Dr. Rogers ACS Part 1

Question 1

Types of acute coronary syndrome

Answer 1

-Silent ischemia
-Stable ischemic heart disease
-Unstable angina
-Non-ST elevation myocardial infarction
-ST elevation myocardial infarction

Question 2

Epidemiology of ACS

Answer 2

-Median age at ACS presentation is 68 years
-Males are more likely to have ACS
-For some patients, ACS is initial presentation of CAD
-In the United States, >780,000 persons per year will experience and ACS

Question 3

Risk factors for ACS

Answer 3

-Diet
-Age
-Smoking
-Obesity
-Genetics
-Male
-Diabetes
-Renal insufficiency
-Presence of peripheral

Question 4

Precipitating factors for ACS

Answer 4

-Cold
-Wind
-Walking upstairs
-Recent diet
-Sexual intercourse
-Emotions

Question 5

Signs and symptoms of ACS

Answer 5

-Retrosternal chest pain
-Nausea or vomiting
-Diaphoresis
-Shortness of breath

Question 6

Atypical symptoms of ACS

Answer 6

-Epigastric pain
-Indigestion
-Stabbing or pleuritic pain
-Increasing dyspnea in the absence of chest pain

Question 7

What kind of patients are more likely to experience atypical symptoms?

Answer 7

-Elderly
-Females
-Diabetics
-Impaired renal function
-Dementia

Question 8

When should a patient be sent to the hospital?

Answer 8

-Continuing chest pain
-Severe dyspnea
-Syncope/presyncope
-Palpitations

Question 9

How do you diagnose ACS?

Answer 9

All patients with acute chest pain should have an ECG within 10 minutes of arrival at an emergency facility and should have troponin measured as soon as possible after presentation

Question 10

Q wave changes in STEMI

Answer 10

-Often not present on initial ECG, but develops over hours to days
-Electrical hole - scar tissue cannot conduct electricity
-May disappear after early reperfusion if stunned tissue can recover
-Often remain permanently

Question 11

Typical ECG in a patient with NSTEMI or UA

Answer 11

-May have normal ECG
-ST depression, transient ST-elevation, or new T-wave inversion are possible
-Q wave changes unlikely
-No ST elevation

Question 12

Why do we prefer high sensitivity troponin?

Answer 12

-Greater sensitivity and negative predictive values
-Shorter time from onset of chest pain to a detectable concentration

Question 13

Normal values of troponin

Answer 13

-High sensitivity: <14 ng/L
-Conventional: <0.05 ng/mL

Question 14

How often should troponin levels be measured?

Answer 14

-3 levels over 12 hours
-Initial may be negative

Question 15

Acute myocardial injury biomarkers

Answer 15

-Tachyarrhythmia
-Hypotension or hypertension
-Cardiac trauma
-Acute HF
-Myocarditis and pericarditis
-Pulmonary embolism
-Sepsis
-Burns
-Respiratory failure
-Acute neurological diseases
-Drug toxicity

Question 16

Chronic myocardial injury biomarkers

Answer 16

-LV hypertrophy or ventricular dilation
-Renal insufficiency

Question 17

Clinical presentation of stable angina

Answer 17

Chest pain that occurs during physical exertion that is predictable, relieved by rest, and lasts a short time

Question 18

Clinical presentation of unstable angina

Answer 18

-Chest pain may occur at rest, while sleeping, or with little physical exertion
-Comes as a surprise
-Is more severe and lasts longer than stable angina

Question 19

Difference between unstable angina and NSTEMI/STEMI

Answer 19

-Unstable angina has less ischemia and does not lead to detectable quantities of troponin
-NSTEMI/STEMI has elevated troponin

Question 20

Difference between NSTEMI and STEMI

Answer 20

-NSTEMI has no ST elevation on ECG (may have ST depression or T wave inversion)
-STEMI has persistent ST elevation of ECG

Question 21

Complications of ACS

Answer 21

-Heart failure
-Valvular dysfunction
-Arrhythmias
-Bradycardia/heart block
-Pericarditis
-Stroke secondary to LV thrombus
-Cardiogenic shock
-Death

Question 22

What is ventricular remodeling?

Answer 22

-Changes in the size, shape and function of the left ventricle after an ACS
-Leads to heart failure

Question 23

Which factors are involved in ventricular remodeling?

Answer 23

-Activation of the renin-angiotensin-aldosterone system
-Hemodynamic factors (increased preload and afterload)

Question 24

What are major adverse cardiac events (MACE)?

Answer 24

Usually includes stroke, MI, and cardiovascular death