Acute Coronary Syndrome

Question 1

What are symptoms and signs?

Answer 1

Central/left sided chest pain
Radiates to jaw or left arm
Heavy pain
Dyspnoea
N&V
Sweating

May be
- pale and clammy
- haemodynamically stable

Question 2

What investigations are required>

Answer 2

Troponin
ECG
- looking ST elevation to differentiate between STEMI and NSTEMI

Question 3

What ECG changes may represent infarcts in different arteries?

Answer 3

Lead V1-V4= left anterior descending

Leads II, III, AVF= right coronary

Leads I, AVL, V5-V6= left circumflex

Question 4

What is the management of STEMI?

Answer 4

1) Antiplatelet= Aspirin 300mg
- If having PCI then prasugrel (if not already on anti-coagulation) Or ticagrelor/clopidogrel if high bleeding risk
Clopidogrel if already on anti-coag
- If not for PCI then ticagrelor or clopi (if high bleeding risk)

2) PCI
- Primary PCI if possible within 2 hours and symptoms present <12 hours
- Can consider if late presentation but ongoing ischaemia
- PCI NOT available within 2 hours= treat with fibrinolysis
– drugs such as alteplase, streptokinase, alongside antithrombin e.g. fonaparinux
– then repeat ECG 60-90mins later, if ST elevation >50% remaining then PCI and angio

Question 5

What is the management of unstable angina/NSTEMI?

Answer 5

Risk assessment
- GRACE score= looks at BP, Age, HR, Systolic BP, trop, ECG

1) Antiplatelets
- Aspirin 300mg
- Grace >3%= Angio and PCI within 72 hours, and add prasugrel/ticagrelor (or clopi of on anticoag)
- Grace <3%= Ticagrelor or clopi (high bleed risk) and imaging before discharge

2) Antithrombin
Fonaparinux- unless PCI or high bleed risk
- Unfractionated heparin if high bleed risk or renal impairment

3) Further management
- If unstable= offer angiography

Question 6

What is secondary prevention?

Answer 6

Cardiac rehab
Aspirin 75mg OD for life
Second antiplatelet e.g. clopidogrel (NSTEMI)
ACEi
Beta blocker
Statin- high dose

Consider aldosterone antagnoist for HFrEF

Question 7

What are complications of MI?

Answer 7

Vfib- most common cause of death

Arrythmias- esp AV block

Pericarditis- within 2-3 days
- pain on lying flat

Dressler Syndrome- occurs at 4-6 weeks
- similar symptoms to Pericarditis
- treat with NSAIDs

Left ventricular aneursym
- Persistent ST elevation and LV failure
- treat with NOAC

LV free wall rupture
- occurs at 1-2 weeks
- Presents with cardiac tamponade (Beck triad- Acute HF, raised JVP, quiet heart sounds)

Ventricular septal defect
- 1-2 weeks post MI
- Harsh pansystolic murmur

Mitral regurg
- papillary muscle rupture
- pansystolic murmur, heart failure and hypotension