Coronary artery disease

Question 1

What is the pathophysiology in brief of acute coronary syndromes?

Answer 1

Plaque rupture, thrombosis, inflammation

Question 2

Differential for acute coronary syndrome?

Answer 2

  Angina 
  Peri / endo / myocarditis 
  Dissection 
  PE, pneumothorax, pneumonia 
  Costochondritis 
  GI: e.g. GORD, spasm 
  Anxiety

Question 3

What are the three divisions of ACS?

Answer 3

unstable angina
NSTEMI
STEMI

Question 4

What are the features of NSTEMI on ECG?

Answer 4

ST depression and T wave inversion

Question 5

When is the peak of troponin rise in MI?

Answer 5

24 hour

Question 6

At what time period do you need to repeat troponin?

Answer 6

Trop elevated 3-12 hr, peaks at 24hr

Question 7

What is the treatment for NSTEMI/UA?

Answer 7

medical

elective angio +- PCI/CABG

Question 8

What is PCI?

Answer 8

Percutaneous Coronary Intervention (PCI, formerly known as angioplasty with stent) is a non-surgical procedure that uses a catheter (a thin flexible tube) to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup, a condition known as atherosclerosis.

Question 9

What is CABG?

Answer 9

Coronary artery bypass surgery restores normal blood flow to the heart by creating a “detour” (bypass) around the blocked artery/arteries. This is done by using a healthy blood vessel, called a graft. Grafts usually come from your own arteries and veins located in the chest, leg or arm. The graft creates a new pathway to carry oxygen-rich blood to the heart.

Question 10

List four complications of MI

Answer 10

Death
Pericarditis
Dressler's syndrome
Arrythmias
Pump failure
Embolism

Question 11

What is the viability time frame of PCI?

Answer 11

<12 hr

Question 12

Two complications of PCI?

Answer 12

bleeding, arrhythmia, emboli

Question 13

What is the ECG criteria for thrombolysis?

Answer 13

ST elevation >2 chest leads or >2 limb leads

New LBBB

Question 14

What are the contraindications for thrombolysis in STEMI?

Answer 14

AGAINST
 Aortic dissection 
 GI bleeding 
 Allergic reaction previously 
 Iatrogenic: recent surgery 
 Neuro: cerebral neoplasm or CVA Hx 
 Severe HTN (200/120) 
 Trauma, inc. CPR

Question 15

Two complications of thrombolysis?

Answer 15

bleeding
stroke
arrhythmia
allergic reaction

Question 16

Secondary management of MI?

Answer 16

 ACEi: start w/i 24hrs of MI (e.g. lisinopril 2.5mg)
 β-blocker: e.g. bisoprolol 10mg OD (or, CCB)
 Cardiac rehabilitation (group exercise and info) / Heart Manual
 DVT prophylaxis until fully mobile
 Continue for 3mo if large anterior MI
 Statin: regardless of basal lipids (e.g. atorvastatin 80mg)

Question 17

What lifestyle advice would you offer for patient post-MI?

Answer 17

 Stop smoking 
 Diet: oily fish, fruit, veg, ↓ sat fats 
 Exercise: 30min OD 
 Work: return in 2mo 
 Sex: avoid for 1mo 
 Driving :avoid for 1mo

Question 18

Patient with NSTEMI. What is their inpatient management from the beginning to discharge?

Answer 18

ECG
Admit to CCU
Oxygen
IV access
Hx + exam
Antiplatelet- aspirin clopidogrel
Anticoagulate
Analgesia + antiemetics
GTN
Assess CDV risk: GRACE

Question 19

In which conditions are there raised troponin levels?

Answer 19

STEMI, NSTEMI, myocarditis, PE, intense exercise

Question 20

What are the different types of MI?

Answer 20

Type 1,2, 3, 4a, 4b, 5

Question 21

What is type 1?

Answer 21

CORONARY ARTERY ASSOCIATED- spontaneous MI due to primary coronary event (coronary artery plaque rupture and formation of thrombus)

Question 22

Type 2?

Answer 22

increaed oxygen demand or decreased oxygen supply- HF, sepsis, anaemia, hypertension
congestive HF, tachyarrhythmias, PE, sepsis, apical ballooning syndrome, anything that stresses the heart

Question 23

ST elevation is observed in inferior leads. Which coronary artery is affected?

Answer 23

RCA

Question 24

How can you determine post MI on ECG?

Answer 24

anterior lead is directly opposite and will see the opposite of any current generated at post wall i.e. post ST elevation=ant ST depression

Question 25

Following a successful PCI, what is the subsequent secondary prevention management?

Answer 25

ACE inhibitors, beta blockers, STATINS, cardiac rehab

Question 26

Which antiplatelet therapy is recommended for NSTEMI?

Answer 26

dual anti-platelet therapy= aspirin and P2Y12 inhibitor=ticagrelor

Question 27

Why would you do a FBC for suspected ACS?

Answer 27

to rule out type 2 cause of MI e.g. hypofusion caused by anaemia, sepsis, internal bleeding etc

Question 28

Why would you carry out CXR for suspected ACS?

Answer 28

to rule out HF and pulmonary origin of chest pain

Question 29

Explain the concept of silent MI

Answer 29

Diabetes patients do not experience typical chest pain during acute coronary syndrome

Question 30

What is the treatment for acute NSTEMI?

Answer 30

BATMAN- beta blockers, aspirin, ticagrelor, morphine, anticoagulant, nitrates

Question 31

What is Dressler’s syndrome?

Answer 31

post-myocardial infarction syndrome- localised immune response causing pericarditis