FN: Acute coronary Syndromes

Question 1

Definition

Answer 1

ACS = unstable angina + evolving MI
Divided into:
1. ST elevation or new onset LBBB
NSTEMI

Question 2

Epi

Answer 2

Incidence 5/1000 for STEMI

Question 3

Pathophysiology

Answer 3

1. Plaque rupture, thrombosis and inflammation

2. Rarely due to coronary spasm

Question 4

Risk Factors modifiable

Answer 4

HTN
DM
Smoking
raised cholesterol
Obesity

Question 5

Non-modifiable

Answer 5

Age
Mal
FH (MI ,55yrs)

Question 6

Symptoms

Answer 6

Acute central/left chest pain >20 min
Radiates to left jaw or arm
Nausea
sweating
Dyspnoea
Palpitations

Question 7

Silent MIs in

Answer 7

Elderly/diabetes
1. Syncope
Delirium
Post-op oliguria/hypotension

Question 8

Signs

Answer 8

1. Anxiety
2. Pallor sweating
3. Pulse low or high
4. BP low or high
5. 4th heart sound
6. Signs of LVF (basal creps, raised JVP, 3rd heart sounds)
7. PSM: papillary muscle dysfunction/rupture

Question 9

Differential

Answer 9

1. Angina
2. Peri/endo/myocarditis
3. dissection
4. PE, pneumothorax, pneumonia
5. Costochondritis
6. GI e.g. GORD, spasm
7. Anxiety

Question 10

Investigations

Answer 10

1. ECG
2. Bloods
3. CXR

Question 11

ECG

Answer 11

1. STEMI seqeunce
2. NSTEMI
3. No Q waves = subendocardial infarct

Question 12

STEMI seqeunce

Answer 12

1. Normal
2. ST elevation + hyperacute (tall) T waves
3. Q waves: full-thickness infarct
4. Normalisation of ST segments
5. T wave inversion
6. (New onset LBBB also = STEMI)

Question 13

Bloods show

Answer 13

1. Troponin T/I
   a. Myofibrillar proteins linking actin and myosin
   b. Elevated from 3-12h therefore need 12h trop to exclude MI
   c. Peak at 24hrs
   d. Baseline from 5-14d
2. FBC, U + E, glucose, lipids, clotting

Question 14

CXR

Answer 14

Cardiomegaly
Pulmonary oedema
Widened mediastinum: aortic rupture

Question 15

Diagnosis
STEMI/LBBB show
NSTEMI show
UA show

Answer 15

1. STEMI/LBBB: Typical symptoms + ST elevation (/LBBB)
2. NSTEMI: Typical symptoms + no ST elevation + +ve troponin
3. UA: typical symptoms + no ST elevation + ive troponing

Question 16

Treatment

Answer 16

STEMI: PCI or thrombolysis

NSTEMI/UA: medical + elective angio ±PCI/CABG