E: Acute Coronary Syndrome Flashcards
1
Q
What is an acute coronary syndrome
A
Complete or Partial Occlusion of a coronary artery
2
Q
What are the 3 types of acute coronary syndrome
A
STEMI
NSTEMI
Unstable Angina
3
Q
What are the 2 types of myocardial infarction
A
STEMI
NSTEMI
4
Q
What is myocardial infarction
A
Continous ischaemia that leads to the death of myocardial cells, which release troponin
5
Q
What is a type of myocardial ischaemia
A
Unstable Angina
6
Q
What causes myocardial ischaemia
A
Lack of blood supply to cardiac cells
7
Q
What type of MI are ACS
A
Type I
8
Q
What is a type I MI
A
Spontaneous MI
9
Q
What causes a STEMI
A
Rupture of an atherosclerotic plaque
10
Q
What causes an NSTEMI
A
Formation of a thrombus on an atherosclerotic plaque
11
Q
What causes unstable angina
A
Progressive narrowing of coronary artery or spasm of a coronary artery disrupting blood supply
12
Q
What are the 3 non-modifiable risk factors for ACS
A
Age
Gender
FHx
13
Q
What is the prevalence of ACS in males compared to females
A
3 times more common in males
14
Q
What family history increases risk of ACS
A
MI in first degree relative under the age of 55y
15
Q
What are 7 modifiable risk factors of ACS
A
Smoking HTN DM Dyslipidaemia Obesity Sedentary lifestyle Cocaine use
16
Q
How do ACS present clinically
A
Cannot be distinguished from one another
17
Q
What are 5 symptoms of ACS
A
- Chest pain >20m
- Dyspneoa
- Pale and clammy
- Palpitations
- Nausea
18
Q
What are the possible symptoms of a silent MI
A
- Syncope
- Epigastric pain
- Acute confusional state
- Pulmonary oedema
19
Q
Describe the pathophysiology of a STEMI
A
Complete occlusion of a coronary artery resulting in TRANS MURAL infarction
20
Q
Describe the pathophysiology of an NSTEMI
A
Partial occlusion of a coronary artery resulting in sub-endocardial infarction
21
Q
Describe the pathophysiology of unstable angina
A
Partial occlusion of a coronary artery causing myocardial ischaemia
22
Q
What coronary artery is most commonly affected in ACS
A
Left anterior Descending
23
Q
1
A
1
24
Q
If the RCA is affected what may be an outcome
A
Arrhythmias (SA node) Heart Block (AV node)
25
What are the 4 criteria to diagnose an ACS
1. Symptoms of ischaemia/infarction
2. ST elevation
3. New onset LBBB
4. Loss of R waves
26
What is first-line investigation for ACS
ECG
27
In what time frame should an ECG be performed when a patient presets with ACS
Within 10 minutes
28
What is the first sign of a STEMI on ECG
Hyperacute (peaked) T waves
29
How long will peaked T waves last on ECG
Minutes
30
What are two other early (within hours) changes of an MI on ECG
ST Elevation
| LBBB
31
What are ECG changes in hours to days of a STEMI
T wave inversion
| Pathological Q Waves
32
What happens in the first 24h of a STEMI on ECG
T wave inversion
33
How long do pathological Q waves persist
Indefinitely
34
What do pathological Q waves on ECG indicate
Sign of previous MI
35
What is the ECG criteria for a STEMI
ST elevation in two anatomically contagious leads
1. Male >40= >2mm in V2-V3, >1mm in all other leads
2. Male <40 = >2.5mm in V2-V3m >1mm in all other leads
3. Female = >1.5mm in V2-V3, >1mm in all other leads
36
What does ST elevation on an ECG in a STEMI correlate to
The coronary artery affected
37
What artery is affected in an anterior MI
Left Anterior Descending
38
What leads will have ST elevation in an anterior MI
V1,V2,V3,V4
39
What artery is affected in a lateral MI
Left circumflex
40
What leads will have ST elevation in a lateral MI
I, aVL, V5 + V6
41
What artery is affected in an inferior MI
Right coronary artery
42
What leads are affected in an inferior MI
II, III, aVF
43
What artery is affected in a posterior MI
Left circumflex and Right coronary artery
44
What leads are affected in a posterior MI
Tall R waves and ST depression in V1 and V2
45
What are the ECG changes in NSTEMI
non-lead specific:
ST depression
T wave inversion
Loss of R wave
46
What are the ECG changes in unstable angina
Normal ECG
47
When should a troponin be measured after an ACS
3h and 6h
48
How long does troponin remain high for
10d
49
How will troponin present in the following:
a. STEMI
b. NSTEMI
c. Unstable Angina
a. Raised
b. Raised
c. Normal
50
How are the different ACS differentiated from each other
On ECG STEMI will have ST elevation. NSTEMI and Unstable Angina will not. Then a troponin is performed. It will be elevated in NSTEMI but not in unstable angina.
51
What are two other cardiac markers
CK-MB
| Myoglobin
52
When does myoglobin increase and when does it peak
1h. Peaks at 4-12h
53
What is the problem with myoglobin as a marker for ACS
Non-specific
54
When does CK-MB increase
4-9h
55
When does CK-MB peak
12-24h
56
What other Ix may be done in ACS and why
Lipid profile - as individuals are often put on a statin
57
In the management of all ACS what is the first step
Aspirin (300mg) and Ticagrelor (180mg)
58
What dose of aspirin is given
300mg initially (loading dose) and then 75mg thereafter
59
When should aspirin not be given in ACS
If an individual is already on aspirin. Individual has a contraindication to aspirin
60
What dose of ticagrelor is given
180mg loading dose. Then 80mg BD
61
When should ticagrelor not be given
History of intracranial haemorrhage
62
What is step 2 in the management of ACS
Morphine
63
What dose of morphine is given
2.5-5mg
64
What should be given with morphine
Metclopramide
65
What dose of metclopramide is given
10mg IV over 2 minutes.
66
Why is metclopramide given
Prevent vomitting due to morphine
67
When is oxygen given in ACS
If SpO2 <94%
68
What is target saturations in ACS
94-99% or 88-92% if risk of type II resp failure
69
Who should oxygen NOT be given to in ACS
SpO2 of 94-99% on room air
70
What is step 4 in management of ACS
Fondaparinux
71
What dose of fondaparinux is given
2.5mg SC OD
72
When should fondaparinux not be given
If on DOAC or warfarin and INR is >2
73
What are the 4 steps of initial ACS management
1. Aspirin + Ticagrelor
2. Morphine
3. Oxygen
4. Fondaparinux
74
After initial ACS management what is done for STEMI
Assess whether there is ST elevation on ECG and whether PCI could be reached in 120 minutes
75
If PCI is available in 120m what should be done
primary PCI
76
If PCI is not available in 120m what should be done
Fibrinolysis
77
Who should PCI be offered to
- Those presenting within 12h of symptom onset and can reach PCI centre in 120m
78
What is the time frame for fibrinolysis following STEMI
- Ideally performed up to 30m after. Can be performed up to 12h after.
79
What is used for fibrinolysis
Tissue plasminogen activation (Teneplase)
80
What is the initial management for an NSTEMI
1. Aspirin + Ticagrelor
2. Oxygen
3. Morphine
4. Fonaparinux
81
After initial management what is given in NSTEMI
GTN spray PRN
82
What should then be done for a NSTEMI
GRACE score should be calculated
83
What GRACE score is high risk
>140
84
What GRACE score is intermediate risk
109-140
85
What GRACE score is low risk
<109
86
How should someone with a low GRACE score be managed
Discharged and Outpatient Investigations (eg. stress test) organised
87
How should someone with a high or intermediate GRACE score be managed
B blocker
88
What dose of bisoprolol is given
2.5mg
89
What should then be given if the individual has continous chest pain or pulmonary oedema
IV GTN
90
What is the next step in management of NSTEMI
Arrange cardiology review for angiography
91
If an individual is high risk, in what time frame should a cardiology review be sought
24h
92
If an individual is intermediate risk, in what time frame should a cardiology review be sought
72h
93
What is the long-term management of ACS
1. B blocker
2. Dual anti-platelet
3. ACEi
4. Statin
```
GTN
Aldosterone receptor antagonist
Smoking Cessation
Mediterranean diet
Cardiac rehabilitation
```
94
What dose of ramipril is given
1.25mg
95
What dose of bisoprolol is given
2.5mg
96
What dose of atorvostatin is given
80mg
97
When is eplerenone given
If LEVF is <40% on ECHO
98
How soon can someone with a group I license return to driving following a ACS
1W post angiography
| 4W if no angiography
99
How soon can someone with group II license return to driving following an ACS
Stop driving and contact DVLA
100
When can an individual return to work following an ACS
Depends on the JOB.
Pilot, Lorry Driver, Bus driver - need to undergo functional testing.
101
What is the mnemonic to remember immediate ACS management
MONARCH
```
Morphine
Oxygen
Nitrates
Aspirin
Reperfusion
Clopidogrel - now ticagrelor
Heparin
```
102
What is a mnemonic to remember long-term ACS management
DABS
Dual antiplatelet
Aspirin
B blocker
Statin
103
According to the GRACE score what are 5 poor prognostic factors of NSTEMI
```
Age
HF
Reduced systolic BP
PVD
Killip class
Initial serum creaitnine
```
104
What are 3 complications of MI that can occur in 0-24h
1. Arrhytmias
2. Sudden cardiac death
3. Acute left heart failure
105
When are arrhythmias more common and why
Inferior MI - due to affecting the SA node
106
What complication may occur 1-3d post-MI
Pericarditis
107
What 3 complications may occur 3-14d post MI
1. Rupture left ventricular free wall
2. Rupture papillary muscles
3. Ventricular septal rupture
108
What may papillary muscle rupture cause
Mitral regurgitation
109
What typically causes VSD rupture
Anterior MI
110
How will rupture of the VSD present
holosytolic murmur and onset of right heart failure symptoms
111
How will rupture of the free wall of the left ventricle present
Cardiac tamponase
112
What are the signs of cardiac tamponade
1. Hypotension
2. Raised JVP
3. Muffled HS
113
What is Becks Triad
1. Hypotension
2. Distended neck veins
3. Muffled HS
114
What 4 complications can occur 14d to months afterwards
Dresslers Syndrome
Congestive HF
Arterial + Ventricular Aneurysms
Arrhythmias (AV block)
115
What is dresslers syndrome
Pericarditis - due to auto antibodies attacking the pericardium
116
When is sinus bradycardia more common complication of MI
Inferior MI
117
What is heart block more common complication of MI
Anterior MI
118
How will Dresslers syndrome present
Raised ESR
Fever
Anaemia
