ACS

Question 1

What is included in ACS?

Answer 1

Unstable Angina
NSTEMI
STEMI

Question 2

Pathophys of an NSTEMI or unstable angina?

Answer 2

Ruptured coronary plaque with subocclusive thrombus

Question 3

Pathophy of a STEMI?

Answer 3

Ruptured coronary plaque with occlusive thrombus

Question 4

What is the treatment for STEMI?

Answer 4

Emergency reperfusion preferable with primary percutaneous intervention

Question 5

Difference in ECGs between STEMI and NSTEMI/unstable angina?

Answer 5

• STEMI = ECG ST elevation or new LBBB

- NSTEMI/unstable angina = ECG normal or ST depression

Question 6

Troponin

Answer 6

Biomarker for cardiac necrosis

Isoforms I and T

Question 7

Definition of an MI

Answer 7

Rise and/or fall of troponin with at least 1 value >99th percentile of the URL plus 1 of

• myocardial ischaemia symptoms
• ECG changes
• loss of myocardium/wall motion abnormality by imaging
• angiography/autopsy showing intracoronary thrombus

Question 8

Type 1 AMI

Answer 8

Spontaneous

Plaque Rupture

Question 9

Type 2 AMI

Answer 9

Ischaemic imbalance

Coronary spasm, embolism, dissection, hypotension

Question 10

Type 3 AMI

Answer 10

Cardiac death

Presumed AMI

Question 11

Type 4a AMI

Answer 11

Related to PCI

>5 times URL for troponin

Question 12

Type 4b AMI

Answer 12

Caused by stent thrombosis

Confirmed at angiography or autopsy

Question 13

Type 5 AMI

Answer 13

Related to CABG

>10 times URL for troponin

Question 14

What is the AMI pathway?

Answer 14

2-7 day long

Emergency admission, diagnose, hospital admission to treat, stay to manage comp., discharge with prevention and rehab

Question 15

Danger in delay in calling help

Answer 15

33% die from AMI before reaching hospital

elderly, women, nocturnal pain, no previous AMI, diabetic > risk

Question 16

Anatomical determinants of infarct size

Answer 16

• occluded artery distribution

- proximity of coronary occlusion

Question 17

Physiological determinants of infarct size

Answer 17

• thrombotic response to plaque rupture

- thrombolysis effectiveness

Question 18

Logistical determinants of infarct size

Answer 18

• time to call help, arrive to hospital, delivery of reperfusion therapy

Question 19

Therapeutic determinants of infarct size

Answer 19

• reperfusion therapy (thrombolysis vs. PPCI)
• antiplatelets
• drugs to prevent against LV remodelling

Question 20

A&E ACS Urgent treatment

Answer 20

• consider alternative sinister illness
• ECG, oxygen, bloods, aspirin, GTN
• if STEMI = PPCI straight away
• if unstable angina/NSTEMI = troponin, ECG, symptom, risk scores
• nondiagnostic = continue evaluation until seek cardiology help

Question 21

When to admit a patient in A&E for chest pain?

Answer 21

• diagnostic ECG
• typical chest pain/HF/unstable rhythm
• troponins positive

Question 22

STEMI Treatment

Answer 22

PPCI
Aspirin + Ticagrelor 
Gp IIb/IIIa inhibitor
UH/LMWH
Give all drugs with cath lab to have procedure

Question 23

Ticagrelor

Answer 23

P2Y12 receptor antagonist
Higher antiplatelet activity
Fast onset action
180mg loading dose then 90mg twice daily

Question 24

P2Y12 receptor antagonists

Answer 24

Clopidogrel lowest activity then prasugrel then ticagrelor

Question 25

NSTEMI low risk <3% treatment

Answer 25

conservative management aspirin fondoparinux/UFH Ticagrelor

Question 26

NSTEMI intermediate risk 3-6% and high risk >6% treatment

Answer 26

``` aspirin fondoparinux/UFH ticagrelor consider tirofiban/eptifibatide coronary angiography within 96 hours to assess PCI or CABG ```

Question 27

Complication Treatment of HF

Answer 27

- diuretics = IV furosemide, haemofiltration if diuretic resistant - RAS inhibiton = ACEi, ARB, eplerenone - ionotropes = NA, dobutamine - LV support device = balloon pump, LVAD

Question 28

What bradyarrthymias can you get from AMI?

Answer 28

Complete AVN block Wenckebach Mobitz 1 Intermittent block of both bundle branches (Mobitz 2) Complete block of both bundle branches

Question 29

How to treat Mobitz 1 and complete AVN block?

Answer 29

Atropine Good prognosis Spontaneous recovery <7d

Question 30

How to treat Mobitz 2 and complete BBB both sides?

Answer 30

Pacing | Poor prognosis

Question 31

What tachyarrythmias do yo get from AMI?

Answer 31

AF VT - in first 12-24hrs VF

Question 32

How to treat AF from AMI?

Answer 32

Beta blocker DC cardioversion if haemodynamically unstable Anticoagulation if persists

Question 33

How to treat VT and VF from AMI?

Answer 33

DC shock for rhythm control If corrected = minor prognostic impact >24 hours occur bad prognosis

Question 34

AMI secondary prevention

Answer 34

``` Lifestyle = smoking, diet, exercise Drugs = aspirin, P2Y12 receptor antagonists, statins, beta blocker, ACEi Prevention = ICD ```

Question 35

Which treatments do you give for life?

Answer 35

``` Aspirin Statins Beta blockers ACEi All except P2Y12 receptor ant. ```

Question 36

What to do if patient death pre hospital?

Answer 36

Defib ASAP | Most due to VF

Question 37

What to do if hospital death from LVF?

Answer 37

Initiate reperfusion therapy ASAP Aldosterone antagonists Avoid calcium antagonists Treat HTN and renal failure

Question 38

What artery is affected in a lateral STEMI?

Answer 38

Circumflex artery

Question 39

What artery is affected in an anterior STEMI?

Answer 39

LAD

Question 40

What artery is affected in an inferior STEMI?

Answer 40

RCA

Question 41

Causes of high troponin

Answer 41

``` Cardiac procedures HTN associated heart disease CKD Tachycardias Myocarditis Cardiomyopathies AF ```

Question 42

When do troponin levels change?

Answer 42

Increase in 3-12 hours Peak in 24-48 hours Return to normal in 5-14 days

Question 43

Which drugs are given for pain

Answer 43

morphine | GTN

Question 44

CK levels change how?

Answer 44

Rises in 3-12 hours Peaks in 24 hours Returns to baseline in after 48-72 hours

Question 45

Symptoms

Answer 45

Typical Chest Pain Complications = arrhythmia HF LVF