Acute Coronary Syndromes

Question 1

What is coronary artery disease (CAD)?

Answer 1

Narrowing of coronary arteries due to atherosclerosis

Question 2

What characterizes chronic coronary syndrome?

Answer 2

Patients with stable angina or no symptoms managed in an outpatient setting

Question 3

What is the main pathophysiology of chronic coronary syndrome?

Answer 3

Fixed narrowing

Question 4

What conditions are included in acute coronary syndrome?

Answer 4

Myocardial infarction (STEMI or NSTEMI) and unstable angina

Question 5

What is the main pathophysiology of acute coronary syndrome?

Answer 5

Sudden occlusion

Question 6

What does the acronym DIABETES stand for in coronary artery disease risk factors?

Answer 6

• D: Diabetes
• I: Inactivity and obesity/metabolic syndromes
• A: Age (older) and gender (men)
• B: Blood pressure high (hypertension)
• E: Elevated cholesterol (hypercholesterolemia)
• T: Tobacco smoking
• E: Ethnicity and family history
• S: Stress

Question 7

Which group has a significantly higher risk of coronary artery disease?

Answer 7

Postmenopausal women compared to premenopausal women

Question 8

What is the QRISK2 Cardiovascular risk score used for?

Answer 8

Screening tool that measures risk of patient having a heart attack or stroke within the next 10 years

Question 9

What are the risk categories for the QRISK2 score?

Answer 9

• Low risk: Less than 10% (1 in 10 chance)
• Moderate risk: Between 10-20% (1 in 2 in 10 chance)
• High risk: More than 20% (over 1 in 5 chance)

Question 10

What is the primary cause of coronary artery disease pathophysiology?

Answer 10

Mostly due to atherosclerosis affecting large and medium arteries, especially at branch points and bifurcations

Question 11

What damages or dysfunctions the artery endothelium?

Answer 11

Due to tobacco or drug toxins, hyperlipidemia, hypertension, trauma

Question 12

What happens to Low-density Lipoprotein (LDL) cholesterol in coronary artery disease?

Answer 12

Accumulates within dysfunctional tunica intima

Question 13

What is fatty streak formation?

Answer 13

LDL accumulation causes monocyte recruitment, converting to macrophages and producing foam cells

Question 14

What is atheroma formation?

Answer 14

Well-defined lipid core with macrophage debris and fibrous connective tissue

Question 15

Describe atheroma morphology.

Answer 15

Raised lesion with soft yellow lipid core covered by white fibrous cap

Question 16

What signals smooth muscle cell migration from tunica media during plaque progression?

Answer 16

Macrophage apoptosis

Question 17

What are the effects of smooth muscle cell migration during plaque progression?

Answer 17

• Secretion of elastin and collagen
• Calcium deposition
• Neovascularization signals

Question 18

What condition does plaque progression cause?

Answer 18

Chronic coronary syndrome

Question 20

What is plaque disruption and thrombus formation?

Answer 20

It is the process where clot formation occurs due to endothelial dysfunction, leading to artery occlusion.

Question 21

What causes clot formation in arteries?

Answer 21

Endothelial dysfunction causes loss of antithrombotic properties and inappropriate vasoconstriction.

Question 22

What are the consequences of weakened plaques in arteries?

Answer 22

They can lead to aneurysm formation and rupture.

Question 23

What conditions are caused by artery occlusion?

Answer 23

Acute coronary syndromes.

Question 24

What is angina?

Answer 24

Chest pain that occurs due to myocardial ischaemia.

Question 25

What causes myocardial ischaemia in angina?

Answer 25

Atherosclerotic plaques partially block coronary arteries.

Question 26

What are the four characteristics of angina?

Answer 26

* Retrosternal pain that can spread to other areas * Feelings of crushing pressure and tightness * Precipitating factors (4 Es): Exertion, eating, emotional distress, extreme temperatures * Attacks last a few minutes

Question 27

What is the typical location of pain in angina?

Answer 27

Retrosternal area, arms, neck, lower jaw, and upper abdomen.

Question 28

What feelings are associated with angina?

Answer 28

Crushing pressure and tightness in the chest.

Question 29

What are the relieving factors for angina?

Answer 29

Rest and/or nitrates provide relief within 2 minutes.

Question 30

How long do attacks of angina typically last?

Answer 30

A few minutes.

Question 31

What is Class I angina severity classification?

Answer 31

Ordinary activity doesn't cause angina.

Question 32

What is Class II angina severity classification?

Answer 32

Slight limitation of ordinary activity.

Question 33

What is Class III angina severity classification?

Answer 33

Marked limitation of ordinary activity.

Question 34

What is Class IV angina severity classification?

Answer 34

Inability to carry on any physical activity without discomfort.

Question 35

What is stable angina?

Answer 35

Stable atherosclerotic plaque narrows lumen, causing angina when oxygen demand exceeds supply during exertion or stress.

Question 36

What are the two approaches to treating stable angina?

Answer 36

Symptomatic treatment and prognostic benefit.

Question 37

What does symptomatic treatment for stable angina include?

Answer 37

Lifestyle management: Regular exercise, smoking cessation, psychosocial stress management, diet.

Question 38

What are the medical management options for stable angina?

Answer 38

1. Anti-anginals: Beta-blockers, calcium channel blockers, nitrates. 2. Vasculoprotective agents: Aspirin, statins, ACE inhibitors.

Question 39

What are first-line anti-anginals?

Answer 39

Beta-blockers and calcium channel blockers, which slow heart rate and increase coronary perfusion in diastole. ## Footnote Examples: Diltiazem, amlodipine.

Question 40

What do nitrates do in the treatment of stable angina?

Answer 40

Reduce left ventricular end-diastolic pressure (LVEDP) and increase coronary vasodilation. ## Footnote Example: Long-acting oral nitrates such as isosorbide mononitrate.

Question 41

What is surgical management for stable angina?

Answer 41

Revascularization with Percutaneous coronary intervention (PCI) or Coronary Artery Bypass Graft (CABG).

Question 42

When is PCI indicated?

Answer 42

If angina isn't controlled on 2 anti-anginals, also used to treat NSTEMI MI urgently and emergency treatment of STEMI MI.

Question 43

When is CABG indicated?

Answer 43

If angina isn't controlled on 2 drugs, indicated in left main stem, proximal 3 vessel diseases, and for more complicated disease and higher risk.

Question 44

What is unstable angina?

Answer 44

Atherosclerotic plaque becomes unstable and ruptures, causing partial occlusion of the artery due to bleeding and thrombosis.

Question 45

What are the symptoms of unstable angina?

Answer 45

Angina at rest or minimal exertion and is prolonged.

Question 46

What is variable/prinzmetal angina?

Answer 46

Coronary artery has intense vasospasm and suddenly narrows at night and during rest.

Question 47

What are the most significant acute coronary syndromes?

Answer 47

STEMI, NSTEMI, unstable angina

Question 48

What is STEMI?

Answer 48

Complete thrombus occlusion of artery, which causes myocardial infarction.

Question 49

What is NSTEMI?

Answer 49

Partial thrombus occlusion of artery, which causes myocardial infarction.

Question 50

What is unstable angina?

Answer 50

Athersclerotic plaque occlusion of artery becomes unstable and ruptures, causing partial occlusion of artery.

Question 51

What are common presentations of acute coronary syndromes?

Answer 51

Angina, nausea/stomach pain, shortness of breath (SOB).

Question 52

What is the first line investigation for acute coronary syndromes?

Answer 52

ECG findings.

Question 53

What is the second-line investigation for acute coronary syndromes?

Answer 53

Cardiac biomarkers in blood test.

Question 54

What does ST elevation indicate in ECG findings?

Answer 54

ST elevation, reciprocal ST depression in leads of other areas of heart.

Question 55

What are elevated cardiac biomarkers in NSTEMI?

Answer 55

Creatine kinase-myocardial band (CK-MB) and Troponin.

Question 56

What are the treatment components for acute coronary syndromes?

Answer 56

MONARCH BASIC.

Question 57

What does 'M' stand for in MONARCH BASIC?

Answer 57

Morphine.

Question 58

What does 'O' stand for in MONARCH BASIC?

Answer 58

Oxygen.

Question 59

What does 'N' stand for in MONARCH BASIC?

Answer 59

Nitrates, e.g., Glyceryl trinitrate spray.

Question 60

What does 'A' stand for in MONARCH BASIC?

Answer 60

Aspirin, an antiplatelet drug.

Question 61

What does 'R' stand for in MONARCH BASIC?

Answer 61

Reperfusion with PCI or thrombolysis.

Question 62

What is primary percutaneous coronary intervention (PCI)?

Answer 62

Balloon is threaded through a blood vessel to the blockage site and inflated to compress the plaque.

Question 63

What is the first-line thrombolytic for thrombolysis?

Answer 63

Alteplase.

Question 64

What does 'C' stand for in MONARCH BASIC?

Answer 64

Clopidogrel, but prasugrel or ticagrelor is preferred.

Question 65

What does 'H' stand for in MONARCH BASIC?

Answer 65

Heparin.

Question 66

What is the first step in secondary prevention for a patient?

Answer 66

Start beta-blocker as soon as the patient is hemodynamically stable.

Question 67

When should beta-blockers be discontinued?

Answer 67

Beta-blockers can be discontinued after 12 months if LVEF is not reduced; otherwise, continue indefinitely.

Question 68

What anticoagulant therapy should be used in secondary prevention?

Answer 68

Use anticoagulant or dual antiplatelet therapy (aspirin with another antiplatelet).

Question 69

How long should aspirin be continued?

Answer 69

Aspirin should continue indefinitely.

Question 70

How long can dual antiplatelet therapy be continued?

Answer 70

Dual antiplatelet therapy can be continued up to 12 months.

Question 71

What is included in secondary prevention besides medications?

Answer 71

Statin and inhibitors (e.g., ACE inhibitor) should be started as soon as the patient is hemodynamically stable and continued indefinitely.

Question 72

What is the goal of correcting risk factors in secondary prevention?

Answer 72

Correction of risk factors has an effectiveness of 83%.

Question 73

What are some cardiac causes of chest pain?

Answer 73

Angina and pericarditis.

Question 74

What are some gastrointestinal causes of chest pain?

Answer 74

GERD, peptic ulcers, biliary coeliac, esophageal spasms.

Question 75

What are some musculoskeletal causes of chest pain?

Answer 75

Cervical radiculitis and costochondral syndrome.

Question 76

What are the further investigations for coronary artery disease?

Answer 76

1. Stress tests (Exercise ECG, Myocardial perfusion imaging, Dobutamine stress echocardiography, Stress MRI) 2. Echocardiogram 3. Angiography (Non-invasive CT coronary angiogram or invasive coronary angiogram) 4. FBC

Question 77

What does blue coloring indicate in myocardial perfusion imaging?

Answer 77

Blue coloring indicates extreme myocardial ischaemia on stress.