acute coronary syndrome (STEMI, NSTEMI, unstable angina)

Question 1

what is acute coronary syndrome (ACS)

Answer 1

number of acute presentations of ischaemic heart disease

includes: STEMI, NSTEMI, unstable angina

Question 2

what is the cause of ACS

Answer 2

gradual build up of fatty plaques within the walls of the coronary arteries (atherosclerosis)

Question 3

what are the complications of atherosclerosis and what can they lead to

Answer 3

physical blockage = reduced blood flow causing angina

rupture = complete occlusion of the artery causing an MI

Question 4

ECG changes in V1-4 is what sort of MI? what artery is blocked?

Answer 4

anterior

L anterior descending

Question 5

ECG changes in II, III, aVF is what sort of MI? what artery is blocked?

Answer 5

inferior

R coronary

Question 6

ECG changes in I, V5-6 is what sort of MI? what artery is blocked?

Answer 6

lateral

L circumflex

Question 7

what is the initial management for STEM?/NSTEMI

Answer 7

MONA+C

morphine (and anti-emetic)
oxygen
nitrates (GTN spray)
aspirin 
clopidogrel

Question 8

give a brief outline of atherosclerosis

Answer 8

1. endothelial dysfunction (due to smoking, High BP/cholesterol etc.)
2. LDL moves from blood to tunica intima where it is oxidised to OXLDL
3. monocytes migrate across endothelium and differentiate into macrophage which phagocytose OXLDL into ‘foam cells’ = fatty streak

4, smooth muscle proliferation and migration from tunica media to the intimate results in a fibrous capsule covering the fatty plaque

Question 9

what is the treatment of MI (with regards to time limits)

Answer 9

within 120mins = PCI

after 120mins = thrombolysis

Question 10

what is the long term treatment of MI

Answer 10

aspirin + 2nd antiplatelet 
beta-blocker
ACEI
statin 
clopidogrel

Question 11

what is the difference between stable and unstable angina

Answer 11

unstable = pain is not relieved by rest

Question 12

what investigations should be done for angina

Answer 12

ECG to exclude ACS

angiography

Question 13

what is the treatment of stable angina

Answer 13

1st line = GTN spray
2nd line = beta-blocker OR verampil (rate limiting Ca+ blocker)
3rd line = beta-blocker = amlodipine
4th line = isosorbide mononitrate or nicorandil 
secondary prevention (asprirn, ACEI, statin)

Question 14

what must be present in an ECG to diagnose STEMI

Answer 14

> 1mm ST elevation in 2 adjacent limb leads
OR
2mm ST elevation in 2 contiguous precordial leads

Question 15

what tropinin levels would you expect to see, within what timeframe

Answer 15

increased

takes 4-6hrs to rise, peaks at 12

Question 16

what causes STEMI

Answer 16

myocyte death due to prolonged myocardial ischaemia

Question 17

what symptoms are associated with STEMI

Answer 17

pale, clammy, sweaty
thready pulse
severe chest pain >20mins
SOB

women are more likely to present with ATYPICAL symptoms