Podcast
Questions and Answers
Which of the following is NOT a subcategory of acute coronary syndrome (ACS)?
Which of the following is NOT a subcategory of acute coronary syndrome (ACS)?
- Chronic Stable Angina (correct)
- ST-elevation myocardial infarction (STEMI)
- Unstable Angina
- Non-ST elevation myocardial infarction (NSTEMI)
A 'new left bundle branch block' (LBBB) refers to any LBBB that is newly discovered, regardless of its cause or the patient's previous ECG history.
A 'new left bundle branch block' (LBBB) refers to any LBBB that is newly discovered, regardless of its cause or the patient's previous ECG history.
False (B)
According to the European Society of Cardiology's definition of myocardial infarction, what is the preferred cardiac biomarker for detection?
According to the European Society of Cardiology's definition of myocardial infarction, what is the preferred cardiac biomarker for detection?
troponin
In the context of myocardial infarction, the Q wave on an ECG reflects the depolarisation of the ______.
In the context of myocardial infarction, the Q wave on an ECG reflects the depolarisation of the ______.
Match the following types of myocardial infarction with their primary cause or characteristic:
Match the following types of myocardial infarction with their primary cause or characteristic:
Which of the following conditions can cause a raised troponin level, potentially mimicking myocardial infarction, but is not directly related to coronary artery blockage?
Which of the following conditions can cause a raised troponin level, potentially mimicking myocardial infarction, but is not directly related to coronary artery blockage?
Patients always present with ST-segment elevation in Non-ST-Elevation Myocardial Infarction (NSTEMI).
Patients always present with ST-segment elevation in Non-ST-Elevation Myocardial Infarction (NSTEMI).
What is the gold standard treatment option for patients presenting with STEMI to open the affected vessel as quickly as possible?
What is the gold standard treatment option for patients presenting with STEMI to open the affected vessel as quickly as possible?
In the management of NSTEMI, NICE recommends using the ______ score to predict mortality risk and guide decisions regarding invasive angiography.
In the management of NSTEMI, NICE recommends using the ______ score to predict mortality risk and guide decisions regarding invasive angiography.
Match the following ECG locations with the corresponding affected area in STEMI:
Match the following ECG locations with the corresponding affected area in STEMI:
What is the primary reason for administering aspirin and a second antiplatelet agent (e.g., Ticagrelor or Prasugrel) in the initial management of suspected ACS?
What is the primary reason for administering aspirin and a second antiplatelet agent (e.g., Ticagrelor or Prasugrel) in the initial management of suspected ACS?
In unstable angina, troponin levels are elevated due to significant ischaemic damage to the myocardium.
In unstable angina, troponin levels are elevated due to significant ischaemic damage to the myocardium.
What is the recommended duration (in minutes) that chest pain should last to be considered a typical clinical presentation of ACS?
What is the recommended duration (in minutes) that chest pain should last to be considered a typical clinical presentation of ACS?
The OAT trial suggests that there is limited benefit in opening up the occluded artery after ______ hours from the onset of pain in STEMI patients.
The OAT trial suggests that there is limited benefit in opening up the occluded artery after ______ hours from the onset of pain in STEMI patients.
Associate the following ECG findings with their clinical significance in the context of ACS:
Associate the following ECG findings with their clinical significance in the context of ACS:
A patient with a history of stable angina presents to the emergency department with chest pain that occurs at rest and lasts for 30 minutes. Initial ECG and troponin levels are normal. Which of the following is the most likely diagnosis?
A patient with a history of stable angina presents to the emergency department with chest pain that occurs at rest and lasts for 30 minutes. Initial ECG and troponin levels are normal. Which of the following is the most likely diagnosis?
Thrombolysis is currently the preferred first-line treatment for STEMI due to its lower bleeding risks compared to primary PCI.
Thrombolysis is currently the preferred first-line treatment for STEMI due to its lower bleeding risks compared to primary PCI.
In addition to beta-blockers, what alternative class of medications can be used as rate-limiting agents in the management of NSTEMI if beta-blockers are contraindicated?
In addition to beta-blockers, what alternative class of medications can be used as rate-limiting agents in the management of NSTEMI if beta-blockers are contraindicated?
A type 2 myocardial infarction occurs when there is an imbalance between myocardial oxygen ______ and ______.
A type 2 myocardial infarction occurs when there is an imbalance between myocardial oxygen ______ and ______.
Match each initial management step for suspected ACS with its primary goal:
Match each initial management step for suspected ACS with its primary goal:
Which of the following factors is MOST important to consider when deciding whether to proceed with invasive angiography in a patient diagnosed with NSTEMI?
Which of the following factors is MOST important to consider when deciding whether to proceed with invasive angiography in a patient diagnosed with NSTEMI?
Patients with a low risk of adverse cardiovascular events (predicted 6-month mortality ≤3.0%) should always undergo early coronary angiography.
Patients with a low risk of adverse cardiovascular events (predicted 6-month mortality ≤3.0%) should always undergo early coronary angiography.
According to the definition of stable angina, what is the maximum duration (in minutes) that chest pain should last before it is considered unstable?
According to the definition of stable angina, what is the maximum duration (in minutes) that chest pain should last before it is considered unstable?
In STEMI, ST elevation is a sign of complete occlusion of an ______ coronary artery by thrombus.
In STEMI, ST elevation is a sign of complete occlusion of an ______ coronary artery by thrombus.
Match the following antiplatelet medications with their mechanism of action or clinical use in ACS:
Match the following antiplatelet medications with their mechanism of action or clinical use in ACS:
Which of the following clinical presentations is MOST indicative of acute coronary syndrome?
Which of the following clinical presentations is MOST indicative of acute coronary syndrome?
Performing primary PCI is generally not beneficial if more than 12 hours have elapsed since the onset of chest pain in STEMI.
Performing primary PCI is generally not beneficial if more than 12 hours have elapsed since the onset of chest pain in STEMI.
What potentially life-threatening complication are STEMI patients at elevated risk of, necessitating rapid intervention?
What potentially life-threatening complication are STEMI patients at elevated risk of, necessitating rapid intervention?
If stents occlude post-angioplasty due to patients stopping antiplatelets early or continuing to smoke, it can result in a STEMI due to complete sudden ______.
If stents occlude post-angioplasty due to patients stopping antiplatelets early or continuing to smoke, it can result in a STEMI due to complete sudden ______.
Associate the following scenarios with the corresponding type of myocardial infarction:
Associate the following scenarios with the corresponding type of myocardial infarction:
Flashcards
Acute Coronary Syndrome (ACS)
Acute Coronary Syndrome (ACS)
A syndrome encompassing diagnoses like STEMI, NSTEMI, and unstable angina.
STEMI
STEMI
ST-Elevation Myocardial Infarction; complete occlusion of coronary artery by thrombus.
NSTEMI
NSTEMI
Non-ST Elevation Myocardial Infarction; partial coronary occlusion
Myocardial Infarction (MI) Definition
Myocardial Infarction (MI) Definition
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Evidence of Ischemia
Evidence of Ischemia
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Type 1 MI
Type 1 MI
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Type 2 MI
Type 2 MI
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Typical ACS Symptoms
Typical ACS Symptoms
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Initial ACS Management
Initial ACS Management
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STEMI - Location
STEMI - Location
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STEMI Treatment
STEMI Treatment
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NSTEMI Medication
NSTEMI Medication
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GRACE score
GRACE score
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Unstable Angina Definition
Unstable Angina Definition
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Unstable Angina - Troponin Levels
Unstable Angina - Troponin Levels
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Stable Angina
Stable Angina
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Study Notes
- Acute coronary syndrome (ACS) is a common presentation with varied diagnoses.
- ACS is categorized into ST-elevation ACS (STEMI) and non-ST-elevation ACS (NSTEMI, unstable angina).
- Two of the three diagnoses under ACS are myocardial infarctions (STEMI and NSTEMI).
Definition of Myocardial Infarction (MI)
- MI is defined by detecting a rise or fall in cardiac biomarker values (preferably troponin) above the 99th percentile with at least one of the following:
- Symptoms of ischemia
- New or presumed new ST segment/T wave changes or new left bundle branch block (LBBB)
- Pathological Q wave changes on ECG
- Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality
- Identification of intracoronary thrombus by angiography
- A "new LBBB" due to ischemia results from an occluded proximal left anterior descending (LAD) or left main stem artery, requiring a large amount of affected myocardium.
- Q waves on ECG reflect septal depolarization; their appearance indicates a dead ventricular wall creating a "window" for septal activity.
Troponin
- Troponin levels require clinical context for proper interpretation. A raised troponin can be caused by:
- Myocardial infarction
- Tachy/bradyarrhythmias
- Aortic dissection
- Severe aortic valve disease
- Hypertrophic cardiomyopathy
- Severe respiratory failure
- Severe anemia
- Coronary spasm
- Heart failure
- Takotsubo cardiomyopathy
- Sepsis
- Renal failure
- Stroke
- Subarachnoid hemorrhage
Classification of Myocardial Infarctions
- Type 1: Spontaneous MI occurs due to atherosclerosis where plaque rupture triggers thrombus formation, causing partial or total artery occlusion.
- Type 2: MI secondary to ischemia arises from an imbalance between blood supply and demand.
- Type 3: MI is diagnosed post-mortem.
- Type 4a: MI is related to percutaneous coronary intervention, caused by angioplasty procedures.
- Type 4b: MI is related to stent thrombosis, often due to early cessation of antiplatelet medication or continued smoking.
- Type 5: MI is related to bypass graft (CABG) operation.
Clinical Features of ACS
- The clinical presentations of ACS include:
- Chest pain lasting longer than 15 minutes, possibly radiating to arms, back, or jaw
- Chest pain with nausea, vomiting, sweating, and breathlessness
- Chest pain associated with hemodynamic instability
- New-onset chest pain, or abrupt deterioration in stable angina
Management of ACS
- Initial management includes:
- Resting 12-lead ECG
- Morphine
- Oxygen (if SpO2 is low)
- Nitrates (e.g., glyceryl trinitrate)
- Aspirin (300 mg) and a second rapid-acting antiplatelet (Ticagrelor or Prasugrel)
ST-Elevation ACS
- Patients typically present with acute chest pain and persistent ST-segment elevation (>20 minutes).
- ST elevation indicates complete artery occlusion:
- Anterior: V1-V4
- Inferior: II, III, aVF
- High lateral: I, aVL
- Low lateral: V5, V6
- Posterior: dominant R wave and ST depression in V1-3 (mirror image of anterior MI)
- Rapidly opening the artery minimizes myocardial damage and risk of ventricular arrhythmias.
- The gold standard for STEMI treatment is primary percutaneous intervention (PCI).
- Studies suggest delaying treatment up to 90 minutes for transfer to a PCI center is beneficial.
- Benefit in performing primary PCI exists up to 12 hours from pain onset.
Non-ST-Elevation ACS
- NSTEMIs are more common but have worse long-term outcomes despite lower short-term mortality risk.
- NSTEMIs are typically associated with partial coronary occlusion.
- Diagnosis involves clinical assessment, serial troponin measurements, and ECG analysis.
- Initiate further medical treatment upon confirmed diagnosis, including:
- Beta blockade (or alternative rate-limiting agent)
- ACE inhibitor (unless contraindicated; target SBP ≤120 mmHg)
- Atorvastatin 80mg OD
Risk Assessment for NSTEMI
- The GRACE score is used to predict in-hospital and post-discharge mortality up to 6 months.
- Consider renal function, bleeding risk, patient's ability to lie flat, and significant comorbidities before angiography.
- Offer conservative management without early angiography to patients with low risk of adverse cardiovascular events (predicted 6-month mortality ≤3.0%).
- Offer coronary angiography within 96 hours to patients with intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality >3.0%).
Unstable Angina
- Defined as absence of biochemical evidence of myocardial damage.
- Characterized by:
- Prolonged angina at rest (>20 minutes)
- New onset of severe angina
- Angina increasing in frequency, duration, or lower in threshold
- Angina after recent MI
- Diagnosis is based on clinical assessment; troponin levels and ECG may be normal.
- Management is the same as for NSTEMI.
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