STEMI

Question 1

Risk factors

Answer 1

Same as NSTEMI

Question 2

Pathophysiology

Answer 2

Thrombus in the coronary artery causes complete occlusion or near complete occlusion. The myocardial area of ischaemia is transmural, involving the entire thickness of the myocardium from the endocardium towards the epicardium.

Question 3

Aetiology

Answer 3

Atherosclerosis
Coronary spasm
Coronary embolism
Chest trauma
Spontaneous coronary or aortic dissection

Question 4

Signs

Answer 4

Pallor
Diaphoresis
Low grade fever
LeVine’s sign

Question 5

Symptoms

Answer 5

Acute central chest pain lasting > 20 mins
Associated with nausea
Diaphoresis
Dyspnoea
Palpitations

Question 6

Diagnosis

Answer 6

ECG - hyperacute T waves + ST elevation or new LBBB
T wave inversion and pathological Q waves follow over hours to days
Cardiac enzymes - Myoglobulin, Troponin T+I, Creatinine Kinase MB
CXR - Cardiomegaly, Pulmonary oedema

Question 7

Ambulance treatment

Answer 7

MONAC - in ambulance
Morphine 5-10mg
Oxygen (if SaO2 < 95%)
Nitrates (GTN)
Clopidogrel antiplatelet drug

Question 8

Patient presents within 12 hours of symptom onset ad PCI available in 120 minutes

Answer 8

Emergency PCI
- Prasugrel + Aspirin prior to PCI
- (Clopidogrel with aspirin if taking an oral anticoagulant)
- Offer unfractionated heparin with bailout GPI for radial access
- Consider bivalirudin (+ BO GPI) if femoral access

Question 9

Offer if presenting in 12 hours of symptoms and PCI not possible in 120 mind

Answer 9

• Thrombolysis = Tissue plasminogen activators = TENECTOPLASE/ALTEPLASE
  Do not use thrombolysis in ST depression alone, T wave inversion alone or normal ECG
• Following procedure: ticagrelor + aspirin unless high bleeding risk
• Clopidogrel + aspirin, or aspirin alone, for high bleeding risk
• Consider angiography during same admission if stable after successful fibrinolysis and ongoing myocardial ischaemia

Question 10

Contraindications of Thrombolysis

Answer 10

• previous cranial haemorrhage,
• ischemic stroke < 6 months,
• cerebral malignancy or AVM,
• major head trauma

Question 11

ACS complications

Answer 11

• Death
• Rupture of the heart (LV free wall rupture)
• Edema (Heart Failure due to vent fibrillation)
• Arrhythmias + Aneurysm = first 24 hours
• Dressler’s syndrome = 2-3 weeks post MI = localised immune
  response + causes pericarditis = pleuritic chest pain, low grade
  fever + pericardial rub on auscultation. Can cause pericardial effusion + rarely cardiac tamponade (where fluid constricts the heart + prevents function