CR2: Thomas Lee (Angina/STEMI/NSTEMI)

Question 1

State which ECG leads relate to the SALI areas of the heart

Answer 1

1. Septal: V1-2: LAD
2. Anterior: V3-V4, LAD
3. Lateral : V5-V6, I, aVL: Circumflex
4. Inferior: II, III, aVF; RCA

Question 2

State 5 causes of stable angina [5]

Answer 2

1. Atherosclerosis
2. Anaemia
3. Left ventricular hypertrophy
4. Right ventricular hypertrophy
5. Rapid tachycardiarythmias

Question 3

Which three questions are asked for diagnosis of stable angina? [3]

Answer 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

Question 4

What is the first investigation if suspected stable angina? [1]

Answer 4

ECG

Question 5

Which type of imaging is used to visualize non-calcified plaque and estimate the severity of luminal stenoses?

Answer 5

CTCA

Question 6

What ECG changes might be seen in person with angina? [3]

Answer 6

Between attacks: normal

During attack:
a. May show ST depression
b. Flat or inverted T waves
c. Look for previous MI: pathological q waves

Question 7

Stable angina treatment

Which drugs would be used for increasing O2 delivery:

• Nitrate [1]
• CCB [1]
• Nitrate & K+ blocker? [1]

Answer 7

1. – Nitrates: glyceryl trinitrate
2. – CCBs: verapamil
3. • Revasc.
4. • Nicorandil (Combination of K+ blocker and nitrate)

Question 8

Stable angina treatment

Which drugs would be used for reducing HR:

Beta blockers [2]
Funny current inhibitor [1]

Answer 8

BB:
* Bisoprolol and atenolol (Act on B1 receptor)

funny current inhib:
* Ivabradine

Question 9

Stable angina treatment

Which drug would be prescribed to modify energy metabolism? [1]

Answer 9

Trimetazidine

Question 10

State 6 drugs used for secondary prevention of heart disease [6]

Answer 10

Question 11

Describe the MoA of beta blockers [2]

Answer 11

These drugs have negative inotropic and chronotropic (heart rate) effects due to competitive blockade of cardiac beta-receptors.

Question 12

Describe the pathophysiology of unstable angina [1]

Answer 12

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.

Question 13

What is the most common cause of unstable angina?

Answer 13

Coronary artery narrowing caused by a thrombus that develops on a disrupted atherosclerotic plaque and is usually non-occlusive

Question 14

Name 5 factors that increase O2 demand [5]

Answer 14

a. Arrhythmias
b. Fever
c. Hypertension
d. Cocaine use
e. Aortic stenosis
f. AV shunts
g. Anaemia
h. Thyrotoxicosis
i. Pheochromocytoma
j. CHF

Question 15

Describe how you distinguish unstable angina to NSTEMI or STEMI? [2]

Answer 15

No evidence of STEMI on ECG

Troponin within 60 minutes:
* There will be no dynamic rise above the 99th percentile in patients

Question 16

How do you treat a patient with unstable angina? [4]

Answer 16

Question 17

(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).

Answer 17

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

Question 18

(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).

Answer 18

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

Question 18

(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).

Answer 18

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

Question 19

Which cardiac enzymes are raised in STEMIs? [4]

Answer 19

Cardiac troponin I and T.
Creatine kinase (CK)
Aspartate transaminase
(AST)
Lactate dehydrogenase (LDH)

Question 20

What is the ECG changes seen in STEMI? [4]

Answer 20

ST elevation
Tall T waves
L bundle branch block (LBBB)
T wave inversion and pathological Q waves follow

Question 21

What is Dressler’s Syndrome? [3]

Answer 21

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.

Question 22

Describe the clinical characteritistics of Dressler’s syndrome [5]

Answer 22

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).

Question 23

Describe the clinical characteritistics of Dressler’s syndrome [5]

Answer 23

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).

Question 24

Describe how you diagnosis Dressler’s syndrome [3]

Answer 24

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).

Question 25

Describe how you treat Dressler’s syndrome [3]

Answer 25

Management is with NSAIDs (aspirin / ibuprofen) and in more severe cases steroids (prednisolone). They may need
pericardiocentesis to remove fluid from around the heart.

Question 26

Management of acute STEMI? [2]

Answer 26

Primary PCI (if available within 2 hours of presentation)
Thrombolysis (if PCI not available within 2 hours):