Questions and answers

Question 1

Which 3 clinical presentations come under Acute coronary syndromes (ACS)?

Answer 1

• ST segment Elevation Myocardial Infarction (STEMI)
• Non - ST segment elevation Myocardial Infarction (NSTEMI)
• Unstable angina

Question 2

How is a STEMI defined?

Answer 2

A serious heart attack (myocardial infarction) where one of the hearts major arteries is blocked.

Question 3

For a STEMI to be diagnosed, for at least how long will the ST segment be raised?

Answer 3

It should be raised for more than 20 minutes.

Question 4

What is the main difference between a STEMI and a NSTEMI?

Answer 4

A STEMI (ST-elevation myocardial infarction) is caused by a sudden complete (100 percent) blockage of a heart artery (coronary artery).

A NSTEMI is usually caused by a severely narrowed artery that is not completely blocked.

Question 5

Could the ECG show no changes even though the patient is diagnosed with a NSTEMI?

Answer 5

With NSTEMI and Angina, changes may not be obvious on an ECG or can be transient so diagnosis should always be made clinically with patient assessment and history.

Question 6

Non modifiable risk factors of atherosclerosis

Answer 6

Socioeconomic factors
Premature menopause
South Asians living in the UK
Family history of premature CHD (coronary heart disease)
Gender (male)
Increasing age

Question 7

Modifiable risk factors of atherosclerosis

Answer 7

Diabetes Mellitus
Raised LDL cholesterol
Low HDL cholesterol
Inactivity
Smoking
Obesity

Question 8

State 3 things that can cause the plaque to rupture

Answer 8

• Inflammation
• Physical and emotional stress
• Circadian rhythm

Question 9

If the plaque completely occludes the artery what is the likely result?

Answer 9

Myocardial infarction

Question 10

If the plaque partially occludes the artery what is the likely result?

Answer 10

An NSTEMI or Unstable angina may occur.

Question 11

If the occlusion is intermittent or causes spasm what is the likely result?

Answer 11

Heart attack

Question 12

If there is an occlusion approximately how long will it take for myocardial necrosis to occur?

Answer 12

15- 20 minutes

Question 13

Assessment and symptoms of ACS

Answer 13

Diagnosis of this syndrome is based on patient history, symptoms and diagnostic tests including ECG and troponins.

Patients can be assessed for symptoms like pain in chest, left arm, jaw or back that lasts longer than 15 minutes. Pain in the chest can feel like indigestion. A person may be breathless, have nausea or vomiting or be noticeably sweating.

Question 14

Treatment of STEMI is PCI. What is percutaneous coronary intervention (PCI)?

Answer 14

Percutaneous coronary intervention (PCI) - this is a nonsurgical widening of the coronary artery; a balloon catheter dilates the artery from within. A metallic stent is usually placed after dilatation keeping the artery open.

Question 15

What can you use to treat NSTEMI or unstable angina?

Answer 15

• Oxygen
• Pain relief
• Nitrates (sublingual, oral or intravenous eg Glycerol trinitrate (GTN): for ongoing pain, may help overcome superimposed coronary artery f.
• ASPIRIN loading 300 mg
• Low Molecular Weight Heparin (a combination of heparin and aspirin is more effective than aspirin alone).
• Clopidogrel (antiplatelet) Treatment within 24 hours has been shown to decrease cardiac death, MI or stroke.
• Fondaparinux (anticoagulant)
• Ticagrelor (platelet aggregation inhibitor)
• Beta-blockers

Question 16

How can you identify when someone has unstable angina?

Answer 16

You could identify if someone has unstable angina, when troponin increases. Elevated Troponin levels indicate an increased risk of mortality.

Question 17

Drug treatments for STEMI:

Answer 17

Oral ACE Inhibitor in LV dysfunction.

Beta blocker – diminish the effects of epinephrine (adrenaline) and other stress hormones.

Statins - lower cholesterol.

Question 18

How is unstable angina distinguishable from angina?

Answer 18

Stable angina can be triggered by stress or exercise and can stop within a few minutes of resting.
Unstable angina is random chest pain that can be long lasting.

Question 19

What do beta blockers do and are they recommended?

Answer 19

Beta blockers are used to reduce the effect of adrenaline (which causes the heart to beat quicker) and other stress hormones

Question 20

Aspirin (antiplatelet) reduces the risk of complications by more 50% - it is more effective when combined with what?

Answer 20

Heparin

Question 21

What is unstable angina described as:

Answer 21

Chest pain at rest

Question 22

What is the name of the 2 types of heart attacks?

Answer 22

Transmural infarct and partial thickness

Question 23

What does JVD stand for?

Answer 23

Jugular vein distention

Question 24

What does the p-wave represent in an ECG trace?

Answer 24

Atria contraction

Question 25

What does the QRS complex represent in an ECG trace?

Answer 25

Large ventricles contracting

Question 26

What does the ST segment represent?

Answer 26

How long the heart rests for before contracting.

Question 27

Patients who have acute chest pain, but no elevation of ST segment are diagnosed with what?

Answer 27

NSTEMI because the ST segment is slightly depressed.

Question 28

What happens in atherosclerosis?

Answer 28

1. Endothelium gets damaged.
2. Cholesterol and toxins from the blood form on the damaged site
3. Chemical signals are sent to the blood stream. Monocytes here these signals and move to the damaged site.
4. Monocytes turn to macrophages and digest the cholesterol. The macrophages begin to build up and turn to foam cells. The foam cells turn to a fibrotic plaque in the artery wall.
5. The smooth muscle from the tunica externa move to the surface of the plaque and form a fibrotic plaque.
6. Blood flow can be inhibited during this time.
7. Overtime, the cap can rupture and cause the plaque to move into the bloodstream.
8. The plaque can move in the downwards flow and block blood flow, causing a heart attack.