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SAQ 1

A 64 year old male presents to your rural ED with 30 minutes of right arm pain. He is a smoker, has HTN and DM, but denies high cholesterol. His ECG is shown.

1. List two abnormalities on the ECG and give your diagnosis. (3 marks)
   • ST elevation in inferior (II, III, avF) and lateral (V5/V6) leads – inferolateral STEMI
2. In which coronary artery is the culprit lesion? (1 mark)
   • Left circumflex
3. You decide to thrombolyse. State the drug, dose, route, and rate of administration. (3 marks)
   • tPA 0.9mg/kg, max 90mg. Give 10% over 10 mins, then rest over one hour.
4. List 6 absolute contraindications to thrombolysis. (6 marks)
   • Previous haemorrhagic stroke, ischemic stroke <3/12, active bleeding (not menses), aortic dissection, known intracranial vascular lesion, intracranial malignancy, head/facial trauma 3/12.
5. Ninety minutes after thrombolysis, the patient is still in 8/10 pain with persistent ST elevation on his ECG. What is your next step? Justify your choice. (2 marks)
   • Transfer to nearest PCI centre for angio. Failed thrombolysis, so needs rescue PCI. Repeat thrombolysis won’t do anything.

SAQ 2 (follows on from SAQ 1

Whilst preparing the patient for transfer, the nurse repeats the ECG (shown).

1. What is the rhythm shown? (1 mark)
   • Accelerated idioventricular rhythm – regular, rate 50-110, 3 or more ventricular complexes, wide QRS complexes, fusion and capture beats.
2. The patient remains haemodynamically stable. What actions do you take given the ECG changes? Justify your answer. (2 marks)
   • None – this rhythm is common after thrombolysis and has no prognostic value.
3. Two years after being treated for his MI, the patient presents with three angina attacks at rest over the pat 24 hours. He is now on aspirin, metoprolol, and a statin. His ECG and troponin are normal. What is his TIMI score? (2 marks)
   • TIMI score is 5 (age >65, known IHD, use of aspirin, 2 or more attacks angina, >3 risk factors for IHD)
4. States his disposition and justify your reasoning. (2 marks)
   • Likely unstable angina. Needs cardiology admission for this, even if troponins negative. May need urgent PCI.

SAQ 3

A 46 year old female presents to ED with chest pain for 24 hours. She is a smoker and has hypothyroidism. The pain is described as sharp chest pain, radiating to the left arm and neck, and is associated with dyspnoea. Her sats are 94% on RA. Her ECG is shown.

1. State the likely diagnosis, giving two features of the ECG that support your diagnosis. (3 marks)
   • Widespread concave ST elevation, PR depression evident. Likely pericarditis.
2. List four likely causes of this diagnosis in THIS patient. (4 marks)
   • Hypothyroid – immune related pericarditis, infectious, systemic rheumatic disease, myxoedema, idiopathic.
3. How can the ST/T ratio be used to differentiate between pericarditis and benign early repolarisation?
   • ST/T ratio high in pericarditis (>0.25-0.5), low in BER.
4. The patient remains in pain despite analgesia. Her troponin is 46. A CXR is ordered (shown below). What is the likely diagnosis, and how does this change disposition? (2 marks)
   • Cardiomegaly and cephalisation of pulmonary vessels, heart failure. Patient has myopericarditis with dilated cardiomyopathy and needs admission for management.

SAQ 4

1. Based on current guidelines, what is the recommended timeframe for each of the following interventions? (3 marks)

i.	Time to first ECG in suspected STEM	10 mins maximum
ii.	Time from patient arrival to PCI	90 minutes max (poss up to 120mins – Euro guidelines)
iii.	Time to thrombolysis	<6-12 hrs if PCI not available in <90 mins

2. For each of the following patients, indicate whether PCI, thrombolysis, or both are appropriate if said patient presents with an acute STEMI. Use a tick to indicate appropriate, a cross to indicate not appropriate.
   (9 marks)

	PCI	Thrombolysis
Postpartum 2/52 after LSCS	✓	✗
BP 160/90	✓	✓
On warfarin, INR 2.5	✓	✗
36/40 pregnant	✓	✗
Under CPR for <10 mins	✓	✓
Previous thrombolysis with streptokinase	✓	✓ not streptokinase, though
Dressler’s syndrome	✓	✗
THR 2/52 ago	✓	✗
86 year old with GORD	✗	✗ ?

3. For a patient with acute STEMI and no heart failure or contraindications, list five medications that are given acutely with a brief description of their mechanism of action. (5 marks)
   • Aspirin – antiplatelet action
   • Clopidogrel/ticagrelor – antiplatelet action
   • GTN – vasodilation, reduce myocardial work etc
   • Beta blockers – reduce heart rate etc
   • Antithrombin – heparin etc – thrombin exposed by fibrinolysis etc

SAQ 5

A 56 year old male presents with right arm pain for two hours. He complains of nausea and dizziness. His BP is 100/60 and his pulse rate 40bpm. His ECG is shown.

1. State two abnormalities on his ECG and give the likely diagnosis. (2 marks)
   • Inferior STEMI – STE in inferior leads, STE V1, STD V2. Reciprocal changes.
2. State two possible causes of his bradycardia. (2 marks)
   • Ischaemia of SA node secondary to MI
   • Bezold-Jarisch reflex – vagal response to MI.
3. List a pharmacological and a non-pharmacological treatment for his bradycardia. Give doses where appropriate. (2 marks)
   • Atropine 0.5mg IV. Pacing – either transcutaneous or transvenous
4. The medication for bradycardia fails to have a meaningful result. Briefly outline how you would perform pacing in this patient. (6 marks)
   • *Analgesia/mild sedation – painful process
   • Pads on – preferably AP, but sternal/lateral would be acceptable
   • Start at 10mA – increase by 10 until electrical capture – indicated by pacing spike followed by QRS
   • Look for perfusion as marker of mechanical capture – start at 80bpm and increase until adequate perfusion of patient.