Conditions - UKMLA

Question 1

what are the 3 main types of acute coronary syndrome?

Answer 1

Non-ST elevation myocardial infarction (NSTEMI)
ST-elevation MI (STEMI)
Unstable Angina

Question 2

what are risk factors of acute coronary syndrome?

Answer 2

Hypercholesteroalaemia
Hypertension
Smoking
Reduced HDL cholesterol
Obesity
Type I and II diabetes mellitus
Family history
Stress
Male

Question 3

what is the pathophysiology of acute coronary syndrome?

Answer 3

STEMI - the vessel is typically entirely occluded by plaque rupture and subsequent thrombus formation.
NSTEMI - vessels are likely to be entirely occluded.

Question 4

what are signs and symptoms of acute coronary syndrome?

Answer 4

Chest pain (Levine sign)
Sweating
Pain may be retrosternal with radiation to arm and jaw.
Pain can be intermittent or persistant.
Sweating, nausea, dyspnoea, syncope, epigastric pain.

Question 5

what are investigations for suspected MI?

Answer 5

ECG
Cardiac biomarkers - troponin, creatinine kinase
Other: chest x-ray, echocardiogram, coronary angiography

Question 6

what is the diagnostic criteria of an acute, evolving or recent Myocardial Infarction?

Answer 6

Typical rise and gradual fall of troponin or more rapid rise and fall (CK-MB) and one of the following …
- Ischaemic symptoms
- Development of pathological Q waves on ECG
- ECG changes indicative of ischaemia (ST elevation or depression)

Question 7

what is the diagnostic criteria of an established myocardial infarction?

Answer 7

Anyone one of the following:
- Development of new pathological Q waves on serial ECG
- Pathological findings of healed/healing MI

Question 8

what is the diagnostic criteria of Acute STEMI?

Answer 8

• New ST segment elevation (>2mm in 2 contiguous chest leads)
• Posterior STEMI causes dominant R waves in lead VI but will reveal ST elevation only if a posterior ECG is taken.

Question 9

what is the diagnostic criteria of left bundle branch block?

Answer 9

• Heart rhythm must be supraventricular in origin
• QRS duration must be >120ms
• QS or rS complex in lead VI
• Notched (m shape) R wave in lead V6
• T wave should be deflected opposite the terminal defeldction of QRS

Question 10

what is the diagnostic criteria or an NSTEMI?

Answer 10

• ST depression
• New T wave inversion
• Troponin rise

Question 11

what are cardiac enzymes which can indicate MI?

Answer 11

Troponin: rises 3-12 hours after the event and falls over a week. Repeat levels 6 hours after onset of chest pain.
Creatinine Kinase - which rises and falls much more quickly

Question 12

How long should you be abstinent from driving after myocardial infarction?

Answer 12

one month
No need to inform DVLA

Question 13

what are differential diagnosis of acute coronary syndrome?

Answer 13

Acute pericarditis
Aortic dissection
Pulmonary embolism
Pneumonia
Oesophageal spasm
Gastro-oesophageal reflux
Cholecystitis
MSK chest pain
Acute pancreatitis
Gastric ulcer

Question 14

what are the aims of management of acute coronary syndrome?

Answer 14

Dispersing the clot - aspirin, clopidogrel, heparin
Preventing arrythmia (beta-blockers)
Stabilising plaque - statins
Preventing adverse remodelling.

Question 15

what are different therapy given for acute coronary syndrome?

Answer 15

• Supportive: oxygen, nitrates, analgesia.
• Thrombolysis: streptokinase, urokinase, tPA, rtPA.
• Antiplatelet: Aspirin (300mg, 75mg lifelong), Clopidogrel (300-600mg, 75mg 1 year), Prasugrel (60mg, 10mg 1 year), Triegrelor (180mg, 90mb bd 1 year)
• Anti-coagulants: Heparin, Bivalindin for PPCI
• Beta blockers: metaprolol (25mg tds, bisoprolol 1.25-10mg od) lifelong
• ACE inhibitors (ramipril 2.5-10mg, canderstan (2-32mg lifelog)
• Aldosterone receptor antagonist: spiranolactone (25mg lifelong),
• Lipid-lowering therapy: Atoravostatin (20-80mg) lifelong, Simvastatin (20-40mg) lifelong

Question 16

explain the use of thrombolysis in acute coronary syndrome.

Answer 16

When access to PPCI is limited
Streptokinase, alteplase, reteplase.
Reperfusion arrythmias are common in the first 2 hours.
Contraindications: active internal bleeding, suspected aortic dissection, recent head trauma, intracranial neoplasms, uncontrolled high blood pressure.

Question 17

what is surgical management for NSTEMI?

Answer 17

Inpatient angiography and PCI if thrombolysis is unsuccessful. some may be referred for a CABG

Question 18

what is surgical management for unstable Angina?

Answer 18

may be medically managed, but those with higher risk characteristics may undergo invasive procedures.

Question 19

what is the surgical management of a STEMI?

Answer 19

Primary percutaneous coronary intervention (PPCI) aims to treat within 12 hours of the onset of symptoms.

Question 20

explain a percutaneous coronary intervention (PPCI) .

Answer 20

Permits rapid and low-risk coronary revascularization, which can be performed as emergency (STEMI), urgently (NSTEMI) or unstable angina . electively for stable angina.
Stenoses selected for intervention are then transversed using toquable intracoronary wires, before the stenosis is balloon-dilated and stented.
Drug-eluting stents are anti-mitotic drugs.

Question 21

what arteries may be used for a CABG?

Answer 21

Internal mammary artery
Radial artery
Saphenous vein