Acute Coronary Syndromes

Question 1

How does a STEMI appear on an ECG?

Answer 1

ST elevation that must be >1mm in limb leads and >2mm in chest leads.

Question 2

What would you expect the levels of Troponin I and CK to be in a patient who has a STEMI?

Answer 2

Troponin I >100ng/L and CK is usually above 400 units.

Question 3

What would you expect to find on the ECG of a patient with an NSTEMI?

Answer 3

ST depression, T wave inversion, or it can even be normal.

The indicative sign is this accompanied by a troponin I level of >100ng/L.

Question 4

How would you diagnose unstable angina?

Answer 4

Consistent cardiac like chest pain that presents with ECG changes similar to that of an NSTEMI. This can mean its normal or shows ST depression and/or T wave inversion. This is accompanied by a normal Troponin I level.

Question 5

What levels of troponin suggest myocardial necrosis?

Answer 5

34ng/L in males

16ng/L in females

Nb. Levels 5 times above the normal limit are very sensitive to type I myocardial necrosis. Levels 3 times above the normal limit

Question 6

When should you take troponin levels in a patient with ?ACS?

Answer 6

If the onset was over 3 hours ago you only need one troponin level on admission.

For a rapid diagnosis you can take troponin levels one hour following admission. If you are unsure then you can take a further sample 2 hours after this.

Question 7

Name some causes of false positive elevation of Troponin I?

Answer 7

Congestive cardiac failure

Myocarditis

Renal failure

Large PE

Aortic dissection

Aortic stenosis

Question 8

When are posterior and right ventricular leads on an ECG indicated in a cardiac patient?

Answer 8

This should be done on or soon after admission especially those with an inferior STEMI as diagnostic changes may be transient.

Question 9

What are some causes that may mimic a STEMI on an ECG?

Answer 9

1) Brugada syndrome
2) Young athletic patients can have an up-sloping ST elevation
3) Cocaine use
4) Pericarditis
5) Takotsubo cardiomyopathy

Question 10

What is the initial management of a STEMI?

Answer 10

MONA

Morphine and Metocloperamide

Oxygen (only if hypoxic)

Nitrates

Antiplatelets - 300mg loading dose and 75mg OD for life

Contact cardiologist to arrange PPCI

Question 11

Which antiplatelet other than Aspirin should be prescribed for a patient on admission with a STEMI?

Answer 11

1) Prasugrel is first line - 60mg loading with 10mg daily for 12/12. Restricted to patients who are undergoing PPCI for STEMI whom are <75 years old and who weight >60kg and who have not had a prior TIA or stroke
2) If they do not meet the above criteria then they should be prescribed Clopidogrel 600mg loading dose by 75mg OD for up to 12 months.

Question 12

Which antiplatelet other than Aspirin should be prescribed for a patient with an NSTEMI?

In what situation should these be prescribed?

Answer 12

1) Prasugrel first line only if the patient is <60kg, <75y/o and has not had a prior TIA or stroke
2) Ticagrelor should be used in patients who do not meet this criteria.

These should only be prescribed if the patient has a grace score of >3%

Question 13

What blood tests other than diagnostic tests should be run in a patient presenting with ACS?

Answer 13

Lipid profile

Random glucose

Hba1c

FBC is vital

Question 14

What medications should be prescribed to a patient who has suffered an MI on discharge?

Answer 14

1) Beta blocker - eg. Bisoprolol 1.25mg OD
2) ACE inhibitor - Ramipril 2.5mg OD
3) Antiplatelet - eg. Clopidogrel for 12 months 75mg OD
4) Statin - Eg. Atorvastatin 80mg OD

Question 15

What other medical conditions need to be carefully controlled when a patient has ACS?

Answer 15

1) Diabetes mellitus

2) Hypertension

Question 16

In what scenario should you prescribe a patient a PPI with ACS?

Answer 16

If the patient suffers with AF and is already on alternative coagulation and as a result of their MI will end up on triple therapy - they will need to be prescribe a PPI such as Omeprazole

Question 17

How would you manage an NSTEMI?

Answer 17

Morphine

Oxygen if saturations had been affected

Nitrates

Aspirin 300mg loading and 75mg OD

Low molecular weight heparin - eg. Enoxaparin for 48 hours based on weight and creatinine

Repeat ECG and calculate grace score for those with elevated Troponin I.

Question 18

What differential diagnoses should you consider with Angina?

Answer 18

GORD

MSK - Costochondritis

Pulmonary associated pain/pleuritic

Question 19

When can you rule out Angina as a diagnosis?

Answer 19

If the pain is constant/continuous and has other precipitating factors such as dysphagia and dizziness.

Question 20

What investigations should you carry out if you are considering angina as a diagnosis?

Answer 20

FBC

Glucose

HbA1c

Full lipid profile

Resting 12 lead ECG - a stress test can be used to diagnose in patients with known cardiac disease. If unknown then other imaging will be required such as ian invasive coronary angiography.

Question 21

What pharmacological management should be initiated in a patient with angina pectoris?

Answer 21

1) Beta blockers
2) Statin
3) Non-dihydropyridine CCB - eg. Verapamil. Ivabradine can be used as an alternative to this as a rate control and should NOT be prescribed together with a CCB.
4) Aspirin 75mg OD and if intolerant to this then Clopidogrel 75mg OD can be prescribed.
5) Sublingual GTN - counsel patients on its use.
6) Consider long acting nitrate - eg. isosorbide mononitrate.
7) ACE inhibitor should be considered.