Identification and Management of ACS

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Paul Au

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Identification and Management of ACS – ATOTW 562

15 September 2026

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1) The ESC 4th universal definition of myocardial infarction describes the concept of myocardial injury (defined as elevation of high-sensitivity cardiac troponin T or I) with myocardial infarction representing a subset of these patients who have evidence of actual ischemia.

True False

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Myocardial injury has occurred when there is an elevation of cardiac troponins. MI represents those when underlying actual ischaemic can be demonstrated – e.g. relevant symptoms, ischaemic ECG changes and regional wall motion abnormalities or intracoronary thrombus on imaging

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2) A type 2 MI needs treatment of reversible systemic pathologies in order to restore a mismatch in myocardial oxygen supply and demand.

True False

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This is the treatment for a type 2 MI – examples would be improvement of shock and coronary perfusion pressure or the treatment of anaemia to improve oxygen delivery.

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3) The universal definition subdivides myocardial infarction into 3 distinct subtypes, according to aetiology.

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5 subtypes are described in table 1. The majority of clinicians outside of specialised cardiology settings will only see patients with type 1 or 2 MIs.

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4) Unstable angina is myocardial ischaemia at rest or on minimal exertion in the absence of acute myocardial cell injury or necrosis.

True False

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The presence of acute myocardial cell injury or necrosis would suggest myocardial infarction and would be characterised by raised cTn levels.

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5) Accurate assessment of ST changes in the setting of bundle branch blocks (BBB) can be done via Modified Sgarbossa Criteria.

True False

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Whilst accurate Assessment of ST changes in the setting of bundle branch blocks (BBB) can be a diagnostic challenge, modified Sgarbossa criteria can help identify patients with STEMI equivalent patterns and enable timely referral for revascularisation.

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6) ‘Appropriate discordance’ with the QRS complex means the ST segment changes associated with BBB will be in the opposite direction.

True False

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The typical changes in the ST segment associated with BBB can be ‘appropriate discordance’ with the QRS complex (i.e. they may be in the opposite direction) or concordance (i.e. they may be in the same direction), making accurate interpretation difficult.

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7) According to the modified Sgarbossa criteria, excessive discordance means that ST elevation at the J-point, relative to the QRS onset, is at least 5 mm and has an amplitude of at least 25% of the preceding S-wave.

True False

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According to the modified Sgarbossa criteria, excessive discordance means that STE at the J-point, relative to the QRS onset, is at least 1mm and has an amplitude of at least 25% of the preceding S-wave. See table 6.

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8) Tall, prominent, symmetrical T waves in precordial leads, upsloping ST depression >1 mm at the J-point combined with 0.5-1mm ST elevation in lead aVR represents a STEMI equivalent, known as de Winter’s sign.

True False

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Tall, prominent, symmetrical T waves in precordial leads, Upsloping STD >1 mm at the J-point & 0.5-1 mm STE in lead aVR represents de Winter’s sign. This sign is an Anterior Wall STEMI equivalent & is suggestive of LAD occlusion.

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9) STE in aVR can be suggestive of underlying left main stem disease or triple vessel coronary artery disease.

True False

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STEin aVR >1 mm when accompanied by ST depression in leads I, II, aVL, and/or V4-V6 and an absence of contiguous ST-segment elevation in other leads is suggestive of underlying left main stem disease or triple vessel coronary artery disease.

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10) The ESC recommends the use of a 0h/1h or 0h/2 h rule-out and rule-in algorithms in patients with suspected STEMI.

True False

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The ESC recommends the use of 0h/1h or 0h/2 h rule-out and rule-in algorithms in patients with suspected NSTEMI.

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11) This algorithm typically involves the measurement of high-sensitivity cardiac troponins at 0 h and 1 h or 2 h later after onset of pain.

True False

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The ESC 0h/1h or 0h/2h rule-out and rule-in algorithms typically involves the measurement of high-sensitivity cardiac troponins at 0h (time of initial blood test) and 1h or 2h later.

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12) FoCUS is a standardized version of a limited cardiac scan which can provide immediate information regarding segmental wall motion abnormalities, underlying left ventricle function & acute valvular or mechanical complications in ACS.

True False

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FoCUS as a standardized version of limited cardiac scan that can provide immediate information regarding segmental wall motion abnormalities, underlying left ventricle function & acute valvular or mechanical complications that may be of immediate relevance to the management of ACS. Additionally, it can facilitate the exclusion of alternative aetiologies such as pulmonary embolism or aortic root dissections and also help identify reversible causes or cardiac activity in cardiac arrest.

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13) A loading dose of aspirin 300mg and a second antiplatelet agent should be given to ACS patients via oral or nasogastric route unless contraindicated.

True False

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Antiplatelet drugs are first line medical therapies in ACS.

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14) NSAIDS & COX2 inhibitors should be used as analgesia in patients with ACS.

True False

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NSAIDS and COX2 inhibitors are generally avoided in this patient group as they may increase mortality. Intravenous opioids such as morphine or fentanyl are considered the analgesics of choice in ACS as they can be incrementally titrated and have beneficial effects on myocardial workload.

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15) 25-30% of patients diagnosed with NSTE-ACS may have total occluded coronaries where immediate intervention may be required.

True False

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Patients who are categorized as NSTEMI should be risk stratified and this is because 25-30% of patients with this diagnosis could actually have total occluded coronaries where immediate intervention could prove clinically beneficial. Tables 7 and 8 show criteria to aid such risk stratification.

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16) An immediate invasive strategy should be initiated in patients with NSTE-ACS and at least one high-risk criteria.

True False

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An immediate invasive strategy should be initiated in patients with NSTE-ACS and at least one very high-risk criteria. One high-risk criteria should prompt referral for early (e.g. <24 hours) referral for the same. See table 6.

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17) Candidates with a GRACE 2.0 score >130 should be considered for post-procedural care in a critical care setting.

True False

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The GRACE 2.0 score utilises eight parameters to determine in-hospital mortality. Patients with a score >130 should be considered for post-procedural critical care observation.

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18) A failed fibrinolysis is determined by <100% resolution of ST changes 90 minutes after administration.

True False

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A failed fibrinolysis is determined by <50% resolution of ST changes 90 minutes after administration -or the presence of recurrent chest pain, arrhythmias or hemodynamic instability. The patient would ultimately require a rescue PCI in the setting of an unsuccessful fibrinolysis.

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19) The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) recommend revascularisation of such patients following an acute MI via fibrinolysis.

True False

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The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) recommend revascularisation of such patients following an acute MI via PCI or surgery – the latter being an option for failed PCI or dictated by coronary anatomy such as more extensive three vessel disease.

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20) An Intra-aortic balloon pump (IABP), is recommended for routine use in cardiogenic shock.

True False

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Regarding IABP, the available evidence does not recommend its routine use in cardiogenic shock following acute MI without mechanical complications. It can be utilised as a bridge to definitive treatment in unsuccessful revascularisation procedures

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