Chest Pain

Question 1

What are the investigations for suspected ACS?

Answer 1

• ECG
• Bloods - FBC, U+E, LFT, Troponins, Magnesium, Phosphate, CRP, glucose, lipid profile
• CXR - Look for alternative causes

Question 2

What are the different types of ACS?

Answer 2

Stemi - st elevation or new LBBB
N-Stemi - troponin rise at 12 hours without ST elevation
Unstable angina - ACS without ST elevation or troponin rise

Question 3

What is the immediate treatment for ACS?

Answer 3

MONAC
Mophine - 10mg in 10mls slow IV titrated to pain + 10mg IV metoclopramide IV
Oxygen if less than 94%
Nitrates - sublingual GTN PRN
Aspirin - 300mg PO loading dose
Clopidogrel - 300-600mg PO loading dose

Question 4

What ACSs should recieve PCI?

Answer 4

Stemi if within 2 hours
N-Stemi or unstable angina:
-Haemodynamically unstable, high ischaemic risk (recurrent pain) - immediate
-Intermidiate or high risk GRACE score - within 3 days
-Low risk GRACE score - treated conservatively

Question 5

What scoring system should be used to assess risk in ACS?

Answer 5

Grace score tells you 6-month mortality

Looks at age, HR, SBP, creatinine, ST deviation, troponins, cardiac arrest or LVF

Question 6

When is throbolysis used for ACS?

Answer 6

Rarely used now but if PCI is not availbale within 2 hours

Contraindicated by bleeding disorders e.g. recent surgery, haemorrhagic stroke in last 6 months

Question 7

What is the long term management of ACS?

Answer 7

-Beta blocker - reduces myocardial demand - for 12 months
-ACE inhibitor - prevents adverse cardiac remodelling
-GTN spray - PRN
Cardiovascular risk reduction:
-Aspirin (lifelong) + Clopidogrel/ticagrelor for 12 months
-Statins
-BP control
-Lifestyle modification