Management of Acute MI

Question 1

Outline the immediate management of an acute STEMI. (4)

Answer 1

1. ABCD resuscitation
2. Anti-coagulants
   a. In ambulance:
   - Aspirin 300mg
   - Clopidogrel 300mg
   b. In hospital:
   - Heparin IV
   - Ticagrelor
3. Symptomatic relief:
   a. Morphine 5-10mg
   b. Anti-emetics
4. Reperfusion therapy
   a. Thrombolytics
   b. Primary PCI
   - Transradial percutaneous intervention
   - Balloon angioplasty

Question 2

Outline the immediate management of an NSTEMI. (5)

Answer 2

1. Admission to coronary care unit
2. Anti-coagulants:
   a. Aspirin 300mg
   b. Clopidogrel/ticagrelor
   c. Heparin/fondaparinux
3. Pain relief:
   a. Nitrates
4. Secondary prophylaxis:
   a. Beta blockers
   b. ACE inhibitors
   c. Statins
   d. Second anti-coagulant
5. Cardiac rehab
6. Coronary angiography and echocardiogram

Question 3

Outline the long term management of MI. (5)

Answer 3

1. Observation for MI complications
2. Secondary prophylaxis:
   a. ACE inhibitors
   b. Beta blockers
   c. Statins
   d. Anti-platelet drugs
3. Echocardiogram
4. Cardiac rehabilitation
5. Lifestyle changes

Question 4

Which drug should be given for secondary MI prevention in people with diabetes/LV dysfunction/heart failure?

What type of drug is this?

Answer 4

Eplerenone

Aldosterone antagonist

Question 5

Which 4 tests should be done after an MI?

Answer 5

Repeat troponin

Cholesterol levels

Glucose levels

Echocardiogram

Question 6

List 7 possible complications of acute MI.

Answer 6

Arrhythmias
Heart failure
Cardiogenic shock
Myocardial rupture
Pericarditis
LV mural thrombus
Mitral valve regurgitation

Question 7

How do you assess the need for coronary angiography after an NSTEMI?

What are the clinical applications of this score? (3)

Answer 7

GRACE score

Low risk: discharge on medical treatment
Intermediate risk: discharge PLUS angiograph within 1-2 weeks
High risk: urgent inpatient angiogram

Question 8

Which tests would you do to diagnose MI? (3)

What features would you see on each?

Answer 8

BLOODS:

• Troponin (NOTE: if -normal - repeat in 3 hours)
• U&Es
• LFTs

ECG:

• ST elevation
• Reciprocal ST depression
• Hyperacute T waves
• Q waves
• Inverted T waves (suggest NSTEMI)

CXR:

• Exclude respiratory problems
• Signs of acute heart failure

Question 9

What is the time limit for PCI?

Answer 9

Within 90 minutes of MI

Question 10

Describe the signs O/E of an acute MI. (6)

Answer 10

Tachycardia (100+)
Distressed patient
Heart failure (e.g. lung crackles, raised JVP)
Cardiogenic shock
Arrhythmias
None

Question 11

Define acute MI.

Answer 11

Any elevation of troponin in a clinical setting consistent with myocardial ischaemia

Question 12

Describe the features of an acute STEMI on ECG.

Answer 12

ST elevation
Hyperacute T waves
New left bundle branch block
Q waves

Question 13

List the 5 types of MI.

HINT: one of these types has 2 subtypes.

Answer 13

Type 1 - spontaneous due to CAD

Type 2 - MI due to increased oxygen demand/decreased oxygen supply, e.g. heart failure, sepsis, arrhythmias etc.

Type 3 - MI resulting in sudden cardiac death

Type 4a - MI associated with PCI

Type 4b - MI associated with stent thrombosis

Type 5 - MI associated with CABG

Question 14

What drugs/other advice would you discharge patients with after an acute MI? (7)

Answer 14

Secondary prophylaxis:

• Statins
• Dual anti-platelets (for 3-12 months)
• ACE inhibitors
• Beta blocker
• GTN spray

Lifestyle advice:

• Smoking cessation
• Cardiac rehab