1 - ACS Flashcards
Components of ACS:
STEMI
N-STEMI
Unstable angina
Ischemia vs infarction
Ischemia = reversible
Infarction = irreversible
What is the predominant symptom of CAD?
Chest pain
Resting angina
At rest, prolonged (usually > 20 mins)
New onset angina
Markedly limits physical activity
Increasing angina
Previously dx’d
Now more frequent, longer duration, more limiting, etc
Unstable angina
New angina, Change in existing angina, or angina at rest
LAD
Anterior aspect of the heart
Main blood supply for the anterior and septal
Circumflex
Anterior wall and large portion of the lateral wall of the heart
RCA
Supplies the right side of the heart
Right posterior descending artery
Inferior aspect of the LV
AV conduction system receives blood from
AV branch of the RCA
Septal perforating branch of left anterior descending coronary artery
RBB and the posterior LBB each get blood from
Both LAD and RCA
Coronary artery bloodflow is determined by
The duration of diastolic relaxation of the heart and peripheral vascular resistance
ACS may be caused by secondary reduction in myocardial blood flow due to:
Coronary artery spasm
Disruption or erosion of atherosclerotic plaques
Platelet aggregation or thrombus formation at the site of an atherosclerotic lesion
Main sxs of ischemic heart dz
CP (severity, location, radiation, duration, quality)(tightness, fullness, heaviness, sharp/stabbing)
N/V Diaphoresis Light-headedness Syncope Palpitations
Classic ACS pain:
Substernal or in the left chest, with radiation to the arm, neck, or jaw
Things that can precipitate angina
Exercise
Stress
Cold environment
Duration of angina
Typically less than ten minutes
Sometimes up to 20
Angina usually improves with:
Rest
NTG
O2
Atypical angina sxs
Fatigue
Weakness
Not feeling well
Vague discomfort
Traditional risk factors for AM/ ACS
HTN DM Tobacco use FHx at early age Hypercholesteremia Over 40
Gender and race no longer on the risk factor list
Bradycardic rhythms are more common with:
Inferior wall MI
In the setting of anterior wall MI, what is a poor prognostic indicator?
Bradycardia or new heart block
If the ACS pt has an S3, could be:
Suggestive of a failing myocardium
A new systolic murmur is an ominous sign - why?
Could mean papillary muscle dysfunction
A flail leaflet of the MV with resultant MR
VSD
The presence of JVD suggests
Right sided heart failure
Diagnosis of STEMI?
EKG and clinical symptoms
Diagnosis of NSTEMI?
Elevated cardiac biomarkers
What is the TIMI?
TIMMYYYYYY!!!!!
Thrombosis in Myocardial Infarction
A seven-item tool that helps stratify patients with unstable angina or NSTEMI in the ED
Elements of TIMI
- Age 65 yrs or older
- 3 or more traditional risk factors for CAD
- Prior coronary stenosis of 50% or more
- ST-segment deviation on presenting ECG
- 2 or more anginal events in prior 24hrs
- ASA use within 7 days prior to presentation
- Elevated cardiac markers
Results of TIMI
14 day risk of mortality, new or recurrent AMI or severe recurrent ischemia requiring vascularization
0-1: 5% chance
2: 8% chance
3: 13% chance
4: 20% chance
5: 26% chance
6-7: 41 chance
How long do you have to get the EKG?
10 mins
STEMI is defined as:
1mm or more in at least 2 contiguous leads with reciprocal changes
ST-elevation in V4R is highly suggestive of:
RV infarction
Inferior wall AMI’s should have what performed?
A right-sided EKG
Patients with RV STEMI should not receive:
NTG
BB’s
Slide 28
KNOW IT!!
STEMI locations
A NEW LBBB is considered:
STEMI equivalent
Bc it’s a predictor of increased mortality
In the setting of pre-existing LBBB, AMI can be identified with what select findings?
- ST-elevation of 1mm or greater and concordant with the QRS complex
- ST-depression of 1mm or more in V1/2/3
- ST-segment elevation of 5mm or greater and discordant with the QRS
Slide 41
LBBB criteria examples
Conditions that may present with ST-elevations but not having an AMI
Early repol LVH Pericarditis Mrocarditis LV aneurysm HCM Hypothermia Ventricular-paced rhythms LBBB
Conditions that may present with ST-depressions, but not an AMI
Hypokalemia Digoxin Cor pulmonale and right heart strain Early repol LVH Ventricular paced rhythms LBBB
Conditions that can have t-wave inversions, but not AMI
Persistent juvenile pattern Stokes-Adams syncope or seizures Post-tachycardia T-wave inversion Post-pacemaker T-wave inversion Intracranial pathology MV-prolapse Pericarditis Primary or secondary myocardial dz Pulmonary embolism or cor pulmonale from other causes Spontaneous pneumothorax Myocardial contusion LVH Ventricular paced rhythms LBBB RBBB
Diagnostic criteria for AMI with cTn:
A maximum value above the 99th percentile combined with any of the following:
- Sxs consistent with ischemia
- ECG changes
- Imaging evidence of a new regional wall motion abnormality
- New loss of viable myocardium