Acute Coronary Syndromes

Question 1

define myocardial infarction (MI)

Answer 1

an underperfusion of the myocardium leading to death of the myocardial tissue

Question 2

risk factors of MI

Answer 2

male sex
FH of MI 
smoking 
hypertension 
hyperlipidaemia/hypercholesterolaemia 
obesity 
diabetes

Question 3

types of MI

Answer 3

ST-elevation MI (STEMI)

non-ST-elevation MI (NSTEMI)

Question 4

clinical features of MI

Answer 4

sudden central crushing chest pain 
radiation of pain to left arm, jaw and neck 
nausea
sweating/clamminess 
dyspnoea 
worsened by exertion

Question 5

atypical MI presentations

Answer 5

epigastric pain 
acute breathlessness
palpitations 
acute confusion
hyperglycaemia 
syncope

Question 6

diagnosis of STEMI

Answer 6

cardiac chest pain
persistent ST segment elevation (>1mm in chest leads and >2mm in limb leads)
new LBBB

Question 7

diagnosis of NSTEMI

Answer 7

cardiac chest pain
abnormal ECG with NO ST-elevation
raised troponin

Question 8

investigations of MI

Answer 8

ECG
bloods (troponin, FBC, CRP, RFTs, lipids and glucose)
CXR

Question 9

appropriate timing and testing of troponin levels in MI

Answer 9

at least 3hrs following pain

repeat 6-12hrs following onset of pain

Question 10

coronary artery and area of myocardium affected if ST elevation in leads II, III and aVF

Answer 10

inferior myocardium and right coronary artery

Question 11

coronary artery and area of myocardium affected if ST elevation in V1 + V2

Answer 11

septal myocardium and proximal left anterior descending coronary artery

Question 12

coronary artery and area of myocardium affected if ST elevation in leads V3 +V4

Answer 12

anterior myocardium and left anterior descending artery

Question 13

coronary artery and area of myocardium affected if ST elevation in leads V5 + V6

Answer 13

apex of the myocardium and distal LAD, left coronary and right coronary artery affected

Question 14

coronary artery and area of myocardium affected if ST elevation in I and aVL leads

Answer 14

lateral myocardium and left circumflex artery

Question 15

coronary artery and area of myocardium affected if V7 -V9 leads affected

Answer 15

posterolateral and RCA or left circumflex artery affected

Question 16

management of a STEMI

Answer 16

oxygen therapy 
loading dose of PO aspirin 300mg 
sublingual GTN spray 
IV morphine 
PPCI

Question 17

requirements for treatment with primary percutaneous coronary intervention (PPCI)

Answer 17

presenting within 12hrs of pain onset AND are <2hrs since first medical contact

Question 18

management of an NSTEMI

Answer 18

oxygen therapy
loading dose of 300mg aspirin
sublingual GTN spray
IV morphine
antithrombin therapy (e.g. LMWH or fondaparinux)
if high mortality, angiogram within 96hrs

Question 19

post-MI management

Answer 19

aspirin 75mg OM 
clopidogrel 75mg OD OR ticagrelor 90mg OD
bisoprolol 
ACE inhibitor (ramipril)
high dose statin (atorvastatin 80mg ON)

cardiac rehab
ECHO

Question 20

define stable angina

Answer 20

a constriction like pain in the chest, neck, jaw and arms that is brought on by physical activity and alleviated through use of GTN

Question 21

investigations in stable angina

Answer 21

CT coronary angiography
bloods (FBC, TFTs, troponin)
ECG

Question 22

conservative management of stable angina

Answer 22

smoking cessation
glycaemic control
hypertension
hyperlipidaemia 
weight loss
alcohol intake

Question 23

first line management of stable angina

Answer 23

aspirin
statin
sublingual GTN
beta blocker OR rate-limiting calcium channel blocker

Question 24

indications of re-vascularisation in stable angina

Answer 24

symptoms not satisfactorily controlled with optimal medical treatment
complex 3 vessel disease
significant left main stem stenosis

Question 25

ideal medications provided when combining beta-blocker and calcium-channel blocker

Answer 25

bisoprolol and felodipine

• need to use either amlodipine or felodipine
• do not use a non-dihydropyridine