STEMI / NSTEMI / Unstable Angina

Question 1

ECG changes for MI in anteroseptal?

Answer 1

V1-V4

Left anterior descending

Question 2

ECG changes for MI in Inferior?

Answer 2

II, III, aVF

Right coronary

Question 3

ECG changes for MI in Anterolateral?

Answer 3

V5- 6, I, aVL

left circumflex

Question 4

ECG changes for MI in Posterior?

Answer 4

// CHANGES IN V1-3

USUALLY LEFT CIRCUMFLEX, ALSO RIGHT CORONARY //

Question 5

new left bundle branch block (LBBB) may point towards a diagnosis of

Answer 5

acute coronary syndrome

Question 6

poor prognostic indicator in acute coronary syndrome

Answer 6

// CARDIOGENIC SHOCK // IS a poor prognostic indicator (eg blood pressure of 89/71mmHg)

Question 7

x

Answer 7

x

Question 8

in stable angina - where there is normal ECG , and chest pain after exertion what is the first step of investigation?

Answer 8

CT coronary angiogram with contrast

2nd line: non-invasive functional imaging (looking for reversible myocardial ischaemia)
-myocardial perfusion scintigraphy with single photon emission computed tomography (MPS with SPECT)
-or stress echocardiography
// -OR FIRST-PASS CONTRAST-ENHANCED MAGNETIC RESONANCE (MR) PERFUSION
-OR MR IMAGING FOR STRESS-INDUCED WALL MOTION ABNORMALITIES

3RD LINE: INVASIVE CORONARY ANGIOGRAPHY //

Question 9

in angina attacks what are the first line drugs to prevent angina attacks from happening

Answer 9

Beta blocker (bisoprolol and atenolol)
or
Calcium channel blocker - rate limiting one such verapamil and diltiazem if used as A MONOTHERAPY
=====

if there is a poor response to initial treatment then medication should be increased to the maximum tolerated dose (e.g. for atenolol 100mg od)

=======

2nd line -
combo of BETA BLOCKER and calcium channel blocker
(verapamil however contraindicated whilst taking a beta blocker and diltiazen used with caution due to bradycardia )

if calcium channel blocker used as a combo therapy - use a longer-acting dihydropyridine calcium channel blocker - amlodipine, modified-release nifedipine

======
if a patient is taking both a beta-blocker and a calcium-channel blocker then only add a third drug whilst a patient is awaiting assessment for PCI or CABG

3rd line
isosorbide mononitrate 10mg BD

Question 10

In stable angina how long does it take to relive pain by GTN spray ?

Answer 10

relieved by rest or GTN in about 5 minutes

Question 11

How does NICE guidelines define angina pain

Answer 11

Constricting discomfort in front of the chest , neck , shoulders , jaw or arms
Precipitated by exercise
Relived in 5 mins by GTN spray

All three features - typical angina
Only two of the above - atypical angina
1 or none - non angina chest pain

Question 12

if a patient is on monotherapy for stable angina and cannot tolerate the addition of a calcium channel blocker or a beta-blocker then which drugs should be considered :

Answer 12

a long-acting nitrate
ivabradine
nicorandil
ranolazine

Question 13

which drugs is most likely to improve long-term prognosis in STABLE ANGINA

Answer 13

ALL patient should have ASPIRIN AND STATIN

benefit of ACE inhibitors and beta-blockers are significant in patients who’ve had a myocardial infarction , but modest in those with stable angina

Strong evidence exists supporting the use of aspirin

Question 14

percutaneous coronary intervention
should be offered if

Answer 14

STEMI has been confirmed

presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes

if patients present after 12 hours and still have evidence of ongoing ischaemia then PCI should still be considered

Question 15

Once a STEMI has been confirmed s if primary PCI cannot be delivered within 120 minutes

Answer 15

fibrinolysis
should be offered within 12 hours of the onset of symptoms

ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI

Question 16

Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)?

Answer 16

immediate: patient who are clinically unstable (e.g. hypotensive)

within 72 hours: patients with a GRACE score > 3%

Question 17

patient with nstemi - BP of less than 90 , hr 117 , rr 24 , ECG showing new t wave inversion what is the best step management

Answer 17

immediate coronary angiography due to high grace score

angiography within 72 hours stable patients with NSTEMI

Question 18

before Percutaneous coronary intervention for patients with STEMI/NSTEMI/unstable angina what should be given

Answer 18

// UNDERGOING PCI WITH RADIAL ACCESS:
UNFRACTIONATED HEPARIN WITH BAILOUT GLYCOPROTEIN IIB/IIIA INHIBITOR (GPI)- REGARDLESS OF WHETHER THE PATIENT HAS HAD FONDAPARINUX OR NOT //

further antiplatelet (‘dual antiplatelet therapy’, i.e. aspirin + another drug) prior to PCI

Question 19

Conservative management for patients with NSTEMI/unstable angina

Answer 19

Further drug therapy
further antiplatelet (‘dual antiplatelet therapy’, i.e. aspirin + another drug)
if the patient is not at a high risk of bleeding: ticagrelor
if the patient is at a high risk of bleeding: clopidogrel

Question 20

C

Answer 20

C

Question 21

C

Answer 21

C

Question 22

C

Answer 22

C

Question 23

C

Answer 23

C

Question 24

C

Answer 24

C

Question 25

How do we refer patients to the hospital for chest pain

Answer 25

If currently occurring chest pain then immediate emergency admission

If chest pain occurred 12-72 hour ago -refer to hospital same day for assessment

If chest pain occurred more than 72 hours ago - do ECG and troponin to see if referring to hospital is appropriate

Question 26

x

Question 27

x

Question 28

x

Question 29

x

Question 30

x

Question 31

x

Question 32

Patients undergoing fibrinolysis for a STEMI should be given what before ?

Answer 32

antithrombin drug - It should be given before fibrinolysis.

Fondaparinux is an antithrombin medication.

It works by activating antithrombin 3 which causes the inactivation of factor Xa.

In patients undergoing fibrinolysis. Its role in STEMI is to prevent the clot from getting bigger.

Question 33

X

Question 34

X

Question 35

X

Question 36

X

Question 37

common side effect of ticagrelor and is estimated to occur in up to 15% of patients is ?

Answer 37

Dyspnea

Aspirin and ticagrelor is started for ACS
Switch to aspirin and clopidrogel

Question 38

x

Question 39

x

Question 40

x

Question 41

x

Question 42

x

Question 43

x

Question 44

history of ischaemic heart disease is keen to try sildenafil for erectile dysfunction. Which medications may be contraindicated ?

Answer 44

nitrates

Question 45

if stemi is caused by consuming cocaine what is given ?

Answer 45

lorazepam