Acute Coronary Syndrome

Question 1

Definition of ACS

Answer 1

Unstable angina + evolving MI

Question 2

3 categories of ACS?

Answer 2

ST elevation
LBBB
Non-ST elevation

Question 3

ACS pathophysiology?

Answer 3

Type 1: Atherosclerotic plaque rupture, thrombosis and inflammation

Type 2: MI secondary to ischaemia due to increased oxygen demand or reduced supply due to coronary spasm/embolism/arrhythmia/anemia/hypotension etc.

Question 4

Levine’s sign?

Answer 4

Patient describing pain by putting clenched fist on chest

Question 5

Symptoms of ACS?

Answer 5

Acute central/left chest pain lasting > 20min, radiating to left arm or jaw
Nausea
Sweating
Dyspnoea
Palpitation

Question 6

Signs of ACS?

Answer 6

Anxiety
Pallor sweating
Pulse or BP up/down
4th heart sound
Signs of LVF
PSM (due to MR)

Question 7

ACS Differential

Answer 7

Angina
Peri/myo/endocarditis
Dissection
PE/pneumothorax/pneumonia
Costochondritis
GORD, oesophageal reflux 
Anxiety

Question 8

What is the STEMI sequence on ECG?

Answer 8

Normal
ST elevation and hyperacute T waves
Q waves
Normalisation of ST segments
T wave inversion

Question 9

What is seen on ECG during a NSTEMI?

Answer 9

ST depression

T wave inversion

Question 10

Which waves are NOT present in a subendocardial infarct?

Answer 10

Q waves

Question 11

What are troponins and how are they used to diagnose MI?

Answer 11

Troponins are myofibrillar proteins linking actin and myosin.
They are released 3-12 hours post-MI, peak at 24h and return to baseline in 5-14 days.
Need to monitor troponins for 12h to exclude MI

Question 12

What is the difference between UA and NSTEMI?

Answer 12

UA and NSTEMI may present with typical symptoms and no ST elevation.
UA has NEGATIVE TROPONINS while NSTEMI associated with POSITIVE TROPONINS.

Question 13

What is the Killip classification for?

Answer 13

4 classes of heart failure post-MI

Question 14

What are the steps in STEMI management?

Answer 14

ECG
O2 (aim for >94% sats)
IV access
Brief assessment
Antiplatelet (aspirin and clopidogrel 300mg PO)
Morphine (5-10mg IV) + metoclopramide
GTN 2 puffs 
Beta-blockers
LMWH
PCI or thrombolysis

Question 15

When is PCI indicated?

Answer 15

If <12h onset of symptoms

Question 16

What is PCI?

Answer 16

Angioplasty & stenting

+ GPIIb/IIIa inhibitor (tirofiban) if high risk

Question 17

When is thrombolysis contraindicated?

Answer 17

If > 24h after pain onset
AGAINST mnemonic
Aortic dissection, GI bleeding, allergic reaction, iatrogenic (recent surgery), neuro (cerebral neoplasm/recent CVA), severe HTN, trauma

Question 18

What agents are used for thrombolysis?

Answer 18

rt-PA, streptokinase, tenecteplase

Question 19

What drug is given for 1month post-MI?

Answer 19

Clopidogrel

Question 20

Continuing therapy post-MI?

Answer 20

ACE-I
Beta-blocker
Cardiac rehabilitation
DVT prophylaxis until fully mobile
Statin (regardless of basal lipids)

Question 21

Management of UA/NSTEMI?

Answer 21

Same as STEMI (ECG, O2, IV access, assessment, aspirin, clopidogrel, fondaparinux, analgseia, anti-ischaemia.
Then if high-risk consider PCI/thrombolysis , but if low risk (UA) then can discharge if troponin is negative.
Continuing therapy is the same.