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Acute Coronary Syndrome Flashcards

1
Q

How many types of acute coronary syndromes are there?

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

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

A
  1. R coronary artery
  2. L coronary artery
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3
Q

What does the R coronary artery supply?

A
  • Right atrium
  • Right ventricle
  • Inferior aspect of the left ventricle
  • Posterior septal area
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4
Q

What does the L coronary artery divide into to become?

A
  • Circumflex artery
  • Left anterior descending (LAD)
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5
Q

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

A
  • Left atrium
  • Posterior aspect of the left ventricle
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6
Q

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

A

Anterior aspect of the left ventricle
Anterior aspect of the septum

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7
Q

What is the typical presentation of acute coronary syndrome?

A

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

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8
Q

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

A

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

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9
Q

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

A

Symptoms should continue at rest for more than 15 minutes.

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10
Q

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

A

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.

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11
Q

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

A

ST-segment elevation and new left bundle branch block.

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12
Q

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

A

ST segment depression and T wave inversion.

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13
Q

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

A

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.

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14
Q

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

A

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

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15
Q

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

A

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

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16
Q

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

A

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

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17
Q

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

A

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

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18
Q

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

A

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

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19
Q

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

A

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

20
Q

What does a rise in troponin levels indicate?

A

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

21
Q

How is an NSTEMI diagnosed using troponin results?

A

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).

22
Q

Why are troponin tests not required to diagnose a STEMI?

A

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

23
Q

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

A

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

24
Q

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

A

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.
25
Under what conditions is unstable angina diagnosed?
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.
26
What are the possible diagnoses when a patient presents with chest pain but both troponin and ECG results are normal?
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.
27
What mnemonic can be used to remember the initial management of acute coronary syndrome, and what does each letter stand for?
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)
28
What should be done for a patient who is pain-free but had chest pain within the past 72 hours?
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.
29
When might a patient with recent chest pain require emergency admission?
Emergency admission may be required if there are ECG changes or complications, such as signs of heart failure.
30
What are the two primary treatment options for a patient with STEMI presenting within 12 hours of onset?
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.
31
What is the role of aspirin and prasugrel in STEMI management?
Aspirin and prasugrel are given in preparation for PCI to prevent further clot formation.
32
What does Percutaneous Coronary Intervention (PCI) involve?
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.
33
What does thrombolysis involve, and what is a significant risk associated with it?
Thrombolysis involves injecting a fibrinolytic agent to break down fibrin in blood clots. A significant risk associated with thrombolysis is bleeding.
34
What mnemonic can be used to remember the medical management of an NSTEMI, and what does each letter stand for?
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)
35
When should oxygen be administered to a patient with NSTEMI?
Oxygen should be given only if the patient’s oxygen saturation drops below 95%, unless they have COPD.
36
When should unstable NSTEMI patients be considered for angiography?
Unstable NSTEMI patients should be considered for immediate angiography, similar to patients with STEMI.
37
What does the GRACE score estimate in NSTEMI patients?
The GRACE score estimates the 6-month probability of death after an NSTEMI.
38
When should patients at medium or high risk based on the GRACE score undergo early angiography?
Patients at medium or high risk should undergo early angiography with PCI within 72 hours.
39
What are the key components of ongoing management after the initial treatment of an NSTEMI?
Key components include an echocardiogram to assess heart function, cardiac rehabilitation, and secondary prevention.
40
What mnemonic helps remember the medications for secondary prevention after an NSTEMI, and what does it stand for?
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
41
Why is it important to monitor renal function in patients taking ACE inhibitors and aldosterone antagonists?
Both medications can cause hyperkalemia, and there is a risk of fatal hyperkalemia when used together.
42
What mnemonic can be used to remember the complications of a myocardial infarction, and what does each letter represent?
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
43
What is Dressler’s syndrome, and when does it typically occur?
Dressler’s syndrome, or post-myocardial infarction syndrome, is an immune response causing pericarditis, usually occurring 2-3 weeks after an MI.
44
How does Dressler’s syndrome present, and what are the key diagnostic findings?
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).
45
What is the management for Dressler’s syndrome?
Management includes NSAIDs (e.g., aspirin or ibuprofen), steroids for severe cases, and pericardiocentesis if there is a significant pericardial effusion.
46
What are the four types of myocardial infarction, and what mnemonic can help remember them?
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)

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