CR2: Thomas Lee (Angina/STEMI/NSTEMI) Flashcards
State which ECG leads relate to the SALI areas of the heart
- Septal: V1-2: LAD
- Anterior: V3-V4, LAD
- Lateral : V5-V6, I, aVL: Circumflex
- Inferior: II, III, aVF; RCA
State 5 causes of stable angina [5]
- Atherosclerosis
- Anaemia
- Left ventricular hypertrophy
- Right ventricular hypertrophy
- Rapid tachycardiarythmias
Which three questions are asked for diagnosis of stable angina? [3]
Does it go away after 15 mins
Is it onset by exercise
Is it relieved by GCN
b. Answer = <1, No diagnostic testing, no medication
c. Answer = 2 characteristics = atypical angina
d. Answer = 3 characteristics = typical angina
What is the first investigation if suspected stable angina? [1]
ECG
Which type of imaging is used to visualize non-calcified plaque and estimate the severity of luminal stenoses?
CTCA
What ECG changes might be seen in person with angina? [3]
Between attacks: normal
During attack:
a. May show ST depression
b. Flat or inverted T waves
c. Look for previous MI: pathological q waves
Stable angina treatment
Which drugs would be used for increasing O2 delivery:
- Nitrate [1]
- CCB [1]
- Nitrate & K+ blocker? [1]
- – Nitrates: glyceryl trinitrate
- – CCBs: verapamil
- Revasc.
- Nicorandil (Combination of K+ blocker and nitrate)
Stable angina treatment
Which drugs would be used for reducing HR:
Beta blockers [2]
Funny current inhibitor [1]
BB:
* Bisoprolol and atenolol (Act on B1 receptor)
funny current inhib:
* Ivabradine
Stable angina treatment
Which drug would be prescribed to modify energy metabolism? [1]
Trimetazidine
State 6 drugs used for secondary prevention of heart disease [6]
Describe the MoA of beta blockers [2]
These drugs have negative inotropic and chronotropic (heart rate) effects due to competitive blockade of cardiac beta-receptors.
Describe the pathophysiology of unstable angina [1]
Myocardial ischaemia occurs at rest due to transient occlusion of a coronary artery at the site of atheromatous disease by the formation of thrombus within the lumen.
What is the most common cause of unstable angina?
Coronary artery narrowing caused by a thrombus that develops on a disrupted atherosclerotic plaque and is usually non-occlusive
Name 5 factors that increase O2 demand [5]
a. Arrhythmias
b. Fever
c. Hypertension
d. Cocaine use
e. Aortic stenosis
f. AV shunts
g. Anaemia
h. Thyrotoxicosis
i. Pheochromocytoma
j. CHF
Describe how you distinguish unstable angina to NSTEMI or STEMI? [2]
No evidence of STEMI on ECG
Troponin within 60 minutes:
* There will be no dynamic rise above the 99th percentile in patients
How do you treat a patient with unstable angina? [4]
(1) Mr Lee initially complains to his GP about experiencing chest pains whenever he walks up the hill from the shops. Explain (i) why Mr Lee is experiencing exertional angina (2 marks) and (ii) how this is relieved by rest or with a spray (1 mark).
Myocardial blood flow must be sufficient to meet o2 demands for myocardial function. During exercise, increased energy demands can’t be met because of reduce blood flow.
Rest: relieves o2 demand, can relax
GTN: nitrate vasodilator
(1) Mr Lee initially complains to his GP about experiencing chest pains whenever he walks up the hill from the shops. Explain (i) why Mr Lee is experiencing exertional angina (2 marks) and (ii) how this is relieved by rest or with a spray (1 mark).
Myocardial blood flow must be sufficient to meet o2 demands for myocardial function. During exercise, increased energy demands can’t be met because of reduce blood flow.
Rest: relieves o2 demand, can relax
GTN: nitrate vasodilator
(1) Mr Lee initially complains to his GP about experiencing chest pains whenever he walks up the hill from the shops. Explain (i) why Mr Lee is experiencing exertional angina (2 marks) and (ii) how this is relieved by rest or with a spray (1 mark).
Myocardial blood flow must be sufficient to meet o2 demands for myocardial function. During exercise, increased energy demands can’t be met because of reduce blood flow.
Rest: relieves o2 demand, can relax
GTN: nitrate vasodilator
Which cardiac enzymes are raised in STEMIs? [4]
Cardiac troponin I and T.
Creatine kinase (CK)
Aspartate transaminase
(AST)
Lactate dehydrogenase (LDH)
What is the ECG changes seen in STEMI? [4]
ST elevation
Tall T waves
L bundle branch block (LBBB)
T wave inversion and pathological Q waves follow
What is Dressler’s Syndrome? [3]
This is also called post-myocardial infarction syndrome
It usually occurs around 2-3 weeks after an MI. It is caused by a localised
immune response and causes pericarditis (inflammation of the pericardium around the heart). It is less common as the management of ACS becomes more advanced.
Describe the clinical characteritistics of Dressler’s syndrome [5]
It presents with pleuritic chest pain, low grade fever and a pericardial rub on auscultation. It can cause a pericardial effusion and rarely
a pericardial tamponade (where the fluid constricts the heart and prevents function).
Describe the clinical characteritistics of Dressler’s syndrome [5]
It presents with pleuritic chest pain, low grade fever and a pericardial rub on auscultation. It can cause a pericardial effusion and rarely
a pericardial tamponade (where the fluid constricts the heart and prevents function).
Describe how you diagnosis Dressler’s syndrome [3]
A diagnosis can be made with an ECG (global ST elevation and T wave inversion), echocardiogram (pericardial effusion) and raised
inflammatory markers (CRP and ESR).
Describe how you treat Dressler’s syndrome [3]
Management is with NSAIDs (aspirin / ibuprofen) and in more severe cases steroids (prednisolone). They may need
pericardiocentesis to remove fluid from around the heart.
Management of acute STEMI? [2]
Primary PCI (if available within 2 hours of presentation)
Thrombolysis (if PCI not available within 2 hours):
