Acute coronary syndrome

Question 1

What are the signs of STEMI?

Answer 1

-Clinical sounding chest pain
-ST elevation on ECG in 2 or more leads from the same zone.
-Troponin I >100
-CK>400
- could also be the presence of left bundle branch block (M signs in v4,5,6- and RAD)

Question 2

Clinical signs of a NSTEMI?

Answer 2

-cardiac sounding chest pain-
-ST depression and T wave inversion
-Troponin I will be >100

Question 3

Clinical Signs of Unstable Angina?

Answer 3

-Cardiac sounding chest pain
-ST segment depression
- NORMAL TROPONIN

Question 4

Describe the changes in TROPONIN after a MI?

Answer 4

• rise 3-4 hours after an MI- stay elevated for 2 weeks

Question 5

How to test for TROPONIN?

Answer 5

Usually take two tests- one on admission and another an hour later. If however, the patients MI was 3+ hours ago the one TROPONIN rest is sufficient

Question 6

Reference ranges for men and women for TROPONIN indicative of myocardial necrosis?

Answer 6

Men-34ng/l
Women-16ng/l

Question 7

Which conditions also present with raised TROPONIN?

Answer 7

-aortic dissection
-Pulmonary Embolism
-Severe Congestive cardiac failure
-renal failure
-aortic stenosis
-tachyarrythmias

Question 8

What indicates a posterior myocardial infarction?

Answer 8

ST depression in leads v1-v4. These patients should have their posterior leads checked as well v7-v9

Question 9

What are the strange clinical signs associated with Inferior MI?

Answer 9

Abdominal, epigastric pain- often confused with acid reflux

Question 10

What changes on the ECG can be confused for STEMI?

Answer 10

-Younger more athletic patients have upsloping of ST segment- more common in Afro-Carribean
-Pericarditis- saddle shaped ST elevation
-Brugada syndrome
-Takotsubo Cardiomyopathy

Question 11

Management of STEMI

Answer 11

IV Access
Pain relief
Oxygenation
Aspirin-300mg loading dose- 75mg dose od for life
Prasugrel 1st line
Clopidogrel -12months 60mh od (2nd line)
Ticagrelor(2nd line)
Percutaneous coronary intervention
-lipid profile, random glucose and HB1AC
-FBC
-bisoprolol -1.25mg od
-ACEi-ramipril 2.5mg O.D (after checking renal function)
Or- Losartan-25mg of
-Statin to reduce LDL <1.8mmol
-ccontrol hypertension, diabetes and smoking
- patients with AF and STEMI- are on anticoagulants, do they are taking three anticoags- TRIPLE THERAPY- risk of bleeding very high

Question 12

Management of NSTEMI

Answer 12

-Pain relief
-Aspirin 300mg loading and 75mg OD
-Low molecular weight heparin
-Repeat ECG
-Risk Assessment for patients with elevated Troponin I and if it’s > 3% Ticagrelor 180mg loading dose and 90mg BD
-Anti-anginals- Nitrates, Ranolazine

Question 13

Symptoms of ANGINA

Answer 13

-Chest discomfort- usually brought on by exercise, emotion and relieved by rest
-Throat tightness and arm heaviness
-Fear
-Sweating
-Nausea
-pain is not constant
-Pain is not very prolonged

Question 14

What is Angina?

Answer 14

chest pain usually associated with some kind of coronary artery disease - like Aortic stenosis, hypertensive heart

Question 15

When is Angina not a concern?

Answer 15

when the heart is structurally normal and normal coronary arteries- some people experience recurrent angina

Question 16

What physical examinations do you do in Angina?

Answer 16

-BMI - obesity is an indication of CVS disease
-Blood pressure- hypertensive heart
-Presence of murmurs- aortic stenosis
-hyperlipidaemia-
-Peripheral vascular disease- diabetes

Question 17

Investigations for Angina?

Answer 17

-FBC- glucose/HbA1C
-Full lipid profile
-12 lead ECG’s

Question 18

What is the medication used for ANGINA?

Answer 18

-Aspirin 75mg OD
(for those allergic give clopidogrel)
-Sublingual GTN spray
-B-blockers and Ca2+ channel blocker
-Long acting nitrates-Isosorbide Mononitrate OR potassium channel opening drugs - Nicoranadil- DON’T PRESCRIBE BOTH- BECAUSE PATIENT WILL DEVELOP NITRATE TOLERANCE
-Ivabradine- more useful where B-blocker is contraindicated.Never give with non-dihydropyridine Ca2+ channel blockers
-Ranolazine- be careful cannot give to patients with eGFR <30

Question 19

Describe the three stages of hypertension

Answer 19

Stage 1 Hypertension 140/90mmHg, or average is 135/80 or higher
Stage 2- 160/100 or average 150/95
Severe- systolic 180 or diastolic is 110

Question 20

When should ambulatory monitoring be offered?

Answer 20

if the BP is >140/90. however if the BP is severe hypertensive, start them on treatment without ABPM

Question 21

What is Ambulatory Blood pressure monitoring?

Answer 21

-Monitoring BP over 24hrs

Question 22

Symptoms of Hypertension

Answer 22

-Sometimes asymptomatic or headache
-Sweating, headache, palpitations and anxiety- all indicate Phaechromocytoma
-Muscle weakness/ tetany - HYPERALDOSTERINSM

Question 23

What are the investigations we do for hypertension?

Answer 23

-examine for Cushings, polycystic kidney disease, coarctation of aorta.
-test for preteinuria, haematuria
-Measure plasma glucose,electrolytes, creatinine,eGFR, total cholesterol and HDL
-FBC- electrolytes
-Examine the fundi for hypertensive retinopathy
-12 lead ECG

Question 24

Treatment for Hypertension

Answer 24

Non pharm- weight loss and reducing salt intake
Pharmacological- ACEi or Ca2+ channel blocker, then all three( ARBS) then consider B-blocker, for persistent Hypertension refer to specialist.

Question 25

Difference between hypertensive urgency and emergency

Answer 25

Emergency is an elevation of BP with critical event -oedema, AKI
Whereas Urgency is elevated BP without critical event

Question 26

What is the treatment for hypertensive emergency?

Answer 26

Sodium nitroprusside
Labetalol
GTN
Esmolol
The aim is to get diastolic BP around 110 mmHg

Question 27

Hypertensive urgency treatment

Answer 27

Amlodipine
Diltiazem
Lisonopril
ACEi
calcium antagonist
Nifedipine and amlodipine (forever)
Aim for BP 100mmHg diastolic

Question 28

What is the triadic symptom associated with Phaechromocytoma?

Answer 28

-headache
-sweating
-tachycardia

Question 29

How do you test for Phaechromocytoma?

Answer 29

Urine metanephrines and a CT or MRI- often scans can’t detect it

Question 30

Treatment for Phaechromocytoma

Answer 30

Usually surgical resection.
Awaiting surgery, patients should have BP control, alpha blocker

Phenoxybenzamine- if this is not tolerated by the patient try calcium channel blocker nicardine
After alpha blocker then give beta blocker NEVER give beta blocker first