Acute Coronary Syndrome Flashcards
Give the full definition of a type 1 MI
Raised troponin >99th centile + 1 of the following
a) Sx of MI
b) New ECG changes/pathalogical Q waves
c) ECHO showing loss of viable myocardium/wall motion abnormality
d) Identification of a coronary thrombus by angiography or autopsy.
There are 5 types of MI. Which ones are clinically relevant? Define them
Type 1 - Acute atherosclerotic plaque disruption with raised troponin.
Type 2 - Myacardial demand > suppy with raised troponon and !without atherothrombus.
Which types of MI are iatrogenic? Define them
Type 4 - Raised troponin secondary to PCI in the tx of MI, with troponon 5x upper limit
Type 5 - Raised Troponin secondary to CABG with troponin 10x upper limit
Which type of MI is typically diagnosed on autopsy? Define it
Type 3 - Diagnosis on autopsy with evidence of symptoms and ECG findings but bloods not sent => no troponin levels
Define the 5 types of MI
Type 1 - Acute atherosclerotic plaque disruption with raised troponin
Type 2 - Myacardial demand > suppy with raised troponon and !without atherothrombus
Type 3 - Diagnosis on autopsy with evidence of symptoms and ECG findings but bloods not sent
Type 4 - Raised troponin secondary to PCI in the tx of MI, with troponon 5x upper limit
Type 5 - Raised Troponin secondary to CABG with troponin 10x upper limit
List the symptoms of an acute MI
1) Chest pain - Acute sudden onset central crushing chest pain radiating to the jaw, neck, or left arm +/- angina =>worse on exertion/unstable angina
2) Palpitations
3) Syncope/presyncope
4) Nausea/diaphoresis
5) SOB (at rest or on exertion)
6) Symptoms of heart failure (leg swelling, dyspnea, orthopnoea, PND, sacral oedema)
You are conducting a cardiac examination on a patient suffering from an acute MI. What can you expect to hear on auscultation?
Mitral regurgitation
Gallop rhythm (HF)
You are conducting a cardiac examination on a patient suffering from an acute MI. Go through the examination stating what you are looking for in this context.
General inspection: Ashen colour, dyspnoeic
Closer inspection: Tar stains, Xanthomata, Peripheral cyanosis, Central cyanosis, Hypotension, Tachycardia, tachypnoea, scars, subcutaneous devices
Palpation: Raised JVP, Heave, Peripheral oedema, Pulmonary oedema, sacral oedema
Auscultation: Mitral regurgitation, Gallop rhythm (S3)
When examining a patient who just had an acute MI, you note a gallop rhythm. what does that indicate? What is the likely underlying diagnosis in this scenario?
S3 - It indicates rapid ventricular filling consistent with HF secondary to an acute MI
Give 5 RF for ACS
1) Prior hx or fam hx of ACS (especially in a 1st degree relative <55 males, <65 females
2) Environmental - smoking, drinking alcohol
3) Hypertension
4) Hypercholestrolaemia/ dyslipidaemia
5) Obesity
6) Diabetes
You would like to conduct an ECG on a patient suspected of suffering from an acute MI. What findings are you looking for in general?
a) ST elevation in 2 contiguous leads or new LBBB
b) ST depression or T wave changes
c) Arrhythmia
What are the Cardiac biomarkers? (3)
Troponin, CKMB, Myoglobin
What does CKMB stand for?
What is it primarily used for?
How does its levels compare to troponin?
Creatine Kinase myoglobin
Primarily used for detecting re-infarction.
It rises and falls faster than troponin
You are conducting a CXR on a patient that presenting with signs and symptoms of an acute MI. You note alveolar oedema. How does that appear on the CXR?
Perihilar/bat wing opacification
You perform a CXR on a patient that presenting with signs and symptoms of an acute MI. You note Kerley B-lines. What does that indicate?
Interstitial oedema
How is pleural effusion noted on CXR?
Fluid in the horizontal fissure
Blunting of the costophrenic
Meniscus-shaped line
white out
What are the expected findings of HF on CXR?
ABCDE
Alveolar oedema (Perihilar/bat wing opacification)
kerley B-lines (interstitial oedema)
Cardiomegaly (>50% thoracic cavity)
Dilation of upper lobe vessels
pleural Effusions (blunting, fluid in fissure, meniscus)
What CXR finding supports the diagnosis of an aortic dissection instead of MI?
widened mediastinum
Name the 2 types of echo and which one is more invasive?
What findings are you looking for when conducting an ECHO for a patient with MI
TTE ECHO looking for a
1) Atrial/ventricular size (LA enlargement, LV hypertrophy),
2) RV systolic pressure (RHF)
3) presence of valvular disease e.g. papillary rupture causing acute mitral regurgitation (rule out),
4) Atrial and ventricular filling,
5) Pericardial disease (dressler)
TOE needed for identifying left atrial thrombus. (also rule out vegetations in IE)
What murmur may occur after an MI? Describe the murmur. How is it confirmed on ECHO (2)?
What arrhythmia is common post-MI? What findings on ECG would support this?
A patient presents post-MI with bradycardia, what is the most likely ECG finding?
Mitral regurgitation (Pansystolic murmur radiating to the axilla) typically secondary to papillary rupture seen on ECHO and backflow of blood from LV to LA
Atrial fibrillation: irregularly irregular rhythm with absent P waves
Bonus points: Heart block as well!
What imaging would you use when conducting investigations for MI (all)? Explain your reasoning (what youre looking for)
What specifically on these investigations would be consistent with MI?
CXR checking for widened mediastinum to rule out aortic dissection as well as findings of HF (ABCDE). nothing specific for MI
TTE ECHO looking for a
1) Atrial/ventricular size (LA enlargement, LV hypertrophy),
2) RV systolic pressure (RHF)
3) presence of valvular disease e.g. papillary rupture causing acute mitral regurgitation (rule out),
4) Atrial and ventricular filling,
5) Pericardial disease (dressler)
TOE needed for identifying left atrial thrombus. (also rule out vegetations in IE)
Specific for MI (papillary rupture causing mitral regurg and dressler)
For each of the following, answer the questions:
STEMI:
NSTEMI:
Unstable Angina:
Which present with chest pain?
What ECG changes are consistent with the dx?
Which of these are likely to have raised troponin?
STEMI: Yes for Chest pain and troponin rise, ST elevation or new LBBB.
NSTEMI: Yes for chest pain and troponin rise. ST depression and/or T-wave inversion
Unstable Angina: Yes for chest pain, no raise in troponin, ECg may be normal or have non-specific changes
Using an ECG, how will you determine the location of the insult in an MI?
Tell me each type of MI with their respective leads and most likely vessel affected
+ Anterolateral: I, aVL, V1-V6 -> Proximal LAD
How is Primary coronary intervention performed?
Radial or femoral artery access followed by placing the stent delivery system -> stent expands as balloon inflates -> Catheter removed, stent implanted.
