Acute Coronary Syndrome

Question 1

How many types of acute coronary syndromes are there?

Answer 1

1. Unstable angina
2. ST elevated myocardial infarction (STEMI)
3. Non-ST elevated myocardial infarction (NSTEMI)

Question 2

What are the 2 coronary arteries that branch from the root of the aorta?

Answer 2

1. R coronary artery
2. L coronary artery

Question 3

What does the R coronary artery supply?

Answer 3

• Right atrium
• Right ventricle
• Inferior aspect of the left ventricle
• Posterior septal area

Question 4

What does the L coronary artery divide into to become?

Answer 4

• Circumflex artery
• Left anterior descending (LAD)

Question 5

What does circumflex artery (curves around the top, left and back) supply?

Answer 5

• Left atrium
• Posterior aspect of the left ventricle

Question 6

Which areas of the heart does the left anterior descending (LAD) artery supply as it travels down the middle of the heart?

Answer 6

Anterior aspect of the left ventricle
Anterior aspect of the septum

Question 7

What is the typical presentation of acute coronary syndrome?

Answer 7

Acute coronary syndrome typically presents with central, constricting chest pain.

Question 8

What are some common symptoms associated with the chest pain in acute coronary syndrome?

Answer 8

Common symptoms include:
- Pain radiating to the jaw or arms
- Nausea and vomiting
- Sweating and clamminess
- A feeling of impending doom
- Shortness of breath
- Palpitations

Question 9

How long should symptoms of acute coronary syndrome persist at rest to raise concern?

Answer 9

Symptoms should continue at rest for more than 15 minutes.

Question 10

What is a silent myocardial infarction, and which group of patients is particularly at risk?

Answer 10

A silent myocardial infarction occurs when a person does not experience typical chest pain during acute coronary syndrome. Patients with diabetes are particularly at risk of silent MIs.

Question 11

What are the characteristic ECG changes seen in a STEMI (ST-elevation myocardial infarction)?

Answer 11

ST-segment elevation and new left bundle branch block.

Question 12

What ECG changes are typically seen in an NSTEMI (non-ST-elevation myocardial infarction)?

Answer 12

ST segment depression and T wave inversion.

Question 13

What do pathological Q waves on an ECG suggest, and when do they typically appear after symptom onset?

Answer 13

Pathological Q waves suggest a deep infarction involving the full thickness of the heart muscle (transmural). They typically appear 6 or more hours after the onset of symptoms.

Question 14

Which artery is associated with an anterolateral infarction, and which ECG leads would show changes?

Answer 14

The left coronary artery is associated with an anterolateral infarction, and changes would be seen in leads I, aVL, and V3-6.

Question 15

Which artery is involved in an anterior infarction, and which ECG leads would reflect this?

Answer 15

The left anterior descending artery is involved in an anterior infarction, with changes seen in leads V1-4.

Question 16

In which ECG leads would changes be observed in a lateral infarction, and which artery is responsible?

Answer 16

Changes in a lateral infarction would be observed in leads I, aVL, and V5-6, with the circumflex artery being responsible.

Question 17

Which artery is involved in an inferior infarction, and what are the corresponding ECG leads?

Answer 17

The right coronary artery is involved in an inferior infarction, with corresponding changes seen in leads II, III, and aVF.

Question 18

What is troponin, and where is it found in the body?

Answer 18

Troponin is a protein found in cardiac muscle (myocardium) and skeletal muscle.

Question 19

Why is it important to check the local policy when interpreting troponin levels?

Answer 19

The specific type of troponin, normal range, and diagnostic criteria vary based on different laboratories, so it is essential to check the local policy.

Question 20

What does a rise in troponin levels indicate?

Answer 20

A rise in troponin levels is consistent with myocardial ischemia, as troponins are released from ischemic muscle tissue.

Question 21

How is an NSTEMI diagnosed using troponin results?

Answer 21

An NSTEMI is diagnosed using troponin results by assessing for a high or rising troponin level in the context of suspected acute coronary syndrome, often with repeated tests (e.g., at baseline and 3 hours after symptom onset).

Question 22

Why are troponin tests not required to diagnose a STEMI?

Answer 22

Troponin tests are not required to diagnose a STEMI because it is diagnosed based on clinical presentation and ECG findings.

Question 23

Name some alternative causes of a raised troponin level other than acute coronary syndrome.

Answer 23

Alternative causes of a raised troponin level include:
- Chronic kidney disease
- Sepsis
- Myocarditis
- Aortic dissection
- Pulmonary embolism

Question 24

What additional investigations are typically performed in patients with suspected or confirmed acute coronary syndrome, and what is the purpose of each?

Answer 24

Additional investigations in patients with suspected or confirmed acute coronary syndrome include:

• Baseline bloods (e.g., FBC, U&E, LFT, lipids, and glucose) to assess overall health and identify any contributing factors or complications.
• Chest X-ray to investigate for pulmonary edema and other potential causes of chest pain.
• Echocardiogram once the patient is stable to assess the functional damage to the heart, particularly the left ventricular function.

Question 25

Under what conditions is unstable angina diagnosed?

Answer 25

Unstable angina is diagnosed when there are symptoms suggestive of acute coronary syndrome (ACS), the troponin is normal, and the ECG shows either a normal pattern or other changes, such as ST depression or T wave inversion.

Question 26

What are the possible diagnoses when a patient presents with chest pain but both troponin and ECG results are normal?

Answer 26

When a patient presents with chest pain but both troponin and ECG results are normal, the diagnosis could be unstable angina or another cause, such as musculoskeletal chest pain.

Question 27

What mnemonic can be used to remember the initial management of acute coronary syndrome, and what does each letter stand for?

Answer 27

The mnemonic “CPAIN” can be used:
C: Call an ambulance
P: Perform an ECG
A: Administer Aspirin 300mg
I: Intravenous morphine for pain if required (with an antiemetic, e.g., metoclopramide)
N: Administer Nitrate (GTN)

Question 28

What should be done for a patient who is pain-free but had chest pain within the past 72 hours?

Answer 28

They should be referred to the hospital for a same-day assessment, usually by the medical team in the Ambulatory Care Unit, depending on local pathways.

Question 29

When might a patient with recent chest pain require emergency admission?

Answer 29

Emergency admission may be required if there are ECG changes or complications, such as signs of heart failure.

Question 30

What are the two primary treatment options for a patient with STEMI presenting within 12 hours of onset?

Answer 30

The two primary treatment options are Percutaneous Coronary Intervention (PCI) if available within 2 hours, or thrombolysis if PCI is not available within 2 hours.

Question 31

What is the role of aspirin and prasugrel in STEMI management?

Answer 31

Aspirin and prasugrel are given in preparation for PCI to prevent further clot formation.

Question 32

What does Percutaneous Coronary Intervention (PCI) involve?

Answer 32

PCI involves inserting a catheter into the radial or femoral artery, guiding it to the coronary arteries under x-ray, and using contrast to identify blockages. Treatment may include angioplasty (widening the artery with a balloon), removal of the blockage, and usually inserting a stent to keep the artery open.

Question 33

What does thrombolysis involve, and what is a significant risk associated with it?

Answer 33

Thrombolysis involves injecting a fibrinolytic agent to break down fibrin in blood clots. A significant risk associated with thrombolysis is bleeding.

Question 34

What mnemonic can be used to remember the medical management of an NSTEMI, and what does each letter stand for?

Answer 34

The mnemonic “BATMAN” can be used:
B: Base the decision about angiography and PCI on the GRACE score
A: Aspirin 300mg stat dose
T: Ticagrelor 180mg stat dose (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M: Morphine titrated to control pain
A: Antithrombin therapy with fondaparinux (unless high bleeding risk or immediate angiography)
N: Nitrate (GTN)

Question 35

When should oxygen be administered to a patient with NSTEMI?

Answer 35

Oxygen should be given only if the patient’s oxygen saturation drops below 95%, unless they have COPD.

Question 36

When should unstable NSTEMI patients be considered for angiography?

Answer 36

Unstable NSTEMI patients should be considered for immediate angiography, similar to patients with STEMI.

Question 37

What does the GRACE score estimate in NSTEMI patients?

Answer 37

The GRACE score estimates the 6-month probability of death after an NSTEMI.

Question 38

When should patients at medium or high risk based on the GRACE score undergo early angiography?

Answer 38

Patients at medium or high risk should undergo early angiography with PCI within 72 hours.

Question 39

What are the key components of ongoing management after the initial treatment of an NSTEMI?

Answer 39

Key components include an echocardiogram to assess heart function, cardiac rehabilitation, and secondary prevention.

Question 40

What mnemonic helps remember the medications for secondary prevention after an NSTEMI, and what does it stand for?

Answer 40

The mnemonic “6 A’s” helps remember:
- Aspirin 75mg once daily indefinitely
- Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
- Atorvastatin 80mg once daily
- ACE inhibitors (e.g., ramipril) titrated as tolerated
- Atenolol (or another beta blocker, e.g., bisoprolol) titrated as tolerated
- Aldosterone antagonist (e.g., eplerenone) for those with clinical heart failure

Question 41

Why is it important to monitor renal function in patients taking ACE inhibitors and aldosterone antagonists?

Answer 41

Both medications can cause hyperkalemia, and there is a risk of fatal hyperkalemia when used together.

Question 42

What mnemonic can be used to remember the complications of a myocardial infarction, and what does each letter represent?

Answer 42

The mnemonic “DREAD” can be used:
D: Death
R: Rupture of the heart septum or papillary muscles
E: ‘‘edema” (heart failure)
A: Arrhythmia and Aneurysm
D: Dressler’s Syndrome

Question 43

What is Dressler’s syndrome, and when does it typically occur?

Answer 43

Dressler’s syndrome, or post-myocardial infarction syndrome, is an immune response causing pericarditis, usually occurring 2-3 weeks after an MI.

Question 44

How does Dressler’s syndrome present, and what are the key diagnostic findings?

Answer 44

It presents with pleuritic chest pain, low-grade fever, and a pericardial rub on auscultation. Diagnostic findings include global ST elevation and T wave inversion on ECG, pericardial effusion on echocardiogram, and raised inflammatory markers (CRP, ESR).

Question 45

What is the management for Dressler’s syndrome?

Answer 45

Management includes NSAIDs (e.g., aspirin or ibuprofen), steroids for severe cases, and pericardiocentesis if there is a significant pericardial effusion.

Question 46

What are the four types of myocardial infarction, and what mnemonic can help remember them?

Answer 46

The mnemonic “ACDC” helps remember:
Type 1: A – ACS-type MI (acute coronary event)
Type 2: C – Can’t cope MI (ischemia due to increased demand or reduced supply)
Type 3: D – Dead by MI (sudden cardiac death suggestive of ischemia)
Type 4: C – Caused by us MI (associated with procedures like PCI, stenting, or CABG)