Acute coronary syndrome

Question 1

What is ACS

Answer 1

umbrella term covering a number of acute presentations of ischaemic heart disease

Question 2

What conditions are part of ACS

Answer 2

STEMI
NSTEMI
unstable angina

Question 3

What is unstable angina

Answer 3

considered to be present in patients with ischaemic symptoms suggestive of an ACS and no elevation in troponins- with / without ECG changes indicative of ischaemia

Question 4

What disease predisposes patients to ACS

Answer 4

those who have ischaemic heart disease

Question 5

What is ischaemic heart disease

Answer 5

term synonymous with coronary heart/ coronary artery disease

describes gradual build up of fatty plaques within walls of coronary arteries

Question 6

What 2 problems does ischaemic heart disease lead to

Answer 6

gradual narrowing - less blood and therefore oxygen reaching myocardium at times of increased demand- leading to angina

risk of sudden plaque rupture - leads to sudden occlusion of the artery which can result in no blood/oxygen reaching area of myocardium

Question 7

What are some unmodifiable risk factors

Answer 7

increasing age
male
gender
family history

Question 8

What are some modifiable risk factors

Answer 8

smoking
diabetes mellitus
hypertension
hypercholesterolaemia
obesity

Question 9

What may someone with ACS present with

Answer 9

chest pain
– typically central/left sided
–may radiate to jaw or left arm
– often described as heavy

dyspnoea
sweating
nausea and vomiting

Question 10

What are first investigations needed for someone with suspected ACS

Answer 10

ECG
cardiac markers- troponin
bloods

Question 11

What ECG changes relate to which arteries

Answer 11

Anterior-, V1-V4, LAD

Inferior , I,III,aVF , right coronary

Lateral , I, V5-V6 , left circumflex

Question 12

What is the general management for ACS

Answer 12

MONA
Morphine - if severe pain
Oxygen if <94%
Nitrates – caution if hypotensive
Aspirin - 300mg

Question 13

What are the management steps for a STEMI

Answer 13

Once STEMI identified– aspirin

If PCI possible within 120 minutes then
-give PRASUGEL
-give unfractionated heparin and bailout glycoprotein IIIb/IIIa inhibitor

If PCI not possible within 120 minutes
FIBRINOLYSIS
-give antithrombin at same time
-following procedure give TICAGRELOR

Question 14

What assumptions are made in the management of STEMI

Answer 14

patient presents within 12 hours of symptom onset
– if after 12 hours consider PCI

patient is not at high bleeding risk
-if at high risk swap prasugrel for ticagrelor / ticagrelor for clopidogrel

Patient is not on oral anticoagulants
- if they are swap prasugrel for clopidogrel

Question 15

What is the management plan for NSTEMI/unstable angina

Answer 15

Asprin 300mg first
Fondaparinux if no immediate PCI planned

Then estimate 6 month mortality if low risk
- Conservative management
Ticagrelor

If high risk
-offer PCI immediately unless clinically unstable
give prasugrel or ticagrelor
unfractionated heparin

Question 16

What assumptions are being made in management of NSTEMI/unstable angina

Answer 16

patient is not at high risk of bleeding
patients is not on oral anticoagulants

Question 17

What lifelong drug therapy needs to be given after an ACS event occurs

Answer 17

aspirin
second antiplatelet
beta blocker
ACEI
Statin

Question 18

What risk assessment is used

Answer 18

Global registry of Acute coronary events - GRACE

Question 19

What factors does GRACE take in

Answer 19

age
heart rate, BP
cardiac and renal function
cardiac arrest on presentation
ECG findings
troponin levels

Question 20

How do you interpret the results of GRACE

Answer 20

Predicted 6 month mortality
relates to risk of future adverse CV events

<1.5% - lowest
1.5-3% - low
3-6% - intermediate
6-9% - high
over 9% - highest

Question 21

Which patients with NSTEMI/unstable angina should have coronary angiography

Answer 21

Immediate - patients who are clinically unstable

-within 72 hours and follow on PCI- patients with GRACE score >3%

-should also be considered for patients if ischaemia is subsequently experienced after admission