Acute Coronary Syndrome (ACS)

Question 1

3 types of ACS

Answer 1

Unstable Angina - no troponin rise
STEMI - trop rise - ST elevation or new LBBB
NSTEMI - trop rise - St depression, TWI, or normal ECG

Question 2

Non-modifiable risk factors

Answer 2

Age
Gender
FHx of IHD
MI in 1st degree relative at <55 years

Question 3

Modifiable risk factors

Answer 3

Smoking
Hypertension
T2DM
High lipids
obesity
cocaine use

Question 4

Symptoms of ACS

Answer 4

chest pain
nausea
SOB
sweating
palpitations

Question 5

Signs of ACS

Answer 5

Pallor/grey
Sweaty
High or low pulse
High or low BP
4th heart sound

Signs of heart failure
- raised JVP
- 3rd heart sound
- basal creps
- pansystolic murmur (papillary muscle rupture)

Question 6

Who is more at risk of a SILENT MI?

Answer 6

T2DM
Elderly patients

Question 7

What symptoms are experienced during a silent MI instead of pain?

Answer 7

Syncope
Pulmonary oedema
vomiting
oliguria
confusion

Question 8

Important investigations in ACS

Answer 8

ECG
Bloods - including Troponin, glucose, lipids
CXR - cardiomegaly/pulmonary oedema
ECHO

Question 9

Name at least 3 differentials of ACS

Answer 9

Stable angina
Pericarditis/Myocarditis
Aortic Dissection
PE
Reflux
MSK Pain (costochondritis)
Pneumothorax
Takotsubo’s Cardiomyopathy
Pancreatitis

Question 10

Acute Mx of ACS

Answer 10

MONA + T
Morphine
Oxygen
Nitrates
Aspirin 300mg

+ Ticagrelor 180mg loading dose
(then 90mg BD)

Question 11

Definitive management of STEMI

Answer 11

PCI
If unavailable within 2 hours
Fibrinolysis

Question 12

Management of NSTEMI

Answer 12

If haemodynamic instability = angiography +/- PCI

Load on Aspirin 300mg, Ticagrelor 180mg
Fondaparinux 2.5mg OD subcutaneous

Add beta blocker - bisoprolol 2.5mg OD

Then refer to cardiology for angiography

Question 13

Secondary Prevention in ACS

Answer 13

Aspirin 75mg OD

2nd antiplatelet for 12 months
- Clopidogrel 75mg OD or Ticagrelor 90mg BD

Beta blocker (start low and slow)

ACEi if reduced LV function/diabetes/HTN

Statin - atorvastatin 80mg OD

Question 14

When should a patient with an NSTEMI have their angiography if haemodynamically stable?

Answer 14

GRACE Score >140 = within 24 hours
GRACE Score 109-140 = within 3 days

Question 15

What definitive management should be considered if a patient presenting with an ACS has multi vessel disease?

Answer 15

CABG

Question 16

How soon after angioplasty can patients drive?

Answer 16

1 week following successful angioplasty

4 weeks following unsuccesful angioplaty but Ejection Fraction >40%

Group 2 Holders must inform DVLA and stop driving

Question 17

Name at least 3 complications of MI

Answer 17

Cardiac arrest
Cardiogenic Shock
LV failure
Bradyarrhythmias
Tachyarrhythmias
Pericarditis
Tamponade
Mitral Regurg. (papillary muscle rupture)
Ventricular Septal Defect
Dresslers Syndrome

Question 18

What is Dressler’s Syndrome and how soon after an MI does it develop?

Answer 18

Symptoms develop 1-3 weeks post MI:
Pericarditis
Effusions
Fever
Anaemia
Raised inflammatory markers

Question 19

Tx for Dressler’s syndrome

Answer 19

NSAIDs

Question 20

What complication can arise from a large anterior MI?

Answer 20

LV mural thrombus causing systemic embolism

Tx with 3 months warfarin

Question 21

When do late malignant ventricular arrhythmias occur? How can they be avoided?

Answer 21

1-3 weeks after MI
AVOID HYPOKALAEMIA

Question 22

When can a left ventricular aneurysm occur post MI?

Answer 22

4-6 weeks post MI

Question 23

Presentation of LV aneurysm post MI

Answer 23

LV failure
Angina
recurrent VT
Systemic emoblism
ECG shows persistent ST elevation