ERC - ACS

Question 1

You suspect ACS in a patient but the ECG is normal and markers are all negative. What do you do

Answer 1

chest pain observation unit
multidetector computer tomographic angiography MDCTA (good detection but ++ radiation and could overdiagnose)
Echo

Question 2

What is the pharmacoinvasive strategy of PCI and fibrinolysis

Answer 2

Fibrinolysis then PCI 3-4hrs after

Question 3

What is rescue PCI

Answer 3

PCI following unsuccessful fibrinolysis

Question 4

define unsuccessful fibrinolysis

Answer 4

<50% resolution of the ST elevation 90 minutes after fibrinolysis

Question 5

what is facilitated PCI

Answer 5

PCI immediately after fibrinolysis

Question 6

You get ROSC in a STEMI patient, what next

Answer 6

PCI and TTM

Question 7

You get ROSC in a non STEMI patient, what next

Answer 7

very dependant on the patient: downtime, comorbidities, ECG changes, neurological status all factor in to decision if to PCI or not

Question 8

Describe post ACS care in terms of long term drugs prescribe

Answer 8

Bblocker
ACE-i (or ARB)
statin

Question 9

Where is ST elevation measured from on an ECG

Answer 9

J point - termination of QRS and start of ST

Question 10

What is needed for the diagnosis of STEMI

Answer 10

clinical signs and symptoms +
0.1mv rise in 2 adjacent limb leads
0.2mv rise in 2 adjacent chest leads
new LBBB

Question 11

What would make you suspect an inferior STEMI

Answer 11

isolated ST depression in V1-V3 (indicating posterior infarct)
ST elevation in 2,3, AVF

Question 12

how would you confirm a posterior STEMI

Answer 12

ST elevation and Q waves in V7-V9

Question 13

Which troponins are most cardiac specific

Answer 13

T or I

Question 14

clinical signs and symptoms of ACS + non STEMI ECG changes + troponin +ve = what diagnosis

Answer 14

NSTEMI

Question 15

clinical signs and symptoms of ACS + non STEMI ECG changes + troponin -ve = what diagnosis

Answer 15

unstable angina

Question 16

Which non-STEMI patients are high risk

Answer 16

dynamic ECG changes
ST-depression
diabetic
haemodynamically unstable 
use of high risk scores eg TIMI, GRACE

Question 17

Describe some factors that TIMI and GRACE take into consideration

Answer 17

TIMI - age, CAD risk factors (diabetes, cholesterol, HTN, FH, smoker), ST changes, cardiac enzymes, angina episodes in past 24 hours
GRACE - age, HR, BP, ST changes, cardiac enzymes, Killip class, creatinine, if they’ve been in arrest

Question 18

What do all ACS patients get regardless of STEMI or NSTEMI

Answer 18

Morhpine 3-5mg (repeat until no pain)
Nitroglycerin (GTN) sublingual 0.4mg
Aspirin 300mg chewable

Question 19

What are the contraindications to giving nitroglycerin (GTN)

Answer 19

Systolic BP <90
bradycardia
suspected inferior MI

Question 20

Which STEMI patients get PCI and which get fibrinolysis

Answer 20

PCI if can get there in 60-90 minutes, in cardiogenic shock, contraindication to fibrinolysis
Fibrinolysis if can’t get to PCI in time

Question 21

What adjunctive treatments do you give to STEMI patients undergoing PCI or fibrinolysis

Answer 21

Antithrombin - heparin, enoxaparin, bivalirudin or fondaparinux
Antiplatelet - clopidogrel or ticagrelor

Question 22

What is the dose of clopidogrel in ACS

Answer 22

300mg for STEMI patients undergoing fibrinolysis and for non STEMI patients
600mg for STEMI patients undergoing PCI

Question 23

In which patients does prasugrel increase the risk of an intracranial bleed

Answer 23

history of stroke or TIA
>75 y/o
<60kg body weight

Question 24

What adjunctive drugs are given to non-STEMI ACS patients

Answer 24

antithrombin - heparin or enoxaparin (or fondaparinux if high bleeding risk)
antiplatelet - clopidogrel or ticagrelor

Question 25

What are the advantages of ticagrelor over clopidogrel

Answer 25

Reversible
faster
not reliant on genetic differences in drug metabolism

Question 26

What class of drugs are clopidogrel, ticagrelor and prasugrel

Answer 26

Adenosine diphosphate (ADP) receptor antagonists

Question 27

What is a late presenter

Answer 27

presenting >3 hours since symptom onset