Heart Attack

Question 1

What are the characteristics of stable angina?

Answer 1

• fixed stenosis
• demand led ischaemia
• predictable
• safe

Question 2

What advice is given to patients having an angina attack?

Answer 2

‘stop, sit spray’ - have one spray of GTN leave 5 mins and spray again - if pain persists call 999

Question 3

Define acute coronary syndrome

Answer 3

any acute presentation of coronary disease

• unstable angina
• acute non-STEMI
• STEMI

Question 4

How does it differ from stable angina?

Answer 4

• dynamic stenosis
• supply led ischaemia
• unpredictable
• dangerous

Question 5

Name six factors affecting plaque rupture

Answer 5

• lipid content of plaque
• thickness of fibrous cap
• sudden changes in pressure
• bending/twisting of artery
• plaque shape
• mechanical injury

Question 6

What is the result of an occlusion in a stemi?

Answer 6

everything downstream from the occlusion starts to die

Question 7

Can heart muscle regenerate?

Answer 7

Nope - it begins to scar

Question 8

What is the result of scarring?

Answer 8

Dilation & aneurysm –> heart failure

Question 9

Describe a classical presentation of a heart attack

Answer 9

Severe, central crushing chest pain radiating to the jaw and left arm. Associated with sweating and nausea

Question 10

What must be present to diagnose a STEMI from an ECG?

Answer 10

> 1mm ST elevation in 2 adjacent limb leads

>2mm ST elevation in 2 contiguous precordial leads

Question 11

What other changes may be seen on an ECG?

Answer 11

Q wave formation, T wave inversion

Question 12

Other than ECG what other test can be done on a patient with a suspected MI?

Answer 12

Protein markers & enzymes

Troponin & Creatinine Kinase

Question 13

What are the three types of troponin?

Answer 13

Troponin C - binds to calcium
Troponin I - binds to actin (deactivates actin after contraction)
Troponin T - facilitates contraction by binding to tropomyosin complex

Question 14

In ischaemia what happens to troponin levels?

Answer 14

They rise 2-4 hours after an MI

Question 15

What does elevated troponin signify?

Answer 15

Cardial necrosis

Question 16

What is the early treatment for a suspected MI?

Answer 16

Morphine ( and anti-emetic) 
Oxygen 
Nitrates
Aspirin 300mg (chewable) 
\+Clopidogrel 300mg

Question 17

When is thrombolysis administered?

Answer 17

If it is going to take more than 2 hours to get the patient to the cath lab for PCI

Question 18

What is an alternative to clopidogrel?

Answer 18

Ticegralor 180mg

Question 19

Name an anti-emetic

Answer 19

Metaclopramide

Question 20

Name four types of complications of an MI

Answer 20

• Death
• Arrhythmic complications
• Structural complications
• Functional complications

Question 21

What is the main, life threatening arrhythmic complication?

Answer 21

Ventricular fibrillation

Question 22

Name three structural complications

Answer 22

• cardiac rupture (left ventricle)
• ventricular septal defect
• mitral valve regurgitation

Question 23

Name three functional complications

Answer 23

• acute ventricular failure
• chronic cardiac failure
• cardiogenic shock

Question 24

What are the four classes of the killip classification?

Answer 24

Risk of mortality 
I - no signs of HF 6% 
II - creps <50% 17%
III - creps >50% 38% 
IV - cariogenic shock 81%

Question 25

State the routine observations done on a patient who has had a recent MI

Answer 25

- Pulse & BP - cardiac monitor - heart sounds - murmurs - crepitations - urine output

Question 26

When is a patient deemed to have a NSTEMI?

Answer 26

When the markers are high but there is no ST elevation on ECG

Question 27

What are the two key parts of the pathophysiology of UA and NSTEMI?

Answer 27

Thrombosis and vasoconstriction leads to reduced coronary blood flow

Question 28

What is the management for a patient with a NSTEMI?

Answer 28

Urgent revascularisation for patients at high risk - anti platelet (aspirin 300mg then 75mg/day for life, clopidogrel 300mg then 75mg/day for 12 months) - antithrombin (LMWH, glycoprotein IIb/IIIa antagonists) - beta blockers, nitrates, calcium channel blockers, ACE inhibitor, statins)

Question 29

When is thrombolysis contraindicated?

Answer 29

- surgery - bleeding/trauma - warfarin - haematoma