Chest pain

Question 1

Timeframe for PCI for STEMI

Answer 1

90 minutes from first medical contact

Question 2

Time-frame for thrombolysis for STEMI

Answer 2

12 hours

Question 3

The four indications for thromobolysis for STEMI

Answer 3

1) PCI unavailable within 90 minutes of first medical contact
2) Chest pain > 30 min < 12 hours
3) ECG
- -persistent ST elevation > 1mm in 2 contiguous limb leads OR
- -persistent ST elevation > 2mm in 2 contiguous chest leads OR
- -new or presumed new LBBB
4) Myocardial infarction likely from history

Question 4

The 7 absolute contraindications to thrombolysis

Answer 4

1) Active bleeding or bleeding diathesis
2) Suspected aortic dissection
2) Significant closed head or facial trauma within 3 months
4) Prior intracranial haemorrhage (ever)
5) Ishcaemic stroke within 3 months
6) Known cerebral vascular lesion
7) Known intracranial malignant neoplasm

Question 5

The 4 thrombolysis medications

Answer 5

1) Aspirin 300mg
2) Clopidogrel 300mg
3) Tenectaplase (weight adjusted)
4) Enoxaparin (age adjusted) OR Heparin (weight adjusted)

Question 6

What is the weight adjusted dose of tenecteplase in STEMI?

Answer 6

< 60 kg = 6000 IU = 30 mg = 6 ml
60 - 70 kg = 7000 IU = 35 mg = 7 ml
70 - 80 kg = 8000 IU = 40 mg = 8 ml
80 - 90 kg = 9000 IU = 45mg = 9 ml
>90kg = 10,000 IU = 50mg = 10 ml

Question 7

When would you consider half dose tenectaplase for STEMI?

Answer 7

Age > 75 to reduce risk of ICH. Discuss with cardiology

Question 8

What is the age adjusted dose enoxaparin in STEMI?

Answer 8

Age < 75
Loading dose = 30mg IV bolus
Maintenance = 1mg/kg subcut BD beginning 15 min post bolus

Age > 75
Loading dose = NONE
Maintenance = 0.75mg/kg subcut BD. MAX 75mg

Renal failure, eGFR < 30ml/min use Heparin

Question 9

What is the dose of heparin in NSTEMI?

Answer 9

IV bolus 60 units/kg max 4000 units +

Infusion 12 units/kg/hr max 1000 units/hr

Question 10

What 7 factors makes up the 12.5 points of the Wells score for PE?

Answer 10

1) PE more likely than alternative diagnosis +3
2) Suspected DVT +3

3) HR > 100 + 1.5
4) Immobilisation or surgery last 4 weeks + 1.5
5) Previous PE/DVT + 1.5

6) Haemoptysis + 1
7) Malignancy (on treatment, treated in past 6 months, palliative) +1

Question 11

The Well’s score is < 2. You’d like to PERC them out. What are the 8 PERC rule out criteria?

Answer 11

1) Age < 50
2) Heart rate < 100
3) Sats >95%
4) No haemoptysis
5) No oestrogen use
6) No surgery/trauma requiring hospitalisation last 4 weeks
7) No hx VTE
8) No unilateral leg swelling

Question 12

In a patient > 50 years old, what is the age adjusted upper limt D-dimer?

Answer 12

0.01 x age

Question 13

What is the risk of PE in a patient Wells < 2 + PERC negative?

Answer 13

1%. Acceptable risk. Stop investigation for PE

Question 14

What is the risk of a PE in patient with a Well’s score of 2-6 and negative D-dimer?

Answer 14

1-2%. Acceptable risk. Stop investigations for PE

Question 15

How do you investigate a PE based on the calculated Well’s score?

Answer 15

< 2 Try to use PERC rule out
2- 6 D-dimer
> 6 CTPA or VQ scan

Question 16

What should you consider a VQ scan for a PE?

Answer 16

YES to all:

1) female
2) < 55 years
3) Normal CXR
4) Haemodynamically stable
5) No significant suspicious of pathology other than PE

Question 17

What are the ECG signs of right heart strain?

Answer 17

SI QT IIII
= S wave in lead one + deep Q wave and TWI lead III

TWI V1 V2

Right axis deviation

Question 18

In addition to aspirin, if a patient is going for PCI what other antiplatelets do you give? Name 3 and dose

Answer 18

1) clopidogrel 300 - 600mg depending on policy OR
2) Ticagrelor 180mg OR
3) Prasugrel 60mg (not if age > 75, < 60kg or hx bleeding/stroke)

Question 19

Why is streptokinase contra-indicated in ATSI population?

Answer 19

High incidence of anti-streptokinase antibodies

Question 20

Treatment of NSTEMI

Answer 20

1) Asprin 300mg then 100mg daily
2) Clopidogrel 300mg-600mg/ticagrelor 180mg/prasugrel 60mg
3) Enoxaparin 1mg/kg/ heparin

Question 21

Treatment unstable angina

Answer 21

1) aspirin

2) admit for inpatient EST

Question 22

What complications should you expect in the setting of ACS?

Answer 22

1) Arrhythmias
2) Cardiogenic shock
3) Cardiac arrest

Question 23

Name 3 cardiac disease predisposing to sudden cardiac death

Answer 23

1) Inherited or acquired long QT
2) Brugada syndrome
3) Short QT syndrome
4) Catecholaminergic polymorphic ventricular tachycardia
5) Hypertrophic cardiomopathy
6) Wolff-Parkinson White syndrome
7) High grade AV block
8) Severe aortic stensosi
9) Dilated cardiomyopathy
10) Ischaemic heart disease
11) Other myocardial disease (amyloid, sarcoidosis, hypertensive)
12) Anomalous coronary artery anatomy