Heart Attack

Question 1

Define acute coronary syndrome.

Answer 1

Any acute presentation of coronary artery disease.

Question 2

What are the 3 acute coronary syndromes?

Answer 2

Unstable angina, acute non-STEMI and STEMI.

Question 3

What causes ACS?

Answer 3

Spontaneous plaque rupture.

Question 4

What are the factors affecting plaque rupture/fissure?

Answer 4

Lipid content of plaque, thickness of fibrous cap, sudden changes in intraluminal pressure or tone, bending and twisting of an artery during each heart contraction, plaque shape, mechanical injury e.g. vascular damage due to PCI.

Question 5

What are the symptoms of ACS?

Answer 5

Severe crushing chest pain (radiates to jaw and arms, similar to angina but more severe, prolonged and not relieved by GTN), sweating, nausea and vomiting.

Question 6

What are the differences in the duration, onset, severity, GTN response and associated symptoms between an anginal attack and an acute MI?

Answer 6

Duration - angina 10 mins, MI 30 mins or longer.
Onset - angina or exertion, MI at rest.
Severity - angina usual pain, MI severe.
GTN - relief in angina, not in MI.
Associated symptoms - none in angina, sweating nausea and vomiting in MI.

Question 7

What are the ECG changes in an acute ST elevation MI?

Answer 7

ST elevation, T wave inversion, Q waves.

Question 8

What is the ECG criteria for a STEMI?

Answer 8

Either greater than or equal to 1mm ST elevation in 2 adjacent limb leads, greater than or equal to 2mm ST elevation in at least 2 contiguous precordial leads or new onset bundle branch block.

Question 9

Describe how the changes in the ECG evolve over time in a STEMI.

Answer 9

ST elevation - first few hours.
Q wave formation (where first part of QRS complex is enlarged) and T wave inversion - first day.
Old MI - Q waves and maybe inverted T waves.

Question 10

What are the inferior, anteroseptal and anterolateral leads?

Answer 10

Inferior: II, III and aVF.
Anteroseptal: V1-4.
Anterolateral: I, aVL, V1-V6.

Question 11

What is the acronym for early treatment of STEMI?

Answer 11

M - morphine and anti-emetic
O - oxygen (if hypoxic)
N - nitrates (if BP greater than 90mmHg). 
A - aspirin
T - ticagrelor

Question 12

When should you do reperfusion therapy (thrombolysis or PCI)?

Answer 12

1. Chest pain suggestive of acute MI (more than 20 mins less than 12 hours).
2. ECG changes: acute ST elevation, new left bundle branch block.
3. No contraindications.

Question 13

What are the guidelines for whether you should give thrombolysis or PCI?

Answer 13

If can get PCI within 2 hours do that, if not get thrombolysis in the community.

Question 14

What are the 3 types of complications of MI?

Answer 14

Arrhythmic (VF), structural, functional.

Question 15

What are the potential structural complications of an MI?

Answer 15

Cardiac rupture, VSD, mitral regurgitation (flash pulmonary oedema), left ventricular aneurysm formation, mural thrombus maybe causing systemic emboli, inflammation, acute pericarditis, Dressler’s syndrome (autoimmune following infarct).

Question 16

What are the functional complications of MI?

Answer 16

Acute ventricular failure (right left or both), chronic cardiac failure, cardiogenic shock.

Question 17

What should you monitor in a patient after MI treatment?

Answer 17

Rhythm, pulse and blood pressure, heart sounds esp added heart sounds, murmurs esp new murmurs, pulmonary crepitations.

Question 18

What is the difference between ST depression and ST elevation?

Answer 18

ST depression is ischaemia, ST elevation is infarction.

Question 19

What may the ECG look like in an NSTEMI?

Answer 19

May be normal or have ST depression.

Question 20

What troponins are specific to the heart?

Answer 20

Troponin I and T.

Question 21

How would you tell the difference between unstable angina and NSTEMI?

Answer 21

NSTEMI will have raised troponin.

Question 22

What is the score called that can assess risk of having NSTEMIs?

Answer 22

Grace score.

Question 23

Even after a stent is put in, what therapy will people still need?

Answer 23

Antiplatelet therapy?

Question 24

What is the stent that releases drugs called?

Answer 24

Drug eluting stents.

Question 25

What other conditions is troponin T elevated in?

Answer 25

CCF, hypertensive crisis, renal failure, PE, sepsis, stroke/TIA, pericarditis/myocarditis, post arrhythmia.

Question 26

What is a type II MI?

Answer 26

MI due to ischaemic imbalance (increased myocardial oxygen demand).

Question 27

What are 2 new terms to describe a type of heart attack?

Answer 27

Non-ischaemic myocardial injury with necrosis, MINOCA (myocardial infarction with non-obstructed coronary arteries).

Question 28

What would you give for secondary prevention of MI?

Answer 28

Keep diabetes under control, take beta-blockers, ACEIs and statins.

Question 29

What are the 4 phases of cardiac rehabilitation?

Answer 29

1. In patient
2. Early post discharge patient.
3. Structured exercise programme - usually hospital based.
4. Long term maintenance of physical activity and lifestyle change - usually community based.