C2F- ACS and HF

FY1 Grace McKay

Pre lecture quiz

You are the FY1 on general medical on call. You are bleeped by W35
to review Mr White, a 65 year old male in bed 3 complaining of chest
pain.
the nurse hands over the following information...

S- 65 yo pt Mr White sudden onset of chest pain >15 mins

B- day 3 post op TKR secondary to OA
A- News 5; increased RR, HR and slightly hypertensive, taken
paracetamol but no improvement
R- Please come and review him!

You go to see the patient...

He is complaining of a severe chest tightness
and a pain in his throat, he keeps hiccuping
and belching during the conversation and
relays that he feels quite sick. Mr White looks
breathless and pale with a sweaty forehead.
The nurse informs you that Mr White has
T2DM diet controlled, hypercholesterolemia
and usually smokes 10 cigarettes a day.

Medications
Simvastatin 40mg PO OD
Ramipril 2.5mg PO OD
Paracetamol 1g PO QDS
Dihydrocodeine 30mg ??
Senna 15ml PO OD
Tinzaparin 4500 units SC OD

Q1. Where is the infarct?

Q2.
1.Which part of the heart is represented by ECG leads V1-V2?
a.
b.
c.
d.
e.

anterior
lateral
inferior
septal
high lateral

Q3.
Which serum biochemical marker will most aid you
in the diagnosis for this patient?
a.
b.
c.
d.
e.

Calcium
D-dimer
Troponin
Creatinine kinase
Lactate

Q4.
Suggest 2 alternative diagnoses for this patient's
acute chest pain- other than ACS.

Q5.
What is the appropriate ultimate management for
this patient?
a.
b.
c.
d.
e.

Aspirin 300mg
Primary PCI
Thrombolysis
IV unfractionated heparin
SC low molecular weight heparin

Q6+7.
What complication
has occurred in
this patient?

How would you

manage it?

Q8.
Luckily your attendance at this lecture means that you manage to save this
patient. He is scheduled to be discharged home 2 weeks after all the drama.
What 3 additional medications would be most important to continue when
discharging the patient?
a. aspirin, clopidogrel, beta-blocker
b. clopidogrel, metformin and atorvastatin
c. isosorbide monotitrate, bendroflumathiazide and beta-blocker
d. aspirin, warfarin and frusomide
e. aspirin, tinzaparin and GTN

Q9.
Fast forward 2 years, you happen to be on a GP rotation when you
meet Mr White again! He has come to the practise complaining of a
nocturnal cough, reduced exercise tolerance and ankle swelling.
What post MI complication has Mr White most likely developed?
a. Pulmonary embolism
b. Pericardial effusion
c. Heart failure
d. Reduced response to ACS medication
e. Ventral septal defect

Q10.
You request an Xray to
investigate these
symptoms further, which
features of this image
support your initial
diagnosis?
(5 points available)

How did you do?

Q1. Where is the infarct?

= ST elevation in Leads 2, 3 and AVF- implies an

inferior infarct. Nb also reciprocal changes seen

Q2.
1.Which part of the heart is represented by ECG leads V1-V2?

= Septum

Q3.
Which biochemical marker will aid you in the
diagnosis for this patient?
= Serum troponin- 12 hours

Q4.
Suggest 2 alternative diagnoses for this patient's
acute chest pain- other than ACS.
1.
2.
3.
4.
5.
6.
7.

Pericarditis
Dissecting aortic aneurysm
Pulmonary embolism
Oesphageal reflux, spasm or rupture
Biliary tract disease
Perforated peptic ulcer
Pancreatitis

Q5.
What is the appropriate ultimate management for
this patient?
= Percutaneous coronary intervention

Q6+7.
What complication
has occurred in
this patient? VF
How would you
manage it? put out a
crash call, start CPR, as
per ALS protocol

Q8.
Luckily your attendance at this lecture means that you manage to
save this patient. He is scheduled to be discharged home 2 weeks
after all the drama. What 3 additional medications might you
consider continuing before discharging this patient? (NB. he is
already on a statin and an ACEI)

a. aspirin, clopidogrel, beta-blocker

Q9.
Fast forward 2 years, you happen to be on a GP rotation when you
meet Mr White again! He has come to the practise complaining of a
nocturnal cough, reduced exercise tolerance and ankle swelling.
What post MI complication has Mr White most likely developed?
c. Heart failure

Q10.
You request an Xray to investigate
these symptoms further, which
features of this image support your
initial diagnosis?
1.Alveolar oedema (bat wings)
2.B lines -Kerley
3.Cardiomegaly
4.Dilated prominent UL vessels
5.Effusions-pleural

ACS

What is ACS- acute coronary

syndrome?

The classic
presentation
Hx: Central chest pain or discomfort with a tightness or ache. Can radiate
to throat, arm, back and epigastrium. Can be accompanied with belching
and indigestion.

O/E: From the end of the bed: Pale, SOB, sweating, anxiety, hiccoughs.
General- why bother?

The great mimics of ACS

1. Pericarditis
2. Dissecting aortic aneurysm
3. Pulmonary embolism
4. Oesphageal reflux, spasm or rupture
5. Biliary tract disease
6. Perforated peptic ulcer
7. Pancreatitis

Some EMQs- match the pain...

1.Aortic dissection
2.Pericarditis
3.Reflux
4.Myocarditis

a. Patient presents with chest pain developing over a few days, other symptoms
include pyrexia, dyspnoea, fatigue and tachycardia.
b. Patient presents with continuous abdominal pain which radiates towards the
back; there are asymmetric pulses in the upper limbs and the patient is
hypotensive.
c. Patient presents with a sharp chest pain, slightly relieved by leaning forwards.
On auscultation, a rubbing noise is audible.
d. Patient presents with a burning retrosternal chest pain, more prominent when
stooping down or straining. other symptoms include waterbrash and belching

Some EMQs- match the pain...

1.Aortic dissection
2.Pericarditis
3.Reflux
4.Myocarditis

a. Patient presents with chest pain developing over a few days, other symptoms
include pyrexia, dyspnoea, fatigue and tachycardia.
b. Patient presents with continuous abdominal pain which radiates towards the
back; there are asymmetric pulses in the upper limbs and the patient is
hypotensive.
c. Patient presents with a sharp chest pain, slightly relieved by leaning forwards.
On auscultation, a rubbing noise is audible.
d. Patient presents with a burning retrosternal chest pain, more prominent when
stooping down or straining. other symptoms include waterbrash and belching

Investigations

examples x 3

-ECG

What does it show?

STEMI
>2mm in chest
>1mm in limbs

-Biochemical
markers
Investigations

Myocardial necrosis = release of troponin

Troponin
What other pathologies can cause a
rise in troponin?

Investigations

-Echo + CXR
SIGN guidelines =
portable CXR to assess
cardiac size and oedema

Classifying ACS
UA

NSTEMI

STEMI

NSTEMI/UA
treatment
M orphine /diamorphine 2.5-10mg + Metoclopramide 10mg
O xygen (if hypoxic) aim 94-98% sats
N itroglycerine- 2 puffs GTN
A spirin 300mg
C lopidogrel 300mg
L mwh therapeutic dose

STEMI treatment
1. MONAC (L)-given in catheter lab
2. Primary Percutaneous Coronary
Intervention
3. Fibrinolysis

Contraindications to
fibrinolysis
Absolute
Relative
1. Prev haemorrhagic stroke
1. Refractory hypertension >180 BP
2. Ischaemic stroke <6mo
2. TIA <6mo
3. CNS damage/neoplasm
3. PO anticoags
4. Major surgery, head injury or major
4. Pregnant/ 1 week post partum
trauma <3 weeks
5. Liver or renal dysfnc
5. Active internal/GI bleeding <1mo
6. LP <1mo
(not mense)
6. Known/suspected aortic dissection 7. >10 mins cpr
7. Known bleeding disorder
8. Non compressible vascular puncture
9. Active peptic ulcer disease
10. Advanced liver disease

Complications of
ACS
VF and sudden death

Pericarditis

HF

Pseudo-anyeursm and free wall

rupture

Cardiogenic shock

Pericardial effusion

VSD

Ongoing chest pain and angina

MR
Arrhythmia

Heart Failure
Massive topic for 30 minutes!

Essentially
What - inadequate cardiac output to perfuse body
Why
Presentation
Diagnosis
Severity
Prognosis
Management

Essentially
What
Why
Presentation
Diagnosis
Severity
Prognosis
Management

Pre pump

Pump

Post pump

Too much blood

eg thyrotoxicosis

MI
Cardiomyopathy
Valvular disease
Drugs
Arrhythmia
Myocarditis
Congenital structural
Chemo agents

Hypertension
Atherosclerosis
Coarctation aorta

Essentially
What
Why
Presentation
Diagnosis
Severity
Prognosis
Management

Essentially
What
Why
Presentation
Diagnosis
Severity
Prognosis
Management

Essentially
What
Why
Presentation
Diagnosis
Severity
Prognosis
Management

Essentially
What
Why
Presentation
Diagnosis
Severity
Prognosis 50% mortality within 4 years
Management

Essentially
What
Why
Presentation
Diagnosis
Severity
Prognosis
Management

Acute Heart failure- Pulmonary

oedema
You are the FY1 on cardiology. You have just been bleeped to review
Mrs Potts a 64 year old female who had primary PCI this afternoon for
a STEMI. The nurse hands over that Mrs Potts is breathless, coughing
up a pink frothy sputum and tachypnoeic. News 5.

The patient is sat up in

bed leaning forwards,
she is pale and sweaty
with tachypnoea and she
seems distressed.
Her chest has fine lung
crackles on auscultation.
JVP is raised.

What do you do?

PODMAN -help
P- osition: upright if not already with pillows
O- xygen: 100% if no pre existing lung disease
D- iuretics: Furosemide 40mg IV slowly
M- orphine/diamorphine 2.5-5mg IV slowly
A- ntiemetic
N- itrates GTN spray to nitrate infusion isosorbide nitrate

Help hopefully
will have come
by then may
need an NIV
decision

Summary of ACS +
HF
1. Triad to diagnose ACS
2. Treatment acronym MONALC- PCI/Thrombo
3. Complications of MI -including Heart failure
4. Acute Heart failure - pulmonary oedema is an
emergency

Fin.