CBL - Acute Coronary Syndrome

Question 1

What are the risk factors of acute coronary syndrome?

1. non-modifiable risk factors? [6]
2. modifiable risk factors? [7]

Answer 1

1. non-modifiable
   
   • increasing age
   • sex
   • ethnicity
   • family history
   • PMHx
   • co-morbidities
2. modifiable
   
   • smoking
   • obesity
   • lack of physical activity
   • diet
   • high cholesterol
   • hypertension
   • co-morbidities

Question 2

What tests should be carried out to confirm a diagnosis of acute coronary syndrome and describe what you’re looking for in each test [3]

Answer 2

1. ECG
   
   • to diagnose acute ST elevation MI or changes of ischaemia
2. Chest x-ray
   
   • look for evidence of pulmonary oedema or cardiomegaly
3. Troponin
   
   • cardiac marker, used to diagnose acute MI

Question 3

What would be the troponin level and ECG changes in a patient with unstable angina? [3]

Answer 3

1. normal troponin
2. ECG changes:
   
   • normal ECG
   • possible ST depression

Question 4

What would be the troponin level and ECG changes in a patient with NSTEMI​? [3]

Answer 4

1. raised troponin
2. ECG changes
   
   • can be normal
   • ST depression
   • T wave inversion

Question 5

What would be the troponin level and ECG changes in a patient with STEMI? [3]

Answer 5

1. raised troponin
2. ECG changes:
   
   • ST elevation
   • hyperacute T waves
   • new LBBB
   • T wave inversion
   • Q wave (shows up days later)

Question 6

If a patient is having an inferior STEMI, on which ECG leads will it show up on and what coronary artery has been affected? [4]

Answer 6

1. ECG leads II, III, aVF
2. right coronary artery has been affected

Question 7

If a patient is having a lateral STEMI, on which ECG leads will it show up on and what coronary artery has been affected? [5]

Answer 7

1. leads I, aVL, (+V5, V6)
2. left circumflex (or left anterior descending) artery has been affected

Question 8

If a patient is having an anterior STEMI, on which ECG leads will it show up on and what coronary artery has been affected? [7]

Answer 8

1. V1-2 septum
2. V3-4 apex
3. V5-6 anterolateral
4. left anterior descending artery has been affected

Question 9

If a patient is having a posterior STEMI, on which ECG leads will it show up on and what coronary artery has been affected? [3]

Answer 9

1. V1-3 ST depression
2. left circumflex or right coronary artery affected

Question 10

What immediate treatments should be given to a patient having a myocardial infarction? [6]

Answer 10

1. morphine (pain relief)
2. antiemetics (for nausea secondary to MI and/or morphine)
3. nitrates [GTN] (lowers vascular resistance, improves blood flow to myocardium)
4. oxygen (only given if sats <94%)
5. dual antiplatelet therapy:
   
   • aspirin
   • tiacagrelol/clopidogrel
6. reperfusion

Question 11

Describe the 2 options for reperfusion therapy [2]

Answer 11

1. primary PCI (percutaneous coronary intervention)
   
   • ​​invasive procedure to open the blocked artery and treat the underlying atheromatous plaque by balloon angioplasty and stent placement
2. thrombolytic therapy
   
   • ​​if pPCI is not available
   • give tenecteplase (= tissue plasminogen activator)

Question 12

What are the potential complications of STEMI? [10]

Answer 12

1. bradycardia
2. ventricular arrhythmia
3. atrial arrhythmia
4. heart failure
5. valvular disease
6. cardiogenic shock
7. myocardial rupture
8. pericarditis
9. LV mural thrombus - may embolise + cause stroke
10. death

Question 13

What are the long-term non-pharmacological treatments recommended for a patient with ACS? [2]

Answer 13

1. modification of risk factors
   
   • smoking cessation
2. cardiac rehab
   
   • education/improving QoL/psychological impact of MI

Question 14

What are the long term pharmacological treatments for patients with ACS? [5]

Answer 14

1. aspirin (lifelong)
2. ticagrelol/clopidogrel
3. beta-blocker
4. ACE inhibitor
5. statins