Acute Coronary Syndromes

Question 1

Acute coronary syndromes

Answer 1

1. Unstable angina
2. NSTEMI
3. STEMI

Question 2

Non-modifiable risk factors for acute coronary syndrome

Answer 2

• increasing age
• male
• family history
• premature menopause

Question 3

Modifiable risk factors for acute coronary syndrome

Answer 3

• obesity
• smoking
• hypertension
• hyperlipidaemia
• diabetes

Question 4

Pathophysiology of acute coronary syndrome

Answer 4

1. endothelial cell injury & inflammation
2. atheromatous plaque formation
3. atheromatous plaque rupture -> clotting cascade, thrombosis -> arterial occlusion

Question 5

Clinical features of acute coronary syndrome

Answer 5

typical:
- central crushing chest pain (+/- radiating)
- anxiety, restlessness
- dyspnoea
- diaphoresis
- nausea and vomiting
- palpitations

non-typical:
- syncope/presyncope
- fatigue
- epigastric pain

Question 6

Population that may not experience chest pain in acute coronary syndrome

Answer 6

• diabetics
• elderly

Question 7

Clinical exam findings in acute coronary syndrome

Answer 7

appearance:
- restless, anxious
- extreme sweating

vitals:
- tachycardia
- tachypnoea
- reduced sats
- hypotension (if shocked)

Question 8

Investigating acute coronary syndrome

Answer 8

1. ECG
2. Bloods - troponin
3. other - cxr, echo, coronary angiography

Question 9

ECG findings in unstable angina & NSTEMIs

Answer 9

• may be normal
• may have ST depression
• may have other abnormal findings (e.g. T wave inversion)

Question 10

Differentiating unstable angina & NSTEMI

Answer 10

• unstable - no troponin increase
• NSTEMI - troponin increase

Question 11

ECG findings STEMI

Answer 11

• ST elevation
• +/- new left bundle branch block

Question 12

Identifying left bundle branch block on ECG

Answer 12

V1 = W
V6 = M

Question 13

Anterior STEMI on ECG

Answer 13

• V1-V4
• Left anterior descending artery

Question 14

Lateral STEMI on ECG

Answer 14

• V5, V6, AVL
• left circumflex artery

Question 15

Inferior STEMI on ECG

Answer 15

• II, III, AVF
• right coronary artery

Question 16

Management of NSTEMI

Answer 16

1. immediate assessment (ECG, troponins)
2. initial therapy (MONA-B) (aspirin, ticagrelor or clopidogrel)
3. anticoagulation (fondapurinux, enoxaparin)
4. risk stratification (Grace Score)
5. long-term management (AAAAL)

Question 17

Initial therapy for acute coronary syndrome

Answer 17

MONA-B
- morphine
- oxygen (if sats < 94%)
- nitrates
- antiplatelets (aspirin 300mg, ticagrelor (or clopidogrel))
- beta-blockers

Question 18

Grace Score in acute coronary syndrome

Answer 18

• determines mortality from MI in next 6 months to 3 years
• low risk (< 3%)
• high risk (> 3%)

Question 19

Low risk Grace Score in NSTEMI

Answer 19

• < 3%
• conservative management

Question 20

High risk Grace score in NSTEMI

Answer 20

• > 3%
• PCI within 72 hours

Question 21

Long-term management in acute coronary syndrome

Answer 21

• dual antiplatelets 12 months (aspirin, ticagrelor or clopidogrel)
• atorvastatin 80mg
• ACE-i or ARB
• atenolol (or other beta blocker)
• aldosterone antagonist (epleronone if HF)
• lifestyle changes

Question 22

Managment of STEMI

Answer 22

1. immediate assessment (ECG, troponins)
2. reperfusion strategy (primary PCI - within 120 mins, thrombolysis - >120 mins for PCI)
3. medical therapy (MONA-B)
4. anticoagulation (during PCI give unfractionated heparin GPI)
5. post-PCI or post-thrombolysis long-term management (AAAAL)

Question 23

Antiplatelets for acute coronary syndrome

Answer 23

• aspirin 300mg
• ticagrelor
• clopidogrel (if on anticoagulants)

Question 24

Anticoagulants used in acute coronary syndrome

Answer 24

• fondapurinux
• enoxaparin
• unfractionated heparin GPI (for during PCI)

Question 25

Secondary prevention lifestyle changes for acute coronary syndrome

Answer 25

• stop smoking
• reduce alcohol consumption
• meditteranean diet
• cardiac rehab (inc. exercise regimen)
• optimise treamtent of other conditions (e.g. BP control)