Management

Question 1

ECG?

Answer 1

Look for signs of ischaemia and arrhythmias.

If suspect PE, look for signs of right heart strain, although tachycardia is the most common finding.

Look for ST elevation or new-onset LBBB as the management protocol for STEMI differs to that of an NSTEMI.

Question 2

Blood tests Troponin?

Answer 2

measured from 3-12hrs from pain onset. Sensitive and specific for damage to cardiac muscle. An alternative is CK-MB which is released more rapidly following damage. Troponin can be raised in ACS, coronary artery spasm, aortic dissection causing ischaemia, myopericarditis

Question 3

Blood tests serum cholesterol?

Answer 3

hypercholesterolaemia is a risk factor for cardiovascular disease.

An MI reduces the cholesterol levels for 2-3months

Question 4

Blood tests FBC?

Answer 4

anaemia from any cause is common and will exacerbate deficiency in cardiac perfusion, resulting in ischaemic heart disease.

Question 5

Blood tests U&Es?

Answer 5

potassium can be a cause for arrhythmias

Question 6

Blood tests inflammatory markers?

Answer 6

WCC and CRP are elevated in pericarditis, aortic dissection and MI

Question 7

Blood tests capillary glucose?

Answer 7

DM increases risk of cardiovascular disease. Diabetics are more likely to suffer silent infarcts, MI in absence of chest pain.

Question 8

Blood tests amylase?

Answer 8

Patients with acute pancreatitis can present with severe central chest pain.

Question 9

Erect CXR?

Answer 9

done to exclude pneumothorax and aortic pathology (aneurysm or dissection giving a wide mediastinum).

If Boerhaaves is suspected, CXR will show pneumomediastinum, pleural effusion and/or pneumothorax.

CXR shows boerhaaves

Question 10

D-dimer levels?

Answer 10

symptomatic of breakdown of a fibrin clot due to any cause such as trauma or recent surgery.

So not diagnostic of DVT or PE.

But rule out DVT or PE as these rarely occur without fibrin breaking down.

Question 11

Dresslers syndrome?

Answer 11

Leucocytosis on FBC and saddle shaped ST elevation on ECG. An echocardiogram may also show pericardial effusion.

Question 12

Dresslers syndrome management?

Answer 12

analgesia, large doses of anti-inflammatory drugs like aspirin.

Question 13

If exhausted all diagnoses?

Answer 13

consider coronary artery spasm or coronary syndrome X, but only after everything.

Question 14

a tall, thin, young individual?

Answer 14

immediately be thinking of pneumothorax or Marfan’s syndrome predisposing to a dissected aortic aneurysm or aortic dissection.

Question 15

Boerhaaves complications?

Answer 15

prone to develop a pleural effusion, pneumomediastinum and/or pneumothorax, perhaps followed by infection with gastrointestinal flora (mediastinitis and sepsis).

Question 16

why can MI patients get nausea and vomiting?

Answer 16

due to infarction of the inferior myocardium irritating the diaphragm.

Question 17

How can occlusion of different coronary vessels be distinguished on ECG?

Answer 17

Question 18

How can occlusion of different coronary vessels be distinguished on ECG Anterior infarct?

Answer 18

ST elevation in leads V2, V3, and V4 indicate infarct on anterior surface of left ventricle, supplied by Left ascending artery.

Question 19

How can occlusion of different coronary vessels be distinguished on ECG right/inferior infarct?

Answer 19

ST elevation in leads II, III, and aVF indicate infarct on inferior surface, supplied by right coronary artery.

Question 20

How can occlusion of different coronary vessels be distinguished on ECG Lateral infarct?

Answer 20

ST elevation in leads V5 and V6 indicates infarction on lateral surface of left ventricle involving circumflex or LAD.

Question 21

How can occlusion of different coronary vessels be distinguished on ECG Posterior infarct?

Answer 21

ST depression in V1-V3 with tall R waves is indicative of circumflex occlusion.

Question 22

Mechanism of action of aspirin?

Answer 22

irreversible inhibitor of COX, which synthesizes inflammatory mediators including the platelet aggregator thromboxane A2. Reversed by synthesis of new platelets.

Question 23

Mechanism of action of clopidogrel?

Answer 23

irreversibly blocks the adenosine diphosphate (ADP) receptor on platelet cell membranes

Question 24

Mechanism of action of Abciximab and tirofiban?

Answer 24

reversibly block fibrinogen binding to the glycoprotein IIb/IIIa receptors on platelet cell membranes that mediate platelet aggregation

Question 25

Investigations for new-onset angina?

Answer 25

Exercise tolerance test; to look for coronary artery disease and so the potential benefit of angioplasty. ST depression or elevation indicate stenosis of the coronary arteries.

Stress echocardiogram; dobutamine is given and cardiac function assessed, a normal heart shows increased motility, ischaemic myocardium is hypokinetic.

CT coronary angiography; contrast is given to view coronary arteries in detail, calcium in calcified atherosclerotic plaques in the lumen.

Angiography/angioplasty; identifies if there is stenosis of a coronary artery. Angioplasty (widen narrowed artaries with a balloon) can be done straight away.

Question 26

Old infarcts are visible on ECGs ?

Answer 26

infarcted tissue no longer conducts electrical impulses. Can be seen as deep Q waves (>2mm).