HEART ATTACK/ACS

Question 1

Mx of acute STEMI

Answer 1

Question 2

what is ACS?

Answer 2

includes unstable angina and myocardial infarctions (MIs)

Question 3

STEMI vs NSTEMI

what size should ST elevation be limb leads and chest leads?

Answer 3

(STEMI): chest pain + persistent ST elevation (or new LBBB) ST elevation should be > 1 mm in LIMB leads & 2 mm in chest leads.

Subsequent hs-TnI will frequently be > 100 ng/L (and CK usually > 400).

(NSTEMI): chest pain. & maybe ST segment depression, T wave inversion or may be normal.

Subsequent hs-TnI will frequently be > 100 ng/L.

Previously established ECG changes such as old MI, LV hypertrophy or a fib may be present.

The hallmark of acute coronary syndrome is labile ECG changes.

Question 4

Myocardial Infarction types of infarct and ECG changes

Answer 4

Acute infarct: ST elevation

Recent infarct: T wave inversion & Pathological Q waves (Q waves over 1/4 the total height of the QRS complex)

Old infarct: Q waves remain

Also new onset LBBB !!

Question 5

when to troponin rise? how long do they remain high?

what levels suggest likelihood of myocardial necrosis in men vs females?

Answer 5

TnI levels begin to rise 3 - 4 hours after myocardial damage and stay elevated for up to 2 WEEKS

• Males: greater than 34 ng/L
• Females: greater than 16 ng/L

Question 6

Rising and/or falling cardiac troponin levels differentiate acute from chronic cardiomyocyte damage (the more pronounced the change, the higher the likelihood of acute MI).

A rise greater than ______ may indicate ACS.

Answer 6

5 ng/L

Levels 5 FOLD above the upper limit have a very high predicve value for type 1 myocardial infarcon (>90%)

Question 7

false positive elevation of hs-TnI is found in which ptx?

Answer 7

advanced renal failure or large pulmonary embolism.

Question 8

Other condions in which hs-TnI may be elevated ?

Answer 8

• aorc dissec
• aorc stenosis,
• hypertrophic cardiomyopathy,
• Takotsubo cardiomyopathy
• malignancy
• stroke
• severe sepsis

Question 9

what does ST depression confined to leads V1 to V4 suggest?

Answer 9

may have true posterior MI and should be treated in the same manner as STEMI.

Question 10

which leads should ALL ptx have done on admission?

Answer 10

All ptx should routinely have POSTERIOR (V7 - V9 below) and RIGHT VENTRICULAR LEADS recorded ON OR SOON AFTER ADMISSION, especially those with inferior STEMI, as diagnosc changes may be transient.

ST elevaon in RV4 is highly sensive for right ventricular infarcon. ?

Question 11

In the case of unstable angina and NSTEMI how might the ECG changes manifest ?

Answer 11

transient ST segment depression or elevation, T wave inversion or flattening, T wave pseudo- normalisaon (or even no change at all).

Question 12

what should be considered in previously established ECG changes?

Answer 12

old MI, LV hypertrophy and digoxin effect need to be considered.

Question 13

what Certain conditions may mimic STEMI on the ECG?

Answer 13

1. Early repolarisation causes up-sloping ST elevation, particularly in leads V1 and V2 (and somemes V3). It is seen more commonly in younger, especially athletic paents. It is also seen in some Afro-Caribbean’s.
2. concave ST elevation in PERICARDITIS and the ST changes may be very widespread.
3. Brugada syndromecan be misdiagnosed as anterior STEMI.
4. Takotsubo cardiomyopathy (stress reacon mostly middle aged females) can also mimic STEMI and NSTEMI.

Question 14

Prasugrel contraindication?

Answer 14

restricted to ptx undergoing primary percutaneous coronary intervenon (PPCI) for STEMI who are under the age of 75 and who weigh more than 60kg and who have not had a prior TIA or stroke.

Question 15

Clopidogrel loading dose?

Answer 15

loading dose 600 mg followed by 75mg od for up to 12 month

Question 16

Complications of MI

Answer 16

Dressler’s syndrome : Recurrent pericarditis, pleural effusions, fever, anae- mia, and  ESR 1–3wks post-MI.

Treatment: consider NSAIDS; steroids if severe.

Question 17

 Acute Mx of cardiac chest pain

Answer 17

Question 18

what medication r those with STEMI must be on and explain why for each?

Answer 18

BAS KHALAAAAAA9

1. Bisoprolol (beta-blocker, reduce HR, avoid in shock or low BP, start dose 1.25mg od).
2. Ace inhibitors (prevent muscle over- damage). Ramipril start dose 2.5 mg od with checking of Renal function) OR ARBS (losartan 25mg od start dose and check renal funcon). Uptrate to max tolerated dose.
3. Statin (such as atorvastatin 80 mg od, target is to reduce LDL-C < 1·8 mmol/L or a 40% reduction in non-HDL-C. Consider _rosuvastati_n 5mg if sensive to atorvastan. Ezetemibe if all stans caused SE.

Question 19

Management of NSTEMI/Unstable Angina

Answer 19

1. Pain relief (as above)
2. Asprin 300 mg loading and 75 mg od
3. Low molecular weight heparin (Enoxaparin for 48 hrs based on weight and creanine).
4. Repeat ECG
5. Risk assessment of paent with elevated hs-TnI. Try grace score
6. Ticagrelor if risk > 3% (medium) 180mg loading and 90mg BD.
7. Whilst waing for inpaent angiography consider an-anginals: nitrates, ranolazine, calcium channel blockers.