NSTEMI

Question 1

What are the ECG changes in NSTEMI?

Answer 1

• ST depression
• Flat/inverted T waves
• No changes
• Pathological Q waves - late infarct

Question 2

What Ix would you order for NSTEMI?

*same like other ACS

Answer 2

• ECG
• FBC (check for anaemia)
• U&Es (prior to ACEi and other meds)
• LFTs (prior to statins)
• Lipid profile
• Troponin test, CK
• Thyroid function tests (check for hypo / hyper thyroid)
• HbA1C and fasting glucose (for diabetes)
• CXR to investigate for other causes of chest pain and pulmonary oedema
• Echocardiogram after the event to assess the functional damage
• CT coronary angiogram to assess for coronary artery disease

Question 3

What score is used to assess PCI in NSTEMI?

Answer 3

• GRACE Score

Question 4

What does the GRACE score entails?

Answer 4

• Assess 6months mortality for pts with c ACS

Question 5

How does the GRACE score work?

Answer 5

• <5% Low Risk
• 5-10% Medium Risk
• >10% High Risk
• If they are medium or high risk they are considered for early PCI (within 4 days of admission) to treat underlying coronary artery disease.

Question 6

What does the GRACE score include?

Answer 6

• Age
• HR
• Systolic BP
• Creatinine
• Cardiac arrest on admisison
• ST deviation
• Abnormal cardiac enzymes
• Killip class

Question 7

What is the Killip classifcation used for?

Answer 7

• Quantifies severity of HF in NSTEMI and predicts 30 days mortality

Question 8

Describe the different classifications in Killip

Answer 8

• I: No signs of congestion:
  
  • <5% 30 days mortality
• II: S3 + basal rales
  
  • 5-10% 30 days mortality
• III: Acute pulmonary oedema
  
  • 10-20%
• IV: Cardiogenic shock
  
  • 10-20%

Question 9

How would you acutely manage NSTEMI?

Answer 9

• Record ECG
• If SaO2 <90% / breathless - low flow O2
• Morphine 5-10mg IV + Metoclopromide 10mg IV
• GTN spray
• Aspirin 300mg loading and 75mg OD
• Measure troponin & GRACE score
• Start mx for either high risk or low risk pts

Question 10

What features do high risk pt have?

Answer 10

• Rise in troponin
• ST or T wave changes
• DM, CKD, LVEF < 40%, early angina post MI, recent PCI, prior CABG,

Question 11

What is the Mx plan for high risk pt?

Answer 11

• Fondaparinux 2.5mg OD SC or LMWH 1mg/kg/12h
• Second platelet
  
  • Ticagrelor 180mg PO
• IV Nitrate if pain continues
  
  • GTN 50mg in 50mL 0.9% saline @ 2-10mL/h
• Bisoprolol 2.5mg OD
• Prompt cardiologist review for angiography

Question 12

What drug class is fondaparinux?

Answer 12

• synthetic pentasaccharide
• inhibits Xa by binding to ATIII, long half life -18h

Question 13

What other medications would you consider for NSTEMI?

Answer 13

• ACEi
• Atorvastatin 80mg OD

Question 14

What are the Cx of MI?

*remember DREAD

Answer 14

• Death
• Rupture of heart sputum
• Edema
• Arryhtmia
• Dressler’s syndrome

Question 15

What is Dressler’s syndrome?

Answer 15

• Localised immuneresponse post MI causing pericarditis

Question 16

How long after an MI would dressler’s syndrome normally occur?

Answer 16

• 2-3 weeks

Question 17

How does Dressler’s syndrome present?

Answer 17

• pleuritic chest pain
• low grade fever
• pericardial rub
• pericardial effusion

Question 18

How would you dx dressler’s syndrome?

Answer 18

• ECG
  
  • global ST elevation and T wave inversion
• Bloods
  
  • raised CRP and ESR
• Echo
  
  • pericardial effusion

Question 19

What is the mx for Dressler’s syndrome?

Answer 19

• NSAIDs
• steroids
• pericardiocentesis

Question 20

What are the medical options for secondary prevention of MI?

*6As

Answer 20

• Aspirin 75mg OD
• Another anitplatelet: clopidogrel or ticagrelor - up to 12months
• Atorvastatin 80mg OD
• ACEi - as tolerated. up tp 10mg OD
• Atenolol
• Aldosterone antagosist (eg; eplerenone - up to 50mg OD)