MI/ACS

Question 1

Fixed RFs for ACS

Answer 1

Age
Gender
FMx (genetics)

Question 2

Most common cause of stable angina

Answer 2

Atheroma

Question 3

What is stable angina?

Answer 3

Clinical manifestation of ischaemia due to obstructed blood flow. Pain is relieved after <5mins when resting

‘Induced by effort and relieved by rest’

Question 4

What else, besides exercise, can bring on symptoms of angina?

Answer 4

Mental and emotional stress
Sexual activity
Tachycardia from any source
Anxiety
Fever

Question 5

Primary prevention of angina

Answer 5

Reduce any RFs related to IHD

Maintain an idea blood pressure (<140/80)

Question 6

Secondary prevention of angina

Answer 6

Patient education RE healthy lifestyle

Antiplatelet therapy indefinitely

Question 7

Investigations to consider in Angina with rationale

Answer 7

ECG - may be normal between attacks but may show ST depression during an attack. This is indicative of ischaemia

Hb - anaemia means the heart has to work harder which may exacerbate angina or cause it without coronary obstruction

Fasting lipid profile - Elevated LDL = increased risk

Question 8

Typical angina symptoms

Answer 8

Pain brought on by exercise or stress
Relived by rest or GTN
Anterior chest ‘squeezing’

Question 9

Pt with diagnosis of angina is not able to tolerate her B-blocker. What can you prescribe?

Answer 9

Calcium Channel Blocker

Question 10

When would a long acting nitrate be prescribed in angina?

Answer 10

When the pt cannot tolerate BB or CCB

Question 11

What should be done if the pt is still symptomatic after LAN, BB and CCB?

Answer 11

Consider revasc. w/ PCI or CABG depending on pt

Question 12

Differentiating factor between angina and unstable angina

Answer 12

UA involves prolonged (>20mins) pain at rest, angina of increasing freq. or that occurs after a recent MI

Question 13

Most common cause of UA

Answer 13

Coronary artery narrowing due to thrombus development on a disrupted atherosclerotic plaque

Question 14

Difference between NSTEMI and UA

Answer 14

NSTEMI involves occluding thrombus which leads to myocardial necrosis and increase in cardiac enzymes

Question 15

Primary prevention of CAD

Answer 15

Lifestyle changes
Statin therapy
Antiplatelet therapy

Question 16

Presentation of unstable angina

Answer 16

Positive RFs in history
Increasing severity of CP
Increasing freq. of CP
Dyspnoea
S4 heard (indicates reduced myocardial relaxation due to ischemia)

Question 17

Investigations to order in UA plus rationale

Answer 17

ECG - obtained and analysed within 10 mins of CP presentation. May be normal or have transient ST depression or T wave inversion. If the ECG is not diagnostic but the pt remains symptomatic then think ACS

Troponin assay - Excludes MI if not elevated

FBC (Hb) - Check for anaemia

BM - Should be normal but if elevated then an assessment for diabetes is reqd.

U+Es - Should be normal. Reqd to establish predictor for mortality

Lipid profile - recommended for risk stratification

Coagulation profile - to establish baseline results as some treatment may affect the coag

CXR - to exclude mediastinal changes

Question 18

UA DDx

Answer 18

Stable Angina
STEMI
NSTEMI
Heart Failure

Question 19

Management of Unstable Angina

Answer 19

Low risk:
Aspirin + Clopidogrel + Analgesia + B-Blocker + lifestyle changes

Stabilised high risk:
Manage with angiography + lifestyle changes + anti platelet therapy + ACEi +

Question 20

Clinical presentation of an MI

Answer 20

Severe crushing CP > 20 mins
No relief w/ GTN or rest
CP radiate to neck, jaw and arm
Dyspnoea, fatigue, syncope
Px is pale and clammy
Thready pulse
Vomiting

Question 21

Which group of patients must be closely monitored in MI history taking?

Answer 21

Diabetics due to silent MIs

Question 22

Which other conditions can cause ST elevation?

Answer 22

ELAVATION

Electrolyte abnormalities
Left bundle branch block
Aneurysm of left ventricle
Ventricular hypertrophy
Arrhythmia disease (Brugada syndrome, ventricular tachycardia)
Takotsubo/Treatment (iatrogenic pericarditis)
Injury (myocardial infarction or cardiac contusion)
Osborne waves (hypothermia or hypocalcemia)
Non-atherosclerotic (vasospasm or Prinzmetal’s angina)

Question 23

ECG findings weeks after an MI

Answer 23

Presence of Q wave
T wave inversion sometimes
T wave flattening

Question 24

Bloods to order in MI

Answer 24

Serum lipids
Glucose
UEs
Cariac Biomarkers

Question 25

DDx in MI

Answer 25

UA
NSTEMI
AAA
PE
Pneumothorax
Pneumonia
GORD
Anxiety

Question 26

Management in suspected MI

Answer 26

Aspirin + O2
Analgesia
GTN

Question 27

Management of unstable MI

Answer 27

Emergency revasc. 
Anticoagulation (abciximab + enox./hep)
Aspirin
Analgesia
O2
Glucose control
Inotrope

Question 28

Subsequent management of stable post MI pt

Answer 28

Aspirin
Beta Blocker
ACEi
Statin
Lifestyle changes

Question 29

Which vessel and aspect of the heart is affected if there are ST elevations in leads II,III and aVF?

Answer 29

Right Coronary Artery and Inferior aspect

Question 30

Which vessel and aspect of the heart is affected if there are ST elevations in leads I, aVL, V5+6?

Answer 30

Left circumflex and anterolateral aspect

Question 31

Which leads represent the LAD and anteroseptal aspect of the heart?

Answer 31

V2-4

Question 32

Which leads and aspect do V2-6 represent?

Answer 32

Anterior aspect and left main stem

Question 33

Which leads represent the posterior aspect + RCA

Answer 33

V1/2/3

Question 34

Lead placement in ECG

Answer 34

V1: 4th ICS RSE
2: 4TH ICS LSE
3: Midway V2-4
4: 5th ICS MCL
5: Midway V4-6
6: 5th ICS MAL
R: R WRIST
Y: L WRIST
G: L ANKLE
B: R ANKLE

Question 35

Indication of absent P waves

Answer 35

AF

SAN block

Question 36

Indication of biphasic P waves / peaked P waves

Answer 36

Left Atrial Hypertrophy / Right atrium Hypertrophy

Question 37

What is the indication of deep ST waves in leads 1-3

Answer 37

True Posterior MI

Rememebr the posterior leads are on the back so the ECG is inverted but it’s still an ST rise