Acute Coronary Syndrome

Question 1

With regards to ischaemic chest pain, what is the most important to find out that will affect treatment?

In a set of OBS with will likely go off first?

Answer 1

• time of onset

- respiratory rate

Question 2

What investigations would you like in ACS?

Answer 2

• ECG

- U+E, FBC, LFT, cholesterol, cardiac markers (CKMB, 12 hour troponin)

Question 3

If a patient doesnt have STEMI, what kind of ECG changes warrant “high risk” treatment?

Answer 3

• ST depression or T wave inversion

Question 4

How long should a P wave and QRS complex be?

Answer 4

• 3-5 small squares (1.2-2mm)

- <3 small squares (1.2mm)

Question 5

How do you distinguish between AF and SVT on ECG?

What rate does SVT usually run at?

In a patient with Fast AF that has been treated what might you see on ECG?

Answer 5

• AF is irregularly irregular (narrow complex)
• SVT is regular (narrow complex)
• 150 BPM
• Large ST depression

Question 6

What does VT look like on ECG?

How should you manage pulseless VT in emergency?

VT with a pulse?

Answer 6

• broad QRS
• High HR
• No P waves
• begin chest compressions and shock patient
• synchronised shock of a patient

Question 7

What happens to QRS and HR in heart block?

Answer 7

• decreased HR and widened QRS

Question 8

What two scores might be used in ACS to assess risk?

Answer 8

• GRACE or TIMI score

Question 9

What is the management common to ALL ACS?

Which drug can also be given in STEMI or NSTEMI?

Answer 9

• morphine 2.5-10mg (with anti-emetic)
• Oxygen 15L NRBM (if 02 <94%)
• GTN (2 puffs)
• Aspirin 300mg
• Fondaparinux 2.5mg S/C (LMWH)
• ticagrelor 180mg PO (glycoprotein inhibitor)

Question 10

What should happen in a STEMI?

Answer 10

• Primary PCI if within 12 hours of onset

- Thrombolysis if PCI not available (<90 mins)

Question 11

If a patient has ongoing chest pain after initial management of STEMI or NSTEMI what can be done?

Answer 11

• GTN infusion (but drops BP so be careful)

- Repeat ECG

Question 12

When is a CABG indicated?

Answer 12

• failed PCI
• cardiogenic shock
• multivessel disease

Question 13

What 4 types of medication should a patient with MI be taking long term after stable?

Answer 13

• beta blocker
• antiplatelet (aspirin/ clopidogrel)
• ACE inhibitor
• statin

Question 14

Describe the ECG with First degree AV block.

Describe 2nd Degree HB (Wankyback) Mobitz type 1

Describe 2nd Degree HB Mobitz type 2

Answer 14

• prolonged PR interval, but uniform across the ECG
• PR interval increases until there is a dropped beat
• Fixed PR but dropped beats (Clarify by using ratio e.g. 3:1, 4:1)

Question 15

Describe ECG of Complete heart Block

Answer 15

• P waves and QRS complexes completely unrelated

Question 16

Describe the location of blockage in First Degree, Mobitz 1 and 2 and complete HB

Answer 16

1st- Between SA and AV node
2nd (type 1)- In the AV node
2nd (type 2)- After the AV node in the bundle of His/ purkinje fibres

3rd- Anywhere from AV node down

Question 17

What kind of wave will you see in wolff parkinson white syndrome?

Answer 17

• Delta wave (sorting hat)

Question 18

How is ST depression defined?

Answer 18

• > 1 small square in relation to the baseline (lacks specificity)

Question 19

Name some other causes of ST depression?

Answer 19

• Anxiety
• Digoxin causes
• Tachycardia
• Haemorrhage, hypokalaemia
• myocarditis