IHD - ACS's (unstable angina, STEMI, NSTEMI)

Question 1

Definition of Acute coronary syndromes

Answer 1

encompasses a spectrum of conditions which include unstable angina, NSTEMI and STEMI

Question 2

How to identify the ACS

Answer 2

Unstable angina
* ST depression, T-wave inversion or normal ECG
* no elevated troponin as there is no myocardial necrosis
* caused by partial occulsion of a CA

NSTEMI
* ST depression, T-wave inversion or normal ECG
* elevated troponin as there is myocardial necrosis
* severe but not complete occlusion of a CA

STEMI
* ST elevation
* elevated troponin
* complete occlusion of a CA

Question 3

Myocardial infarction classification (type 1 and 2)

Answer 3

Type 1 - atherosclerotic plaque rupture
Type 2 - infarction caused by something else e.g. coronary artery spasm, arrythmias, anaemia, hypotension

Question 4

Signs of an ACS

Answer 4

1. central crushing chest pain
2. sudden onset
3. may radiate to left arm, neck and jaw
4. Other symptoms such as nausea, sweating, SOB, syncope
5. may be relived by GTN
6. Epigastric pain (rare)

Question 5

Differential Diagnosis of ACS - 5

Answer 5

Cardiac:
* Myocarditis
* Pericarditis
* Cardiomyopathy
* Valvular disease
* Cardiac trauma
Pulmonary
* PE
* Pneumonia
* Pneumothorax
Vascular
* Aortic dissection
GI
* Oesophagitis
* Peptic ulcer
* Pancreatitis
* Cholecystitis
MSK
* Rib fracture
* Costochondritis
* Muscle injury
* Herpes zoster

Question 6

Investigations of an ACS presentation and why - 7

Answer 6

• ECG (most important invx)
• Troponin - will only show as raised 3 hours after the pain starts
• Renal function test - need good renal function for coronary angiogram and PCI
• HbA1c and lipids - risk factors for CVD
• FBC and CRP - rules out infectious causes
• D-dimer - rule out PE
• CXR - rule out other causes

Question 7

Management of STEMI - 6

MONA

Answer 7

• Targeted O2 therapy (aim for sats over 90)
• Loading dose (300mg) PO aspirin
• Some then add loading dose of second antiplatlet (clopidogrel, ticagrelor, prasugrel)
• Sublingual GTN spray
• IV morphine - vasodilates
• PCI- only for those who present within 12 hours of pain and are less than 2 hours since first medical contact

Question 8

Management of NSTEMI and Unstable Angina - 6

MONA

Answer 8

• Target O2 therapy
• Loading dose aspirin - 300mg
• Fondaparinux
• Sublingual GTN spray
• IV morphine
• Antithrombin therapy - LMWH or fondaparinux

Question 9

Long Term MI Management - 6

BADS

Answer 9

• Beta blocker - bisoprolol
• ACE inhibitors - ramipril
• Dual platelet therapy - aspirin (75mg) and clopidogrel or ticagrelor
• Statins - atorvostatin 80mg
• All pts have an echo to assess systolic function
• Cardiac rehab referral

Question 10

Complications of an MI

Answer 10

1. Ventricular arrhythmia
2. Mitral regurgitation
3. congestive heart failure
4. Heart block
5. Cardiac Tamponade
6. acute pericarditis