ACS

Question 1

what is the role of troponin in diagnosing ACS?

Answer 1

MI diagnosed by; a rise in troponin with at least 1 value above the 99th percentile of upper reference limit

Question 2

what does a rise in troponin indicate?

Answer 2

necrotic cardiomyocytes

Question 3

when are the troponin levels measured?

Answer 3

immediately if pain, 3, 6, 24 hours

Question 4

what are the ST changes in a STEMI?

Answer 4

> 1mm in 2 or more contiguous leads

Question 5

What are other changes can occur on an ECG of a STEMI?

Answer 5

• T wave inversion/flattening
• pathological Q waves
• new LBBB

Question 6

what are pathological Q waves on an ECG?

Answer 6

broad (> 1mm or 40 ms)
deep (> 2mm)
> 25% depth of QRS complex
in V1-V3

Question 7

when should P-PCI be offered to patients, and what is it?

Answer 7

Primary PCI is opening up an occluded coronary artery by balloon insertion via catheter

offered within 12 hours of onset of symptoms

Question 8

What medications and doses should a patient be on post ACS?

Answer 8

Aspirin - 75 mg OD 
Clopidogrel - 75 mg OD
BB - Bisoprolol - 2.5-5.0 mg OD 
ACEi
Statin - SimV 40 mg OD

Question 9

what is the acute management of NSTEMI?

Answer 9

• morphine
• oxygen
• nitrates + BB IV
• aspirin 300 mg
• ticagreolor/clopidogrel 300 mg (antiplatelet)
• fondaparinux (antithrombin)
• Tirofiban (high risk pt.)

Question 10

Who should antithrombin treatment be offered to? and e.g.

Answer 10

Fondaparinux

patients at high risk of bleeding + not having PCI within 24 hours

Question 11

What should be given alternatively to fondaparinux in patient at risk of bleeding , and why?

Answer 11

unfractioned heparin

either if;

• angiography is likely within 24 hours
• patients creatinine is > 265 umol/L

Question 12

name a glycoprotein IIa/IIIb receptor antagonist

Answer 12

Tirofiban

Question 13

name a glycoprotein IIa/IIIb receptor antagonist

Answer 13

Tirofiban

Abciximab

Question 14

what additional medication can be given 3-14 days post STEMI and whats it for?

Answer 14

aldosterone antagonist e.g. eplerenone

if patient post STEMI has signs of HF or LVD

Question 15

DVLA guidelines state that post ACS, how long do you have to abstain from driving?

Answer 15

4 weeks

1 week off driving if you were successfully treated with angioplasty

Question 16

what is the dose for morphine or diamorphine to relieve chest pain in ACS?

Answer 16

2.5-5mg IV

Question 17

what is the aim of the LDL range when taking statins?

Answer 17

< 1.8 mmol/L

Question 18

ST elevation in aVR may be seen in… ?

Answer 18

tripple vessel disease/ occlusion of left main coronary artery

Question 19

what is the exercise recommendations for post ACS lifestyle modifications?

Answer 19

at least 30 minutes of moderate aerobic exercise 5 times/week

Question 20

T wave inversion is normal in which ECG leads?

Answer 20

V1 and aVR

Question 21

Deeper Q waves of > 2mm are a normal variant in which leads?

Answer 21

lead III + aVR

Question 22

what are the ECG characteristics of LBBB?

Answer 22

Broad QRS complex (>0.12 ms/3 small sq.)
Deep S wave in V1
No Q wave in V5/V6

Question 23

When to call 999 when experiencing chest pain on exertion with a diagnosis of stable angina?

Answer 23

15 minutes after the onset of pain

having taken 2 spray doses of GTN under the tongue with 5 minutes interval between

Question 24

While speculating a diagnosis but considering ACS, what monitoring is require?

Answer 24

• pain exacerbations and ensure adequate pain relief
• heart rate and BP
• heart rhythm
• oxygen saturations
• repeat ECG

Question 25

In an INFERIOR STEMI; in which leads would you expect to see elevation and which leads reciprocal depression?

Answer 25

ST elevation; leads II,III, aVF

ST depression; aVL (lateral leads)

Question 26

what are VERAPAMIL + DILTIAZEM ?

Answer 26

rate limiting calcium channel blockers, management of stable angina

Question 27

What medication is varapamil contraindicated with and why?

Answer 27

beta blockers + verapamil are contraindicated

due to risk of complete heart block

Question 28

if wanting to combine a calcium channel blocker and beta blockers, which should you give?

Answer 28

dihydropyridine calcium channel blocker, e.g. modified release nifedipine

Question 29

what is torsades de pointes?

Answer 29

long QT interval arrhythmia; palpitations

Question 30

what is the management of TORSADES DE POINTED?

Answer 30

IV magnesium sulphate

Question 31

list ANTI ISCHAEMIC medications.

Answer 31

• beta blockers
• nitrates
• calcium channel blockers
• nicrorandil
• ivabridine
• ranolazine

Question 32

list ANTIPLATELET medications.

Answer 32

• aspirin
• P2Y12 receptor inhibitors
• clopidogrel
• prasugrel, ticagrelor,
• glycoprotein IIa/IIIb inhibitors

Question 33

name INDIRECT ANTICOAGULANTS.

Answer 33

• unfractioned heparin
• low molecular weight heparin
• factor xa inhibitor = fondaparinux

Question 34

name DIRECT ANTICOAGULANTS.

Answer 34

• bivalirudin
• dabigatran
• factor xa inhibitors; apixaban, rivaroxaban

Question 35

auscultation of AORTIC STENOSIS?

Answer 35

ejection systolic murmur
loudest in aortic area
radiating to carotids

Question 36

auscultation of MITRAL REGURGITATION?

Answer 36

pansystolic murmur
loudest in apex
radiating to axilla

Question 37

auscultation of MITRAL STENOSIS?

Answer 37

mid diastolic rumbling murmur
heard best with bell of stethoscope
at apex w/ patient at left lateral position

Question 38

auscultation of AORTIC REGURGITATION?

Answer 38

early diastolic murmur
heard best at left 4th intercostal space
w/ patient sat forwards on expiration

Question 39

3 feature of typical angina

Answer 39

1) precipitated by physical exertion
2) relived by rest or GTN spray
3) constricting discomfort in the front of the chest, shoulder, jaw, arms, neck

Question 40

risk factors for coronary artery disease

Answer 40

• hyperlipidaemia
• hypertension
• diabetes
• age

Question 41

features of pathological Q waves

Answer 41

• broad
• deep
• > 25% depth of QRS complex
• ## V1-V3