Acute Coronary Syndrome

Question 1

what is ACS?

Answer 1

an atherosclerotic plaque that becomes a thrombus and blocks and artery

Question 2

what is a thrombus in a fast flowing artery usually made up of?

Answer 2

platelets

Question 3

what are the types of ACS?

Answer 3

unstable angina
none ST elevation MI (NSTEMI)
ST elevation MI (STEMI)

Question 4

what does the aorta branch into?

Answer 4

the left ad right coronary arteries

Question 5

what does the left coroanry artey become?

Answer 5

circumflex artery
left anterior descending

Question 6

where is the circumflex artery?

Answer 6

it curves around the top, left and back of the heart

Question 7

what does the circumflex artery supply?

Answer 7

the left atrium
the posterior aspect of the left ventricle

Question 8

where is the LAD?

Answer 8

it travels down the middle of the heart

Question 9

what does the LAD? supply?

Answer 9

the anterior left ventricle
anterior septum

Question 10

what does the right coronary artery supply?

Answer 10

the right atrium
the right ventricle
the inferior left ventricle
posterior septal area

Question 11

how would a patint with ACS present?

Answer 11

usually central constricitn chest pin, assoc w
radiatio to jaw or arm
nausea and vomiting
shortness of breath
sense of impending doom
sweats and claminess
palpitations

Question 12

what is a silent MI?

Answer 12

when a patient has no typical chest pain during ACS

Question 13

who is more at risk of a silent MI?

Answer 13

diabetics

Question 14

how long should symptoms continue to likely be ACS?

Answer 14

at rest for mor than 15 minutes

Question 15

what ECD chnages are see i an NSTEMI?

Answer 15

ST depression
T wave inversion

Question 16

what ECG changes are seen in a STEMI?

Answer 16

ST elevation
new left buncdle branch block

Question 17

what do pahtologicla Q waves suggest?

Answer 17

deep, transmura iinfarction
usually 6+ hours after inset of symptoms

Question 18

what area of the heart is affected by each artery?

Answer 18

LCA - anterolateral
LAD - anterior
RCA inferior
circumflex - lateral

Question 19

which ECG leads are affected by each artery?

Answer 19

LCA - I, aVL, v3-6
LAD- V1-4
RCA - II, III, aVF
circumflex - I, aVL, V5-6

Question 20

what is troponin?

Answer 20

a protein in the myocardium and skeletal muscle

Question 21

what is a rise in troponin assoc w and why?

Answer 21

myocardial ischaemia
as is released from ischael muscle tissue

Question 22

what are troponin results used to diagnose?

Answer 22

NSTEMI
not STEMI (use ECG and clinical presentation)

Question 23

in case of suspected ACS what troponin results indicate an NSTEMI?

Answer 23

high
or rising on repeated tests

Question 24

why is troponin a non specific marker?

Answer 24

rise in troponin can also be caused by:
- chronic kidney disease
- pulmonary embolism
- aortic dissection
- myocarditis
- sepsis

Question 25

what other investigations apart from ECG and troponin are done for suspected/cofirmed ACS?

Answer 25

baseline bloods - full blood count, urea and electrolytes, liver function test, lipids and glucose chest x-ray - look for pulmonary oedema and any there causes of chest pain echocardiogram - to check function damage to heart esp left ventricular function

Question 26

what diagnoses a STEMI?

Answer 26

ST elevation or new left bundle branch block

Question 27

what diagnoses and NSTEMI?

Answer 27

raised troponin with either - normal ECG - other ECG changes (not ST elevation) i.e ST depression or T wave inversion

Question 28

what diagnoses unstable angina?

Answer 28

normal troponin with normal ECG or ECG changes that aren't ST elevation

Question 29

what would a patient with chest pain, normal ECG and normal troponin be diagnosed with?

Answer 29

either unstable angina or another cause of pain such as musculoskeletal pain

Question 30

what is the initial management for ACS?

Answer 30

Call ambulance Perform ECG Aspirin 300mg IV morphine (pain if needed) w antiemetic (metoclopramide) Nitrate (GTN)

Question 31

what should happen to a patient who is pain free but hs had constricting central chest pain in the last 72hrs?

Answer 31

should be admitted to hospital for same day assessment usually seen in ambulatory care unit may need emergency admission if ECG changes or complications - HF

Question 32

what are the two management options for a STEMI and when is each used?

Answer 32

PCI - if available within 2hrs of presnting thrombolysis - if PCI not available within 2hrs

Question 33

what is a PCI?

Answer 33

PERCUTANEOUS CORONARY INTERVENTION angiography angioplasty or devices to remove/aspirate blockage stent usually inserted to keep artery open

Question 34

what is an angiography?

Answer 34

catheter is put into the radial or femoral artery - radial preferred fed through using x-ray contrast injected to identify blockage

Question 35

what is an angioplasty?

Answer 35

balloons being used to widen lumen to treat a blockage

Question 36

what medications may be advised before a PCI?

Answer 36

aspirin or prasugrel

Question 37

what is thrombolysis?

Answer 37

injecting a fibrinolytic agent

Question 38

what do fibrinolytic/thrombllytic agents do?

Answer 38

break down fibrin in blood clots

Question 39

what makes thrombolysis dangerous?

Answer 39

significant bleeding risk

Question 40

give examples of thrombolytic agents

Answer 40

streptokinase alteplase tenecteplase

Question 41

what is the management of NSTEMI?

Answer 41

Base decision on angiogrpah/PCI on GRACE score Aspirin 300mg stat dose Ticagrelor 180mh stat dose Morpgine titrated for pai Antithrombin therapy with fondaparinux Nitrate (GTN)

Question 42

what would be used instead of ticagrelor if a patient with an NSTEMI has a high bleeding risk?

Answer 42

clopidogrel

Question 43

what would be used instead of ticagrelor is a patient with an NSTEMI is getting an angiography?

Answer 43

prasugrel

Question 44

when would a patient with an NSTEMI not be given fondaparinux as an antithrombin?

Answer 44

when they have a high bleeding risk or are getting an immediate angiography

Question 45

what are unstable NSTEMI patients considered for?

Answer 45

an immediate angiography

Question 46

what does the GRACE score measure?

Answer 46

the 6 month probability of death after an NSTEMI

Question 47

what GRACE scores give what level of risk?

Answer 47

3% or less = low risk greater than 3% = medium to high risk

Question 48

what are patients with a medium-rhigh risk calculated by the GRACE score considered for?

Answer 48

an early angiography with PCI within 72hrs

Question 49

what is the ongoing management of ACS?

Answer 49

once stable, an echocardiogram to asses function, especially left ventricular function cardiac rehabilitation secondary prevention

Question 50

what is secondary prevention after an MI?

Answer 50

Aspirin 75mg once daily, indefinitely Another anti platelet for 12months (usually clopidogrel or ticagrelor) Atorvastatin 80mg once daily ACEi titrated as high as tolerated (ramipril) Atenolol (or other beta blocker - bisprolol) titrated as high as tolerated Aldosterone antagonist for patients with clinical HF, eplerenone titrated to 5omg once daily

Question 51

why can dual antiplatelet therapy vary after PCI?

Answer 51

depends on the stent used

Question 52

what is important to monitor in patients taking ACEi and aldosterone antagonists and why?

Answer 52

renal function can cause hyperkalaemia

Question 53

what drug combination carries a risk o fatal hyperkalaemia?

Answer 53

spironolactone or epelerenone (aldosterone antagonists) + ACEi or ARB

Question 54

what are the complications of a MI?

Answer 54

Death Rupture of heart septum or papillary muscles E oEdema - heart failure Arrhythmia or aneurysm Dressler's syndrome