02.16 Acute Coronary Syndrome Flashcards
1
Q
Caused by complete obstruction of a coronary artery
A
STEMI
2
Q
Results in damage or necrosis of the full thickness of the heart muscles
A
STEMI
3
Q
Caused by partial obstruction of a coronary artery
A
NSTEMI
4
Q
Resulting necrosis only involves a partial thickness of the heart muscle
A
NSTEMI
5
Q
2 main components of atherosclerotic plaques
A
Soft, lipid-rick core
Hard, collagen-rich fibrous cap
6
Q
Thick fibrous cap may represent >70% of plaque volume
A
Stable plaque
7
Q
Lipid-rich core may represent the majority of the plaque volume
A
Unstable plaque
8
Q
Due to inflammation by foam cells and other inflammatory mediators that make the plaque more vulnerable to rupture
A
Plaque destabilization
9
Q
Where does plaque destabilization commonly occur
A
At the junction of the plaque and the less diseased vessel wall
10
Q
Primary cause of a heart attack
A
Rupture of unstable plaques
11
Q
Usually >20 minutes in duration
Sudden chest pain patient is at rest
A
Rest angina
12
Q
Markedly limits physical activity
A
New onset angina
13
Q
More frequent, longer in duration or occurs with less exertion than previous angiina
A
Increasing angina
14
Q
Symptoms of acute coronary syndrome
A
Prolonged pain Usually retrosternal location, radiating to the left chest, arm Nausea, vomiting Palpitations Diaphoresis Sense of impending doom
15
Q
Acute coronary syndrome
A
STEMI
NSTEMI
US
16
Q
Risk factors of ACS
A
Advanced age Smoking Hypertension DM Dyslipidemia Family history of early MI Known CAD
17
Q
PE of ACS
A
Anxious and restless Pallor with cold sweats and cold extermities Sympathetic hyperactivity 3th and 4th heart sound Friction rub Signs of congestion
18
Q
If ST deviations are on V3, V4, then the problem is at the ____
A
LAD, anterior of the heart
19
Q
If ST deviations are on V5, V6, the problem is at the _____
A
LCX, lateral of the heart
20
Q
If ST deviation is on II, III and aVF, then the patient has _______
A
Right coronary artery problem
21
Q
Established CAD by angiography, history of CABG or PCI, history of MI, CHF, Multiple CAD risk factors are likely to have _____
A
US/NSTEMI
22
Q
Normal or nonspecific ST T wave changes
ST depression
T wave inversion
A
US/NSTEMI
23
Q
Cardiac markers for US/NSTEMI
A
Cardiac troponin I and T
CK-MB (4-6 hours)
24
Q
Diagnostic approach to US/NSTEMI
A
ECG, Cardiac markers, Treadmill exercise testing, CT angiogram
25
TIMI Risk stratification
```
Age >/= 65 years
>/= 3 CAD risk factors
Prior stenosis >50%
ST deviation
>/= 2 anginal events = 24h
ASA in last 7 days
Elevated cardiac markers
```
26
Pharma intervention for plaque rupture
Statins
27
Pharma intervention for platelet adhesion
ASA, clopidogel, GP IIb/IIa inhibitors
28
Pharma intervention for activation of clotting cascade
Anticoagulant agents
29
Pharma intervention for myocardial ischemia
Beta blockers
Nitrates
Calcium antagonists
30
Treatment of US/NSTEMI
```
Bed rest
Nirates
B-blockers
CCB
Morphine sulfate
```
31
Limited by hypotension and bradycardia
| CI if with pulmonary congestion and severe reactive airways disease
Beta-blockers (metaprolol)
32
Used when betablockers are not effective
CCB (Diltiazem, verapamil)
33
Used for persistent angina
Morphine sulfate
34
Prevent the progression of intracoronary thrombi
Promote stabilization of the atherosclerostic plaque, thereby reducing myocardial ischemia and preventing further complications such as death or MI
Antithrombotic therapy
35
Antiplatelet drugs
```
Aspirin
Clopidogrel
GP IIb/IIa antagonists (Abciximab, eptifibatie, tirofiban)
Prasugrel
Ticagrelor
```
36
Only for PCI patients
Prasugrel
37
Reduced mortality
Increased risk of bleeding
Reversible
Ticagrelor
38
Anticoagulant agents
Unfractioned heparin
Low molecular weight heparin (Enoxaparin)
Fondaparinux
Bivalirudin
39
Standard therapy, continuous IV infusion
Requires periodic monitoring of prothrombin time
To prolong pTT
Unfractioned heparin
40
Longer acting
Subcutaneous administration
No need for PTT monitoring
Low molecular weight heparin (enoxaparin)
41
Once a day administration
Less bledding than enoxaparin
Direct factor X inhibitor
Fondaparinux
42
Direct thrombin inhibitor
Bivalirudin
43
Indications for use of an early invasive strategy in patients with NSTEMI
```
Recurrent angina at rest/low-level activity despite treatment
Elevated TnT or TnI
New ST-segment depression
CHF symptoms, rales MR
EF < 0.40
SustainedVT
PCI < 6 months, prior CABG
High risk findings from noninvasive testing
Hemodynamic instability
Mild-to-moderate renal dysfunction
DM
High TIMI Risk SCore (>3)
```
44
In coronary angiogram, catheter is introduced either via the ____ or ____
Brachial artery
| Femoral artery
45
Coronary angioplasty/stenting
Stent insertion
Stent expansion
Stent remains in the coronary artery
46
Stent has a drug coating that controls recovery to prevent re-narrowing
Drug-eluting stents
47
Long term management for UA/NSTEMI
```
ASA
Clopidogrel
Statins
ACEI or ARB (LV remodeling)
Lifestyle modification
```
48
Ischemic pain at rest caused by spasm of the coronary artery
Transient ST elevation on ECG
Hypercontractility of vascular smooth muscle
Prinzmetal angina
49
Treatment of Prinzmetal angina
Smoking cessation
Calcium antagonists
Addition of long acting nitrates to CCb
50
Detection of rise and fall of cardiac biomarker valus with at least one value above the 99th upper reference limit and at least one of the following: symptoms of ischemia, new or presumed new significant ST segment T wave changes or new left bundle branch block, development of pathologic Q waves in ECG, imaging evidence, identification of an intracoronary thrombus
AMI
51
Spontaneous MI
Type 1
52
MI secondar to ischemic imbalance
Type 2
53
MI resulting in death when biomarkers aren't available
Type 3
54
MI related to PCI
Type 4a
55
MI related to stent thrombosis
Type 4b
56
Mi related to CABG
Type 5
57
Symptoms associated with AMI
```
Prolonged pain
Usually retrosternal location, radiating to left chest, arm
Nausea/vomiting
Palpitations
Diaphoresis
Sense of impending doom
```
58
```
In distress, levine sign
HR, pulse, RR variable
BP variable
Low-grade fever
Examination of JVP
Pulmonary crackles
S4 gallop
S3 gallop
Murmurs
```
STEMI
59
Useful adjunct for chest pain patient with non-diagnostic or uninterpretable ECG
Can identify regional wall motion
2D echo
60
Early presentation
Invasive strategy not an option
Delay to stratery > prolonged transport, door-to-balloon time > 90 minutes
Fibrinolysis
61
```
Skilled PCI lab available with surgical back-up
Door-to-balloon time < 90 minutes
High risk patients
Late presentation
STEMI diagnosis in doubt
```
Primary PCI
62
General measures to address STEMI
Morphine
Oxygen
Aspirin
Nitrate
63
Main goal of fibrinolytic therapy
Full coronary patency
64
Reduces infarct size, limits LV dysfunction, and reduces incidence of serious complications: septal rupture, cardiogenic shock, malignant ventricular arrhythmias
Fibrinolytic therapy
65
Absolute CI of fibrinolytic therapy
```
Hx of cardiovascular hermorrhage
CVA within the past year
BP > 180 systolic or 110 diastolic
Aortic dissection
Active internal bledding
```
66
Relative CI of fibrinolytic therapy
```
Current anticoagulant use
Invasive surgery within 2 weeks
Prolonged CPR
Known bleeding diathesis
Hemorrhagic opthalmic condition
Active peptic ulcer disease
Sever HTN concurrently actively controlled
```
67
Most frequent and potentially most serious complication of fibrinolytic therapy
Hemorrhage
68
Reduce mortality after STEMI
Greatest benefit in patients with large anterior infarctions prior M, globally reduced LV systolic function
Reduces ventricular remodeling and subsequent risk of congestive heart failure
ACE or ARBs
69
Complication of STEMI common in patients with multi-vessel disease
Managements include vasopressors/inotropes, inaortic balloon counter pulsation, early reperfusion/revascularization
Cardiogenic shock
70
1/3 of inferior wall MI have _____, commonly manifested as hypotension, distended neck veins, clear lung fields. In ECG; ST elevation on right sided precordial leads, In 2D echo: RV dilatation and dysfunction
Right ventricular infarction
71
Treatment of right ventricular infarction
Volume expansion to improve LV filling
72
Pericarditis post MI
Dressler syndrome
73
Complication of STEMI that may lead to stroke
Thromboembolism
74
What to give to patients with ventricular premature beats
Beta-blockers
75
One of the worst complications of STEMI
| Can occur within the first 24 hours of STEMI without warning arrhythmias
Ventricular fibrillation/tachycardia
76
Treatment for sustained VT
IV amiodarone
77
Treatment for VF or hemodynamically unstable VT
DC cardioversion
78
Treatment for VF/VT after 48 hours
ICD/Defib
79
Post infaction risk stratification and management
Submaximal stress test (hospital) or full stress test (4-6 w after discharge)
2D echo to assess LV systolic function
80
Secondary prevention of STEMI
```
Antiplatelet therapy
AC-I, ARB
B-blockers
Statin therapy
Risk factor modification
```
