| What conditions increase the likelihood of atypical presentation of symptoms? | known patient of CAD/ multiple risk factors | • Diffuse retrosternal pain, heaviness or constriction. Radiation to arms or neck or back • Associated with sweating • Easily reproduced with post-meal exertion • Consider atypical presentation: Exertional fatigue or breathlessness or profuse sweating or epigastric discomfort More likelihood if known patient of CAD/ multiple risk factors | 296 | relationship | 0.970 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1768823342_cardiology_1-4.pdf | Radiation to arms or neck or back • Associated with sweating • Easily reproduced with post-meal exertion • Consider atypical presentation: Exertional fatigue or breathlessness or profuse sweating or epigastric discomfort More likelihood if known patient of CAD/ multiple risk factors | 1 | page=1,block=20 | 0.700 | valid |
| What classifies as recent worsening of stable angina in acute coronary syndrome? | crescendo | ACUTE CORONARY SYNDROME: 1.Angina at rest or lasting more than 20 minutes 2.Recent worsening of stable angina (crescendo) to CCS class III 3.New onset effort angina of less than 1 month in CCS class II/ III 4.Post infarction angina ECG: - If ST Elevation: Follow ST Elevation MI (STEMI) STW - If no ST Elavation: UA/NSTEMI | 111 | definition | 0.940 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1768823342_cardiology_1-4.pdf | ACUTE CORONARY SYNDROME: 1.Angina at rest or lasting more than 20 minutes 2.Recent worsening of stable angina (crescendo) to CCS class III 3.New onset effort angina of less than 1 month in CCS class II/ III 4.Post infarction angina ECG: - If ST Elevation: Follow ST Elevation MI (STEMI) STW - If no ST Elavation: UA/NSTEMI | 1 | page=1,block=3 | 0.700 | valid |
| What is the preferred revascularization method for diabetic patients with multivessel or left main disease? | CABG over PCI | Continue aspirin and heparin 3. Load with clopidogrel or prasugrel or ticagralor if not already done 4. Optimal medical therapy to continue (BB, high dose atorvastatin, ACE-inhibitors, intra-venous nitrates if ongoing pain, severe MR or LVF) 5. Detailed echocardiography 6. Low risk patients may undergo non-invasive risk stratification with exercise stress test, CT coronary angiography or stress imaging 7. Very high risk, high risk and intermediate risk patients may be subjected to coronary revascularization Revascularization: 1. Discuss pros & cons of re-vascularization and prolonged dual anti-platelet therapy 2. Revascularize if anatomy is suitable 3. Prefer CABG over PCI in DM with multivessel disease or left main disease Revascularization strategy: 1. Very High risk: Urgent re-vacsularization (within few hours) after loading preferably with Ticagrelor or prasugrel if PCI is planned 2. | 668 | comparison | 0.840 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1768823342_cardiology_1-4.pdf | Prefer CABG over PCI in DM with multivessel disease or left main disease Revascularization strategy: 1. | 1 |
| What are the essential investigations listed for patient evaluation? | 1. Hemogram 2. Creatinine 3. Sugar, HbA1C 4. Fasting lipids 6. ECG 7. Troponin T/ Troponin I 8. Plain X-ray chest 9. Echocardiography | Dissection of aorta (unequal/ absent peripheral pulses) Respiratory Evaluation: Pleuritis/ pneumonitis/ embolism/ pneumothorax Pericardial rub Neuralgia or herpes 2. TIMI SCORE: One point for each of following 1. Age >65 yrs 2. More than 3 risk factors 3. Known CAD (>50% lesion) 4. Recurrence of angina in 24 hrs 5. Aspirin use within 7 days 6. ST deviation >0.5 mV 7. Raised cardiac markerss Sum total = TIMI score of patient ESSENTIAL INVESTIGATIONS 1. Hemogram 2. Creatinine 3. Sugar, HbA1C 4. Fasting lipids 6. ECG 7. Troponin T/ Troponin I 8. Plain X-ray chest 9. Echocardiography | 453 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1768823342_cardiology_1-4.pdf | Raised cardiac markerss Sum total = TIMI score of patient ESSENTIAL INVESTIGATIONS 1. Hemogram 2. Creatinine 3. Sugar, HbA1C 4. Fasting lipids 6. ECG 7. Troponin T/ Troponin I 8. Plain X-ray chest 9. Echocardiography | 1 | page=1,block=25 | 0.700 | valid |
| What are the high doses recommended for statins? | Atorvastatin 80 mg OD or Rosuvastatin 20-40 mg OD | Anti-platelets 1. Aspirin: Loading dose 325 mg followed by 75 mg OD 2. Clopidogrel: Loading dose 300 mg followed 75 mg OD 3. Prasugrel: Loading dose 60 mg followed by 10 mg OD 4. Ticagralor: Loading dose 180 mg followed by 90 mg BD Anti thrombotics: 1. Enoxaparin: 1 mg/Kg SC 12 hrly 2. Unfractionated heparin: Bolus of 60 U/Kg (maximum 5000 U) followed by 12 U/Kg hourly infusion to maintain APTT at 50-70 sec Ace-inhibitor Ramipril 2.5 -10 mg OD Enalapril 2.5-10 mg BD Anti-ischemic: 1. Metoprolol: Short acting 25-100 mg BD Long acting 25 -100 mg OD 2. Nitrates: Isosorbide mono-nitare 20 to 60 mg in 2 devided dose Nitroglycerine sustained release 2.6 to 6.5 mg BD Nitroglycerine IV 5-25 mcg/min infusion Statins: High dose Atorvastatin 80 mg OD or Rosuvastatin 20-40 mg OD | 728 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1768823342_cardiology_1-4.pdf | Nitrates: Isosorbide mono-nitare 20 to 60 mg in 2 devided dose Nitroglycerine sustained release 2.6 to 6.5 mg BD Nitroglycerine IV 5-25 mcg/min infusion Statins: High dose Atorvastatin 80 mg OD or Rosuvastatin 20-40 mg OD | 1 | page=1,block=35 |
| What are the optional investigations listed for re-vascularization? | 1. Coronary Angiography 2. CT scan including coronary angiography 3. Stress Radionuclide/ echocardiographic imaging 4. MRI 5. Coronary Fractional Flow Reserve 5. Intra-vascular Ultrasound | A)Low risk: 1.Conservative management: Aspirin, clopidogrel, BB and statin 2. CT coronary angiography/TMT within a week to risk stratify 3.Refer low risk for re-vascularization if -Recurrent pain -Hemodynamic deterioration -New ECG change B. Intermediate/ Very High/ High risk: Re-vascularization OPTIONAL INVESTIGATIONS 1. Coronary Angiography 2. CT scan including coronary angiography 3. Stress Radionuclide/ echocardiographic imaging 4. MRI 5. Coronary Fractional Flow Reserve 5. Intra-vascular Ultrasound Pricking or piercing or stabbing type of pain | 321 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1768823342_cardiology_1-4.pdf | Intermediate/ Very High/ High risk: Re-vascularization OPTIONAL INVESTIGATIONS 1. Coronary Angiography 2. CT scan including coronary angiography 3. Stress Radionuclide/ echocardiographic imaging 4. MRI 5. Coronary Fractional Flow Reserve 5. Intra-vascular Ultrasound Pricking or piercing or stabbing type of pain | 1 | page=1,block=93 |
| What can precipitate pain in the context described? | movement of neck or arms or respiration | If at non-PCI-capable hospital Very high risk: Immediate transfer to PCI-capable hospital High risk: same-day transfer Intermediate risk: transfer for PCI withing 72 h Low risk: transfer if pursuing invasive treatment Variable location or characteristic Long lasting (hours to days) or short lasting (less than a minute) Restricted to areas above jaw or below epigatrium Localized to a point Precipitated by movement of neck or arms or respiration | 408 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1768823342_cardiology_1-4.pdf | If at non-PCI-capable hospital Very high risk: Immediate transfer to PCI-capable hospital High risk: same-day transfer Intermediate risk: transfer for PCI withing 72 h Low risk: transfer if pursuing invasive treatment Variable location or characteristic Long lasting (hours to days) or short lasting (less than a minute) Restricted to areas above jaw or below epigatrium Localized to a point Precipitated by movement of neck or arms or respiration | 1 | page=1,block=75 | 0.700 | valid |
| What clinical scores are used to determine risk categories? | GRACE score & TIMI score | Based on clinical features, GRACE score & TIMI score A).Very high risk: -Acute LVF -Hypotension -Uncontrolled Ventricular arrhythmia -Severe MR B. High Risk: -GRACE score > 140 or TIMI score >4 C. Intermediate Risk: -GRACE score 109-140 or TIMI score 2-3 D. Low Risk: -Grace score <108 or TIMI score 0-1 | 28 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1768823342_cardiology_1-4.pdf | Based on clinical features, GRACE score & TIMI score A).Very high risk: -Acute LVF -Hypotension -Uncontrolled Ventricular arrhythmia -Severe MR B. | 1 | page=1,block=88 | 0.700 | valid |
| What diagnostic tests may low-risk patients undergo for non-invasive risk stratification? | exercise stress test, CT coronary angiography or stress imaging | Continue aspirin and heparin 3. Load with clopidogrel or prasugrel or ticagralor if not already done 4. Optimal medical therapy to continue (BB, high dose atorvastatin, ACE-inhibitors, intra-venous nitrates if ongoing pain, severe MR or LVF) 5. Detailed echocardiography 6. Low risk patients may undergo non-invasive risk stratification with exercise stress test, CT coronary angiography or stress imaging 7. Very high risk, high risk and intermediate risk patients may be subjected to coronary revascularization Revascularization: 1. Discuss pros & cons of re-vascularization and prolonged dual anti-platelet therapy 2. Revascularize if anatomy is suitable 3. Prefer CABG over PCI in DM with multivessel disease or left main disease Revascularization strategy: 1. Very High risk: Urgent re-vacsularization (within few hours) after loading preferably with Ticagrelor or prasugrel if PCI is planned 2. | 342 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1768823342_cardiology_1-4.pdf | Low risk patients may undergo non-invasive risk stratification with exercise stress test, CT coronary angiography or stress imaging 7. |
| What is the recommended management for low-risk patients with acute coronary syndrome at the district hospital? | Conservative management Life style modification Risk factor control Secondary prevention | PHC/CHC LEVEL 1, ECG, Troponin. 2. Start -Aspirin, Clopidogrel in loading dose -Heparin/ LMWH -High dose statin -Metoprolol 3. Risk stratify GRACE score or TIMI score - Refer High/ Intermediate risk to PCI capable centre - Refer Low risk for further evaluation to DH 4. Refer to PCI capable centre if: - Acute LVF - Hypotension - Systolic murmur - Arrythmia DISTRICT HOSPITAL 1.Admit in ICU equipped with ECG monitoring and defibrillator 2.Troponin & bio-chemistry if not done 3.Serial ECG & echocardiography 4.Continue Aspirin, Clopidogrel, Heparin & Metoprolol 5.Add nitrates if needed 6.Management for different risk categories: -Very high,High or Intermediate risk or LVEF <40%: Refer for revascularization -Low risk patients: Conservative management Life style modification Risk factor control Secondary prevention TERTIARY CENTRE 1. Admit, reassess clinically and monitor in ICCU 2. | 731 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1768823342_cardiology_1-4.pdf | Refer to PCI capable centre if: - Acute LVF - Hypotension - Systolic murmur - Arrythmia DISTRICT HOSPITAL 1.Admit in ICU equipped with ECG monitoring and defibrillator 2.Troponin & bio-chemistry if not done 3.Serial ECG & echocardiography 4.Continue Aspirin, Clopidogrel, Heparin & Metoprolol 5.Add nitrates if needed 6.Management for different risk categories: -Very high,High or Intermediate risk or LVEF <40%: Refer for revascularization -Low risk patients: Conservative management Life style modification Risk factor control Secondary prevention TERTIARY CENTRE 1. |