Symposium 1 - Ischaemic heart disease and acute coronary syndrome

Question 1

Complete the diagram of coronary vessels

Answer 1

Question 2

What is ACS characterised by?

Answer 2

ACS is characterised by the development of a thrombosis at the site of acute disruption of an atherosclerotic plaque

Question 3

What are the 2 ways an atherosclerotic plaque can disrupt?

Answer 3

Disruption may be superficial erosion of the endothelium over a fibrous cap or acute deep plaque rupture

Question 4

Complete the diagram on the stages of atherosclerosis

Answer 4

Question 5

Following plaque disruption, thrombus results from what?

Answer 5

• Adherence, activation and aggregation of platelets
• Thrombin and fibrin production via the coagulation cascade (and thrombin release from platelets)
• Release of vasoactive molecules from platelets causing vasoconstriction

Question 6

Complete the diagram of an atherosclerotic plaque

Answer 6

Question 7

Complete the diagram on changes which occur on an ECG during a STEMI?

Answer 7

Question 8

Label each section of the 12 lead ECG with either -

1. Lateral
2. Inferior
3. Anterior
4. Anterior-septal

Answer 8

Question 9

What does this ECG show?

Answer 9

Anterolateral ST elevation myocardial infarction

Question 10

What does this ECG show?

Answer 10

Inferior ST elevation myocardial infarction

Question 11

What does this ECG show?

Answer 11

Lateral ST elevation myocardial infarction

Question 12

How does a heart attack happen?

Answer 12

• Heart disease develops over time as fatty deposits narrow coronary arteries, restricting blood flow to the heart
• The coronary artery occludes usually due to a clot resulting from ruptured atherosclerotic plaque
• Blood flow is restricted and a heart attack begins
• If blockage continues, parts of the heart muscle start to die
• Heart may stop beating, leading to cardiac arrest

Question 13

What stops a heart attack?

Answer 13

• Quick action and medical treatment restores blood flow and saves heart muscle
• ‘Time is muscle’
• Dead heart muscle cannot be restored
• The more heart muscle that is saved, the better the chance of survival and the better the outcome

Question 14

How is a STEMI treated?

Answer 14

Antiplatelet agents (aspirin + clopidogrel)

AND

‘Primary’ angioplasty (balloons, stents): artery is mechanically reopened, restoring blood flow (gold-standard treatment)

“Clot-busting” drug (thrombolysis): pharmacologically break up clots, restoring blood flow (only used if primary angioplasty is not available)

Question 15

What procedure is this?

Answer 15

Balloon Angioplasty & Stent

Question 16

What are heart attack warning symptoms?

Answer 16

Chest discomfort—pressure, squeezing, fullness or pain in center of chest

Chest pain radiating to arm(s), back, neck or jaw

Shortness of breath

Breaking out in a cold sweat

Nausea

Question 17

What is the onset of a heart attack often like?

Answer 17

Often begins with vague symptoms that slowly intensify

Pain or discomfort can be relatively mild

Symptoms may come and go

Question 18

What are the symptoms of heart attacks in women?

Answer 18

May feel pain or discomfort in chest

Other symptoms include:

• Shortness of breath
• Nausea/vomiting
• Back or jaw pain

Question 19

Do men or women delay seeking help more?

Answer 19

Women

Question 20

Which patients have atypical heart attack presentations?

Answer 20

Women

Elderly

• Confusion
• Collapse ? Cause
• In context of pneumonia etc.

Diabetics

• ‘silent’
• Diabetic ketoacidosis
• Breathlessness

Question 21

What is the biggest cause of not receiving rapid care in an MI?

Answer 21

Patient delay

Question 22

What are the theraputic goals in a STEMI?

Answer 22

Restore epicardial vessel patency

Limit myocardial necrosis

Control symptoms

Question 23

What are the 3 elements of medical management in a STEMI?

Answer 23

Anti-platelelet therapy

Anti-ischaemic therapy

Secondary prevention

Question 24

What does secondary prevention for an MI include?

Answer 24

Antiplatelet therapy

• aspirin
• clopidogrel /prasugrel /ticagrelor

Statin

Beta blockers

ACE inhibitors

Smoking cessation

Lifestyle modification

Question 25

What does the catheter lab team include?

Answer 25

Consultant cardiologist

1 middle grade doctor (SpR/fellow)

1 radiographer

1 cardiac physiologist

1 or 2 scrub nurses

Question 26

What is monitiored in a catheter lab?

Answer 26

Blood pressure

Oxygen saturations

ECG – ST segments

Arrhythmias

• Bradycardia
• Tachycardias
• Atrial fibrillation
• Ventricular tachycardia
• Ventricular fibrillation

Question 27

What is cardiac rehabilitation?

Answer 27

“The coordinated sum of activities* required to influence favorably the underlying cause of cardiovascular disease as well as to provide the best possible physical, mental and social conditions, so that patients may by their own efforts, preserve or resume optimal functioning in their community and through improved health behavior, slow or reverse progression of disease’’.

Question 28

What are the patient goals in cardiac rehabilitation?

Answer 28

• Recovery
• Secondary Prevention
• Adoption & Maintenance of Healthy Lifestyle
• Preservation of Mobility and self-Sufficiency
• Return to Work
• Cost-Effectiveness for the Health Service

Question 29

What are the components of cardiac rehabilitation?

Answer 29

• Exercise
• Education
• Psychological support
• Lifestyle and Risk factor modification
• Medical Risk Management

Question 30

What is the delivery / MDT team for cardiac rehabilitation?

Answer 30

• Multidisciplinary team approach
• Cardiac rehabilitation specialist nurses
• Physiotherapists
• Dietician
• Administrator
• Clinical lead
• Psychologist / Psychology practitioners
• Pharmacist
• Occupational therapist