UKMLA AKT Question Bank

Primary percutaneous coronary intervention (PCI) is the gold-standard reperfusion strategy for STEMI, recommended within 120 minutes of first medical contact per NICE NG185. If PCI cannot be delivered within this timeframe, IV thrombolysis should be administered within 12 hours of symptom onset, ideally within 30 minutes of hospital arrival.

Anterior STEMI (V1–V4) indicates left anterior descending artery occlusion - the largest territory at risk. Dual antiplatelet loading (aspirin 300mg plus ticagrelor 180mg or prasugrel 60mg) and parenteral anticoagulation are given pre-procedure. Morphine and antiemetics address symptoms. GTN is avoided in hypotension or right ventricular infarction.

Reciprocal ST depression supports the diagnosis and carries prognostic significance. Troponin confirmation is not required before initiating reperfusion - the ECG alone is sufficient for STEMI diagnosis. Post-PCI management includes dual antiplatelet therapy for 12 months, high-intensity statin, beta-blocker, ACE inhibitor, and cardiac rehabilitation referral.

Remember: STEMI requires immediate reperfusion - primary PCI within 120 minutes is the target, and waiting for troponin delays life-saving treatment.

NSTEMI management is guided by the GRACE score for risk stratification per NICE NG185: high risk (GRACE >140) warrants coronary angiography within 72 hours, intermediate risk (109–140) within 72 hours, and lower risk (<109) before discharge or within 72 hours. Thrombolysis is contraindicated in NSTEMI as there is no complete coronary occlusion.

Initial medical therapy includes dual antiplatelet loading (aspirin 300mg plus ticagrelor 180mg), fondaparinux 2.5mg SC daily (preferred over LMWH unless angiography within 24 hours), and high-intensity statin. Beta-blockers are started unless contraindicated. GTN provides symptomatic relief.

A rising troponin pattern with dynamic ECG changes confirms myocardial injury. The GRACE score incorporates age, heart rate, systolic BP, creatinine, cardiac arrest at admission, ST deviation, elevated cardiac markers, and Killip class. Patients with ongoing ischaemia, haemodynamic instability, or life-threatening arrhythmias require immediate angiography (<2 hours).

Remember: NSTEMI is risk-stratified using the GRACE score - high-risk patients need angiography within 72 hours, and thrombolysis is never indicated for NSTEMI.

Unstable angina is an acute coronary syndrome with ischaemic symptoms (new-onset, crescendo, or rest angina) and dynamic ECG changes but without troponin elevation, distinguishing it from NSTEMI. It represents plaque rupture with non-occlusive thrombus causing transient ischaemia without myocardial necrosis.

Management follows the same ACS pathway as NSTEMI per NICE NG185: dual antiplatelet therapy (aspirin plus ticagrelor), fondaparinux anticoagulation, beta-blocker, high-intensity statin, and GTN for symptom relief. Risk stratification using the GRACE score determines the urgency of coronary angiography. Dynamic ST changes during pain episodes confirm the ischaemic aetiology.

Normal troponin does not exclude significant coronary disease - unstable angina carries substantial risk of progression to MI. The introduction of high-sensitivity troponin assays has reclassified many previously diagnosed unstable angina cases as NSTEMI by detecting smaller degrees of myocardial injury. Serial troponin sampling at 0 and 3 hours (or 0 and 1 hour with high-sensitivity assays) is essential.

Remember: Unstable angina is troponin-negative ACS with ischaemic symptoms and ECG changes - it requires the same initial treatment pathway as NSTEMI per NICE NG185.