Acute coronary syndrome

Question 1

What does acute coronary syndrome mean?

Answer 1

ACS is the term used to describe a cardiac event that is either:

1) Unstable angina
2) Non ST elevation myocardial infarction (NSTEMI)
3) ST elevation myocardial infarction (acute MI)

Question 2

What are the symptoms of a NSTEMI / STEMI?

Answer 2

1) Central, crushing, tight chest pain (not relieved by GTN)
2) severe pain , radiating to neck and left arm
3) nausea, vomiting, sweating
5) SOB
4) symptoms for more than 20mins

Question 3

What is unstable angina?

Answer 3

Angina with increased frequency and unpredictable. Chest pain at rest.

Question 4

What does the ECG of unstable angina look like?

Answer 4

Normal
ST depression
Or T wave changes

Question 5

What does the ECG of a STEMI look like vs a NSTEMI?

Answer 5

NSTEMI:
Same as unstable angina - ST depression or T wave changes.

STEMI:
ST elevation in 2 or more leads.
New Left Bundle Branch Block

Question 6

What is the pathophysiology of acute coronary syndrome>

Answer 6

1) Plaque ruptures
2) thrombosis + inflammation
3) thrombus occludes lumen of coronary artery.
4) In unstable angina / NSTEMI - Ischaemia occurs (O2 demand higher than supply)
5) In STEMI , prolonged lack of oxygen causes infarct.

Question 7

What investigations should be done for acute coronary syndrome?

Answer 7

1) ECG (STEMI or new LBBB)
2) Cardiac troponin
3)

Question 8

what is the immediate management of ACS/

Answer 8

ROMANCE

• reassure
• oxygen
• morphine 10mg IV, (+antiemetic)
• aspirin 300mg
• nitrates
• clopidogrel 300mg
• enoxaparin 2.5mg
• ECG - if STEMI then PCI asap.

Question 9

What are the differential diagnoses of acute coronary sydrome?

Answer 9

• angina
• pericarditis
• myocarditis
• aortic dissection
• PE
• oesophageal reflux or spasm.

Question 10

What is the long term management after an acute corononary syndrome event?

Answer 10

1) stop smoking
2) statin
3) beta blocker
4) ACEi
5) aspirin
6) clopidogrel

Question 11

What are the complications of acute coronary syndrome?

Answer 11

1) cardiac arrest
2) heart failure (LVF)
3) Myocardial rupture / aneurismal dilatation.
4) Ventricular sptal defect
5) Mitral regurgitation (causes by rupture, MI or ischaemia of papillary muscle, MI of inferior wall)
6) Cardiac arrhythmias such as VT / VF are common in STEMI.
- Atrial fibrillation
- bradyarrhythmia
7) Conduction - AV or BBB
8) Post MI pericarditis or Dressler’s syndrome.