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A. MLA Map Acute and Emergency > Unstable Angina > Flashcards

Unstable Angina Flashcards

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1
Q

Acute coronary syndrome (ACS) is usually the result of a thrombus from an atherosclerotic plaque blocking a coronary artery. When a thrombus forms in a fast-flowing artery, it is formed mainly of platelets. This is why antiplatelet medications such as aspirin, clopidogrel and ticagrelor are the mainstay of treatment.

There are three types of acute coronary syndrome:

Unstable angina
ST-elevation myocardial infarction (STEMI)
Non-ST-elevation myocardial infarction (NSTEMI)

A
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2
Q

Unstable angina (UA) is due to transient myocardial ischaemia (MI), often resulting from atherosclerotic plaque rupture and subsequent thrombus formation in the coronary arteries. The symptoms are due to a mismatch in myocardium oxygen demand and supply. Which of the following is NOT a risk factor for UA?

1 - Age
2 - Gender
3 - Tobacco use
4 - Dyslipidaemia and Hypertension
5 - Diabetes mellitus
6 - Obesity and Sedentary lifestyle
7 - Family history

A

2 - Gender

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3
Q

Although there are a variety of causes leading to unstable angina, which of the following can also cause UA?

1 - Atherosclerotic plaque disruption
2 - Vasospasm
3 - Cocaine use
4 - All of the above

A

4 - All of the above

  • Atherosclerotic plaque disruption = most common cause, may be due to transient or partial occlusion of the coronary artery.
  • Vasospasm = UA episodes without significant atherosclerosis (Prinzmetal’s angina).
  • Cocaine use: Cocaine can induce coronary vasospasm leading to unstable angina. It also accelerates atherosclerosis and increases platelet aggregation.
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4
Q

Coronary atherosclerosis is a complex inflammatory process. Although the exact cause is unknown, the trigger id commonly linked with damage and/or dysfunction to the epithelium of blood vessels. Which of the following has not been identified as a trigger causing epithelium damage and/or dysfunction?

1 - morbid hypertension
2 - biochemical abnormalities (LDL)
3 - diabetes mellitus
4 -immunological factors (free radicals from smoking)
5 - inflammation
6 - genetic alteration
7 - biochemical abnormalities (HDL)

A

7 - biochemical abnormalities (HDL)

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5
Q

What is the earliest stage of atherogenosis (atherosclerotic plaque formation, leading to coronary artery heart disease)?

1 - fatty streaks
2 - LDL infiltration
3 - cytokine release
4 - foam cells build up

A

1 - fatty streaks

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6
Q

Following the initial damage/dysfunction to blood vessel epithelium, what is the first things that occurs leading to coronary atherosclerosis?

1 - increased cytokine expression
2 - foam cells build up
3 - LDL cross epithelium
4 - macrophages phagocytose LDL through oxidation

A

3 - LDL cross epithelium

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7
Q

Following the initial damage/dysfunction to blood vessel epithelium, LDL cross the epithelium. What then occurs leading to coronary atherosclerosis?

1 - increased cytokine expression
2 - foam cells build up
3 - LDL cross epithelium
4 - macrophages phagocytose LDL through oxidation

A

4 - macrophages phagocytose LDL through oxidation

  • macrophages cross endothelium to get to LDLs
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8
Q

Following the initial damage/dysfunction to blood vessel epithelium, we have dead macrophages full of LDLs, called foam cells. What is the next thing that occurs leading to coronary atherosclerosis?

1 - increased cytokine expression
2 - foam cells build up
3 - LDL cross epithelium
4 - macrophages phagocytose LDL through oxidation

A

2 - foam cells build up

  • foam cells are macrophages that have died and begin secreting cytokines
  • attract more monocytes to area
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9
Q

What is a fatty streak, which is a term used in atherosclerosis?

1 - build up of HDL beneath epithelium
2 - build up of LDL beneath epithelium
3 - build up of foam cells beneath epithelium
4 - build up of macrophages beneath epithelium

A

3 - build up of foam cells beneath epithelium

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10
Q

Fatty streaks can occur in any patients throughout their life. Why are fatty streaks dangerous?

1 - thrombogenic
2 - increase blood pressure
3 - increase cytokine release
4 - decrease HDL levels

A

1 - thrombogenic

  • susceptible to blood clotting on it
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11
Q

Fatty streaks formed by dead macrophages containing LDL are thrombogenic, meaning they are susceptible to blood clotting. This causes the release of platelet derived growth factor, and then smooth muscle migration and proliferation to the tunica intima from the tunica media. Smooth muscle cells then secretes things that become the fibrous cap. Which of the following is NOT a component of the fibrous cap?

1 - collagen
2 - elastin fibrous cells
3 - elastic cartilage
4 - proteoglycans

A

3 - elastic cartilage

  • purpose of the fibrous cap is to prevent blood clotting
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12
Q

Together the fibrous cap and fatty streak are called what?

1 - thrombosis
2 - embolus
3 - atheroma
4 - plaque

A

4 - plaque

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13
Q

In addition to secreting the contents that make up the fibrous cap, what else do smooth muscle cells secrete in the fatty streak?

1 - Ca2+
2 - Na+
3 - Mg+
4 - Cl-

A

1 - Ca2+

  • normally deposited into vessel walls by LDL
  • cholesterol crystals are also present
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14
Q

In addition to secreting the contents that make up the fibrous cap, smooth muscle cells secrete Ca2+ into the fatty streak, which is normally deposited into the vessel walls by LDL. Normally what then removes the Ca2+ to stop the hardening of blood vessel walls?

1 - lipoprotein lipase
2 - HDL
3 - VLDL
4 - albumin

A

2 - HDL

  • plaques impair HDLs ability to remove Ca2+
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15
Q

Once Ca2+ has been deposited into the fatty streak and vessel walls, do the vessel walls become more elastic or stiff?

A
  • stiff due to Ca2+ forming crystals
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16
Q

What generally causes a myocardial infarction that has been in the arteries for some time?

1 - low nitrates
2 - increased Na+ and K+
3 - fibrous cap of plaque becomes unstable and ruptures
4 - endothelium become damaged and leak collagen

A

3 - fibrous cap of plaque becomes unstable and ruptures

  • rupture is due to thinning of the cap and core expansion
  • thrombogenic contents (foam cells) of plaque leak out causing blood clot
17
Q

During the rupture of fibrous cap or the expansion of a plaque, what % of blood vessel occlusion can lead to stenosis and lead to ischaemia given any increase in O2 demand?

1 - 10%
2 - 30%
3 - 50%
4 - 70%

A

3 - 50%

  • 50% reduction in luminal diameter causes a 70% reduction in luminal cross-sectional area
18
Q

What is the earliest stage of atherogenosis (atherosclerotic plaque formation, leading to coronary artery heart disease)?

1 - fatty streaks
2 - LDL infiltration
3 - cytokine release
4 - foam cells build up

A

1 - fatty streaks

19
Q

As fatty streaks form in the endothelium, platelets bind to damaged epithelium. They then release platelet derived growth factor that drives the development of what?

1 - more macrophages migrate to the area
2 - lymphocytes are activated
3 - smooth muscle cell proliferation
4 - increased cytokine secretion from fatty streak

A

3 - smooth muscle cell proliferation

  • smooth muscle cells move from tunica media to tunica intima
20
Q

When plaques rupture, what is the primary content that is very atherogenic that leaks out causing the formation of red thrombus?

1 - collagen
2 - Ca2+
3 - foam cells
4 - smooth muscle cells

A

3 - foam cells

  • thrombus is blood clot
  • embolism is clot moving in blood
21
Q

Once a plaque ruptures a red thrombus is formed. This thrombus may cause the following:

  • occlusion of the artery
  • partial occlusion of the artery
  • embolise distally
  • plaque progression

Match the above with the following: ST elevated MI, Non-ST elevation MI, stable angina and unstable angina:

A
  • ST elevated MI = occlusion of the artery
  • Non-ST elevation MI = partial occlusion of the artery
  • stable angina = embolise distally
  • unstable angina = plaque progression
22
Q

Does unstable angina present with symptoms during times of exertion?

A
  • No

It may, but typically symptoms present at rest or low intensity.

Unpredictable, and hence the name unstable

23
Q

Unstable angina can be classified based on its severity. Which of the following is the most severe?

1 - New-onset severe angina
2 - Increasing or crescendo angina
3 - Rest or nocturnal angina

A

3 - Rest or nocturnal angina

May be a sign of critical myocardial ischemia.

24
Q

The stereotypical presentation of unstable angina (UA) often involves a patient experiencing chest discomfort at rest or minimal exertion. How long does this typically last?

1 - <30 seconds
2 - <5 minutes
3 - <20 minutes
4 - <1 hour

A

3 - <20 minutes

25
Q

The stereotypical presentation of unstable angina (UA) often involves a patient experiencing chest discomfort at rest or minimal exertion. Which of the following matches the typical description of UA?

1 - pressure across the chest
2 - heaviness and/or tightness in the chest
3 - radiating pain to the neck, jaw, shoulder, back or arm
4 - all of the above

A

4 - all of the above

26
Q

In addition to the typical features of unstable angina (UA), all of the following can occur, but which is very unlikely?

1 - dyspnoea
2 - pitting oedema
3 - nausea and vomiting
4 - syncope
5 - sweating

A

2 - pitting oedema

Common in heart failure, but not UA

27
Q

When examining a patient with unstable angina (UA), the patient may appear normal. But which of the following may be found in a patient with active unstable angina during the time of the examination?

1 - fourth heart sound (S4)
2 - hypotension
3 - transient mitral regurgitation due to papillary muscle dysfunction
4 - pallor and cool extremeties
5 - all of the above

A

5 - all of the above

Atypical symptoms, especially in the elderly may include:

  • epigastric pain
  • indigestion-like symptoms
  • isolated diaphoresis (excessive sweating)
28
Q

Which 2 of the following are the 1st line investigations in a patient with suspected unstable angina (UA)?

1 - echocardiogram
2 - troponin
3 - ECG
4 - creatine kinase MB
5 - chest X-ray

A

2 - troponin
Measured immediately and 3h from symptom onset. An increase indicates myocardial damage, but doesn’t distinguish between MI and UA

3 - ECG

Echocardiogram gives information about the left ventricle, wall anomalies or other pathology

Chest X-ray to rule out other differentials

29
Q

Is troponin typically raised in unstable angina (UA)?

A
  • no

This is how to distinguish between UA and STEMI or NSTEMI.

Gastroesophageal Reflux Disease
- UA = relief with nitroglycerine

Musculoskeletal Chest Pain
- UA = no history of trauma and lack of response to nitroglycerine

30
Q

Are ECGs always abnormal in a patient with unstable angina?

A
  • No

May be normal, BUT common presentations include:

  • ST-segment changes
  • T wave inversion
  • new bundle branch block
31
Q

Which of the following scoring systems is used to help guide the severity of the acute coronary syndrome and guide management?

1 - CURB65
2 - WELLS2
3 - CHA2DS2-VASc
4 - GRACE

A

4 - GRACE

Takes into account age, vital signs, kidney function, cardiac markers among others.

32
Q

GRACE score helps guide the management of patients with acute coronary syndrome. Patients with a score above what would be considered for Coronary Angiography, which may lead to percutaneous coronary intervention?

1 - >1%
2 - >3%
3 - >10%
4 - >20%

A

2 - >3%

> 3% = moderate to high risk of 6-month probability of death

<3% = low risk of 6-month probability of death

33
Q

If a patient presents with symptoms of acute coronary syndrome (ACS) we must perform the following as soon as possible:

  • bloods (troponin)
  • ECG
  • risk scoring (GRACE score)

In addition, patients should be treated with which 4 of the following?

1 - aspirin 300mg
2 - IV morphine
3 - nitrates
4 - enoxaparin
5 - oxygen

A

1 - aspirin 300mg
2 - IV morphine
3 - nitrates (GTN spray)
5 - oxygen

GTN is a vasodilator and can cause a drop in BP and syncope

Fondaparinux may be given as an anti-thrombin therapy if required, but only for NSTEMI and unstable angina

34
Q

If a patient presents with acute coronary syndrome and has a GRACE score >3%, how soon should they have angiography, with a potential follow up for percutaneous coronary intervention?

1 - >12h
2 - <72h
3 - <7 days
4 - >14 days

A

2 - <72h

35
Q

Following the initial presentation, a patient will be advised about lifestyle changes. They will also be placed on all of the following medications as part of secondary prevention, EXCEPT which one?

1 - Bisoprolol
2 - Doxazosin
3 - Dual anti-platelet therapy (aspirin and ticagrelor)
4 - Atorvastain
5 - Ramipril

A

2 - Doxazosin
This is an alpha blocker and not indicated

Swap ticagrelor for clopidogrel if patient has a high bleeding risk.

ACE and B-blocker should be titrated up to maximum doses within 4-6 weeks

36
Q

Before starting an ACE and after 1-2 weeks, all of the following should be monitored, EXCEPT which one?

1 - eGFR
2 - U&Es
3 - LFTS
4 - Blood pressure

A

3 - LFTS

37
Q

How long are patients with acute coronary syndrome advised to take dual anti-platelet therapy for before it needs to be reviewed?

1 - 4 weeks
2 - 12 weeks
3 - 12 months
4 - Lifelong

A

3 - 12 months

38
Q

Which 2 of the following are the most likely complications of unstable angina?

1 - chronic heart failure
2 - superior vena cava obstruction
3 - MI
4 - arrhythmias

A

3 - MI
4 - arrhythmias
- VT and VF may occur

A. MLA Map Acute and Emergency (42 decks)

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