% is low risk
ABOVE 3% medium- high risk

Medium or high risk considered for PCI/ early angiography within 72 hours

Question 13

Complication of MI?

Answer 13

DREAD
Death
Rupture of the heart septum or papillary muscles
Edema (heart failure)
Arrhythmia or aneurysm
Dressler’s syndrome

Question 14

What is Dressler’s syndrome?

Answer 14

2-3 weeks after MI- localised immune response causes pericarditis.

Question 15

What does Dressler’s syndrome present with?

Answer 15

Pleuritic chest pain, low grade fever and a pericardial rub on auscultation. Pericardial effusion and rarely a tamponade.

Question 16

Diagnosis of Dressler’s syndrome is made by?

Answer 16

ECG- ST elevation globally and T wave inversion
Echo pericardial effusion
Raised CRP and ESR

Question 17

How to manage Dressler’s syndrome?

Answer 17

NSAIDs and in severe cases steroids. May require pericardiocentesis

Question 18

Prevention medical management?

Answer 18

6As: aspirin 75mg once daily, another anti platelet clopidogrel or ticagrelor up to 12 months, atorvastatin 80mg once daily, ACE inhibitors ramipril 10mg, atenolol, aldosterone antagonist for clinical heart failure (eplerenone 50mg)

Question 19

Types of MI?

Answer 19

1. due to Acute coronary event
2. Ischaemia due to increased demand or reduced supply of oxygen
3. Sudden cardiac death or cardiac arrest suggestive of ischaemic event
4. MI associated with PCI/ CABG or coronary stunting

Question 20

How does ischaemic heart disease occur?

Answer 20

Initial endothelial dysfunction (smoking HTN hyperglycaemia). This causes changes in endothelium: pro inflammatory, prooxidant and proliferation. Fatty infiltration of sub endothelial space by LDL particle. Monocytes from blood become macrophages and phagocytose LDL turning into foam cells. When these macrophages die they will propagate the inflammatory process. Smooth muscle proliferation and migration from tunica media to intima results in fibrous capsule formation.

Question 21

When should you be cautious about giving nitrates?

Answer 21

If patient is hypotensive

Question 22

ECG changes on STEMI?

Answer 22

Clinical symptoms more than 20 min duration with persistent ECG features more than 20 mins in more than 2 contiguous leads.

More than 2.5 square ST elevation in leads V2/3 in men under 40 and more than 2 square in over 40
1.5 square St elevation in V2/3 for women
And 1 square ST elevation in other leads
New LBBB

Question 23

Which antiplatalet therapy should you give prior to PCI?

Answer 23

Aspirin plus:
If taking orally: clopidogrel
If they cant take orally: prasugrel

Question 24

Drug therapy during PCI for STEMI?

Answer 24

Radial access: unfractionated heparin with bailout glycoproteins IIb/IIA inhibitor
Femoral: bivalirudin with bailout GPI

Question 25

Patients undergoing fibrinolysis should also be given?

Answer 25

Antithrombin drug, ECG should be repeated after 60/90mins. if patient has persistent MI then PCI should be considered

Question 26

NSTEMI management?

Answer 26

Antithrombin treatment: fondaparinux - not at high risk of bleeding/ not having angiography If immediate angiography or creatinine>265 mircomol/L then unfractionated heparin

Question 27

Which patients with NSTEMI/unstable angina should have coronary angiography?

Answer 27

1. Clinically unstable hypotensive 2. GRACE score>3% intermediate, high or highest risk 3. Is ischaemia is subsequently experienced after admission

Question 28

Drug therapy during PCI for NSTEMI or unstable angina?

Answer 28

1. Unfractionated heparin 2. Aspirin plus another anti platelet prior to PCI

Question 29

Conservative management of NSTEMI/unstable angina?

Answer 29

Aspirin plus clopidogrel if high bleeding risk, ticagrelor if low bleeding risk

Question 30

What are Killip class features and 30 day mortality?

Answer 30

1. NO clinical sign of Heart failure - 6% 2. Lung crackles, S3- 17% 3. Pulmonary oedema- 38% 4. Cardiogenic shock- 81%

Question 31

initial management for ACS?

Answer 31

CPAIN Call ambulance Perform ECG Aspirin 300mg IV morphine Nitrate GTN

Question 32

what to give in preparation of PCI?

Answer 32

prasugrel or aspirin

Question 33

medication for thrombolysis?

Answer 33

streptokinase, alteplase, tenecteplase

Question 34

secondary prevention of ACS?

Answer 34

1. Aspirin 75mg once daily indefinitely 2. Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months 3. Atorvastatin 80mg once daily 4. ACE inhibitors (e.g. ramipril) titrated as high as tolerated 5. Atenolol (or another beta blocker – usually bisoprolol) titrated as high as tolerated 6. Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)

Question 35

why should you monitor renal function?

Answer 35

ACEi/ aldosterone antagonists both cause hyperkalaemia

Question 36

type of MI?

Answer 36

Type 1: Traditional MI due to an acute coronary event Type 2: Ischaemia secondary to increased demand or reduced supply of oxygen (e.g. secondary to severe anaemia, tachycardia or hypotension) Type 3: Sudden cardiac death or cardiac arrest suggestive of an ischaemic event Type 4: MI associated with procedures such as PCI, coronary stenting and CABG Type 1: A – ACS-type MI Type 2: C – Can’t cope MI Type 3: D – Dead by MI Type 4: C – Caused by us MI

Question 37

further drug therapy?

Answer 37

antithrombin treatment fondaparinux- not at high risk of bleeding or having angiography immediately if they are having angiography immediately or creatinine above 265 then unfractionated heparin

Question 38

GRACE takes into account?

Answer 38

age heart rate, blood pressure cardiac (Killip class) and renal function (serum creatinine) cardiac arrest on presentation ECG findings troponin levels