ACS

Question 1

What are the clinical symptoms consistent with ACS for a STEMI diagnosis?

Answer 1

Symptoms generally of ≥ 20 minutes duration with persistent ECG features in ≥ 2 contiguous leads.

Question 2

What ST elevation measurements are required for men under 40 years in leads V2-3?

Answer 2

≥ 2.5 mm ST elevation.

Question 3

What ST elevation measurements are required for men over 40 years in leads V2-3?

Answer 3

≥ 2.0 mm ST elevation.

Question 4

What ST elevation measurement is required in leads V2-3 for women?

Answer 4

1.5 mm ST elevation.

Question 5

What is the required ST elevation measurement in other leads for STEMI?

Answer 5

1 mm ST elevation.

Question 6

When should new LBBB be considered in the context of STEMI?

Answer 6

New LBBB should be considered new unless there is evidence otherwise.

Question 7

What is the first step after confirming a STEMI?

Answer 7

Immediately assess eligibility for coronary reperfusion therapy.

Question 8

What are the two types of coronary reperfusion therapy?

Answer 8

• Percutaneous coronary intervention (PCI)
• Fibrinolysis

Question 9

When should PCI be offered?

Answer 9

If presentation is within 12 hours of symptom onset AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.

Question 10

What should be considered if patients present after 12 hours with ongoing ischaemia?

Answer 10

PCI should still be considered.

Question 11

What type of stents are now primarily used in PCI?

Answer 11

Drug-eluting stents.

Question 12

What access route is preferred for PCI?

Answer 12

Radial access.

Question 13

When should fibrinolysis be offered?

Answer 13

Within 12 hours of symptom onset if primary PCI cannot be delivered within 120 minutes.

Question 14

What is a practical example for fibrinolysis administration?

Answer 14

A patient presenting with STEMI to a small DGH without PCI facilities who cannot be transferred within 120 minutes.

Question 15

What is dual antiplatelet therapy?

Answer 15

Aspirin + another drug.

Question 16

What should be given if the patient is not taking an oral anticoagulant prior to PCI?

Answer 16

Prasugrel.

Question 17

What should be given if the patient is taking an oral anticoagulant prior to PCI?

Answer 17

Clopidogrel.

Question 18

What is the recommended drug therapy during PCI with radial access?

Answer 18

Unfractionated heparin with bailout glycoprotein IIb/IIIa inhibitor.

Question 19

What is the recommended drug therapy during PCI with femoral access?

Answer 19

Bivalirudin with bailout glycoprotein IIb/IIIa inhibitor.

Question 20

When should fondaparinux be offered?

Answer 20

To patients not at high risk of bleeding and not having immediate angiography.

Question 21

What should be given if immediate angiography is planned or creatinine is > 265 µmol/L?

Answer 21

Unfractionated heparin.

Question 22

What is the most widely used tool for risk assessment in acute coronary events?

Answer 22

Global Registry of Acute Coronary Events (GRACE).

Question 23

What factors are considered in the GRACE score?

Answer 23

• Age
• Heart rate
• Blood pressure
• Cardiac (Killip class)
• Renal function (serum creatinine)
• Cardiac arrest on presentation
• ECG findings
• Troponin levels

Question 24

When should immediate coronary angiography be performed for NSTEMI/unstable angina?

Answer 24

For clinically unstable patients.

Question 25

When should coronary angiography be performed within 72 hours for NSTEMI/unstable angina?

Answer 25

For patients with a GRACE score > 3%.

Question 26

What should be given to NSTEMI patients regardless of fondaparinux?

Answer 26

Unfractionated heparin.

Question 27

What should be given as further antiplatelet therapy prior to PCI for patients not on anticoagulants?

Answer 27

Prasugrel or ticagrelor.

Question 28

What antiplatelet drug should be given if the patient is at high risk of bleeding?

Answer 28

Clopidogrel.

Question 29

What are some poor prognostic factors in acute coronary events?

Answer 29

* Age * Development (or history) of heart failure * Peripheral vascular disease * Reduced systolic blood pressure * Killip class * Initial serum creatinine concentration * Elevated initial cardiac markers * Cardiac arrest on admission * ST segment deviation

Question 30

What does Killip class I indicate?

Answer 30

No signs of heart failure.

Question 31

What does Killip class II indicate?

Answer 31

Lung crackles and S3.

Question 32

What does Killip class III indicate?

Answer 32

Frank pulmonary oedema.

Question 33

What does Killip class IV indicate?

Answer 33

Cardiogenic shock.

Question 34

What to give patients not previously on anticoagulants in STEMI?

Answer 34

Aspirin and prasugrel

Question 35

What to give patients currently on anticoagulants in STEMI?

Answer 35

Aspirin and clopidogrel

Question 36

What dual antiplatelet therapy for NSTEMI should not be given for patients with a specific background history?

Answer 36

Prasugrel is contraindicated in patients with a history of TIA or stroke due to increased risk of intracranial haemorrhage

Question 37

What to do for patients with STEMI over 12 hour limit for PCI and they are in cardiogenic shock?

Answer 37

NICE guidelines state that they should be considered for immediate intervention with angiography even though she is over the usual 12-hour time limit, as she has evidence of ongoing myocardial ischaemia and cardiogenic shock.

Question 38

Which patients should have higher degree of suspicion for ACS with mild symptoms of chest pain?

Answer 38

Elderly and diabetics

Question 39

When to do synchronised DC cardioversion for ventricular tachycardia?

Answer 39

Myocardial ischaemia

Question 40

What are the indicators for myocardial ischaemia?

Answer 40

Chest pain Haemodynamically instability Pulmonary oedema

Question 41

When does troponin actually rise?

Answer 41

Troponin does not rise until 2 to 3 hours after myocardial infarction ECGs may also be normal

Question 42

In STEMI, what is the second platelet agent for PCI if not already on anticoagulation?

Answer 42

Prasugrel

Question 43

In STEMI, what is the second platelet agent for PCI if already on anticoagulation?

Answer 43

Clopidogrel

Question 44

In STEMI, what is the second platelet agent if not receiving PCI?

Answer 44

Ticagrelor

Question 45

What to do in NSTEMI patients with intermediate or high risk GRACE score?

Answer 45

PCI or coronary angiography within 72 hours

Question 46

What to do for GRACE score less than 3%?

Answer 46

Dual anti platelet therapy

Question 47

What to do for NSTEMI for GRACE score over 3%

Answer 47

Angiography immediately and offer dual antiplatelet therapy

Question 48

What should be done after fibrinolytic?

Answer 48

ECG after 60-90 minutes

Question 49

What should be done if there is persistent myocardial ischaemia following fibrinoylsis?

Answer 49

PCI centre transfer

Question 50

What marker can be used to diagnose re-infarction?

Answer 50

Creatine kinase which remains elevated for 3-4 days

Question 51

How long is troponin elevated?

Answer 51

10 days

Question 52

What is the first bio marker to rise after MI?

Answer 52

Myoglobin

Question 53

What causes self-resolving cardiac chest pain on a background of ischaemic heart disease?

Answer 53

Welles’s syndrome: ECG commonly shows deeply inverted T-waves in leads V2-V3 (which may extend to V1-V6) with no or minimal ST-elevation and preserved R wave progression:

Question 54

What is Wellen’s syndrome caused by?

Answer 54

high-grade stenosis in the left anterior descending coronary artery.

Question 55

What should be given before fibrinolytic?

Answer 55

Fondaparinux

Question 56

What are the risk factors for asystole in bradycardia?

Answer 56

complete heart block with broad complex QRS recent asystole Mobitz type II AV block ventricular pause > 3 seconds

Question 57

What should be given following ACS?

Answer 57

Following an ACS, all patients should be offered: dual antiplatelet therapy (aspirin plus a second antiplatelet agent) ACE inhibitor beta-blocker statin

Question 58

What is the ECG threshold for PCI or thrombolysis intervention in ACS?

Answer 58

ST elevation of greater than 1mm (1 small square) in greater than 2 INFERIOR leads (II, III, avF, avL OR ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads OR New left bundle branch block

Question 59

What idnicated left bundle branch block on ECG?

Answer 59

New Widening of QRS complex and notched QRSZ IN THE LATERAL LEADS

Question 60

What to give for NSTEMI?

Answer 60

fondaparinux should be given in addition to aspirin to all patients unless high bleeding risk

Question 61

What causes intense chest pain with new neurology?

Answer 61

Aortic dissection

Question 62

What GRACE SCORE IS low?

Answer 62

GRACE score 3% or below

Question 63

What grace score is intermediate?

Answer 63

3 to 6%

Question 64

What grace score is high?

Answer 64

6 to 9%

Question 65

What GRACE score is highest?

Answer 65

Over 9%

Question 66

What is the time frame for indication wit certain GRACEA SCORE?

Answer 66

72 hours coronary angiography for patients at minimum intermediate risk with GRACE score ABOVE 3%

Question 67

What other circumstance for coronary angiography in NSTEMI?

Answer 67

coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission

Question 68

What should be given for NSTEMI in patients awaiting PCI

Answer 68

MUST GIVE unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not

Question 69

What are the essential medications for NSTEMIif PCI won’t be performed?

Answer 69

Dual antiplatelet therapy with aspirin, fondaparinux and either Ticagrelor/clopidogrel

Question 70

What is used with PCI for ACS managmeent?

Answer 70

PCI passes catheter through radial artery for balloon to push aside plaque. A Drug eluting stent is used to maintain the artery opening. It is preferred over bare metal due to reduced rates of restenosis however it has a higher risk of re-thrombosis initially necessitating the need for dual anti-platelets usually for 6-12 months.

Question 71

When is CABG indicated!

Answer 71

triple-vessel disease or severe left main stem artery stenosis, esp

Question 72

What csuses reciprocal ST depression in leads I and aVL?

Answer 72

Proximal right artery occlusion