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Senior - EMED 2 > 1 - ACS > Flashcards

1 - ACS Flashcards

1
Q

Components of ACS:

A

STEMI
N-STEMI
Unstable angina

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2
Q

Ischemia vs infarction

A

Ischemia = reversible

Infarction = irreversible

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3
Q

What is the predominant symptom of CAD?

A

Chest pain

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4
Q

Resting angina

A

At rest, prolonged (usually > 20 mins)

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5
Q

New onset angina

A

Markedly limits physical activity

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6
Q

Increasing angina

A

Previously dx’d

Now more frequent, longer duration, more limiting, etc

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7
Q

Unstable angina

A

New angina, Change in existing angina, or angina at rest

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8
Q

LAD

A

Anterior aspect of the heart

Main blood supply for the anterior and septal

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9
Q

Circumflex

A

Anterior wall and large portion of the lateral wall of the heart

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10
Q

RCA

A

Supplies the right side of the heart

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11
Q

Right posterior descending artery

A

Inferior aspect of the LV

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12
Q

AV conduction system receives blood from

A

AV branch of the RCA

Septal perforating branch of left anterior descending coronary artery

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13
Q

RBB and the posterior LBB each get blood from

A

Both LAD and RCA

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14
Q

Coronary artery bloodflow is determined by

A

The duration of diastolic relaxation of the heart and peripheral vascular resistance

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15
Q

ACS may be caused by secondary reduction in myocardial blood flow due to:

A

Coronary artery spasm

Disruption or erosion of atherosclerotic plaques

Platelet aggregation or thrombus formation at the site of an atherosclerotic lesion

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16
Q

Main sxs of ischemic heart dz

A

CP (severity, location, radiation, duration, quality)(tightness, fullness, heaviness, sharp/stabbing)

N/V
Diaphoresis
Light-headedness
Syncope
Palpitations
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17
Q

Classic ACS pain:

A

Substernal or in the left chest, with radiation to the arm, neck, or jaw

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18
Q

Things that can precipitate angina

A

Exercise
Stress
Cold environment

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19
Q

Duration of angina

A

Typically less than ten minutes

Sometimes up to 20

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20
Q

Angina usually improves with:

A

Rest
NTG
O2

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21
Q

Atypical angina sxs

A

Fatigue
Weakness
Not feeling well
Vague discomfort

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22
Q

Traditional risk factors for AM/ ACS

A 
HTN
DM
Tobacco use
FHx at early age
Hypercholesteremia 
Over 40

Gender and race no longer on the risk factor list

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23
Q

Bradycardic rhythms are more common with:

A

Inferior wall MI

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24
Q

In the setting of anterior wall MI, what is a poor prognostic indicator?

A

Bradycardia or new heart block

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25
Q

If the ACS pt has an S3, could be:

A

Suggestive of a failing myocardium

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26
Q

A new systolic murmur is an ominous sign - why?

A

Could mean papillary muscle dysfunction

A flail leaflet of the MV with resultant MR

VSD

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27
Q

The presence of JVD suggests

A

Right sided heart failure

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28
Q

Diagnosis of STEMI?

A

EKG and clinical symptoms

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29
Q

Diagnosis of NSTEMI?

A

Elevated cardiac biomarkers

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30
Q

What is the TIMI?

A

TIMMYYYYYY!!!!!

Thrombosis in Myocardial Infarction

A seven-item tool that helps stratify patients with unstable angina or NSTEMI in the ED

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31
Q

Elements of TIMI

A
  1. Age 65 yrs or older
  2. 3 or more traditional risk factors for CAD
  3. Prior coronary stenosis of 50% or more
  4. ST-segment deviation on presenting ECG
  5. 2 or more anginal events in prior 24hrs
  6. ASA use within 7 days prior to presentation
  7. Elevated cardiac markers
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32
Q

Results of TIMI

A

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

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33
Q

How long do you have to get the EKG?

A

10 mins

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34
Q

STEMI is defined as:

A

1mm or more in at least 2 contiguous leads with reciprocal changes

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35
Q

ST-elevation in V4R is highly suggestive of:

A

RV infarction

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36
Q

Inferior wall AMI’s should have what performed?

A

A right-sided EKG

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37
Q

Patients with RV STEMI should not receive:

A

NTG

BB’s

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38
Q

Slide 28

A

KNOW IT!!

STEMI locations

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39
Q

A NEW LBBB is considered:

A

STEMI equivalent

Bc it’s a predictor of increased mortality

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40
Q

In the setting of pre-existing LBBB, AMI can be identified with what select findings?

A
  1. ST-elevation of 1mm or greater and concordant with the QRS complex
  2. ST-depression of 1mm or more in V1/2/3
  3. ST-segment elevation of 5mm or greater and discordant with the QRS
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41
Q

Slide 41

A

LBBB criteria examples

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42
Q

Conditions that may present with ST-elevations but not having an AMI

A 
Early repol
LVH
Pericarditis
Mrocarditis 
LV aneurysm 
HCM
Hypothermia 
Ventricular-paced rhythms 
LBBB
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43
Q

Conditions that may present with ST-depressions, but not an AMI

A 
Hypokalemia 
Digoxin
Cor pulmonale and right heart strain
Early repol
LVH
Ventricular paced rhythms 
LBBB
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44
Q

Conditions that can have t-wave inversions, but not AMI

A 
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
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45
Q

Diagnostic criteria for AMI with cTn:

A

A maximum value above the 99th percentile combined with any of the following:

  1. Sxs consistent with ischemia
  2. ECG changes
  3. Imaging evidence of a new regional wall motion abnormality
  4. New loss of viable myocardium
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46
Q

Anteroseptal MI

A

Elevations in:
V1
V2
Possibly V3

47
Q

Anterior MI

A 
Elevations in:
V1
V2
V3
V4
48
Q

Anterolateral MI

A 
Elevations in:
V1
V2
V3
V4
V5
V6
I
aVL
49
Q

Lateral MI

A

Elevations in:
I
aVL

50
Q

Inferior MI

A

Elevations in:
II
III
aVF

51
Q

Inferolateral MI

A 
Elevations in:
II
III
aVF
V5
V6
52
Q

True posterior MI

A

Initial R-waves in V1 and V2 > 0.04 and R/S ratio >1

53
Q

Right ventricular MI

A 
Elevations in:
II
III
aVF
R-sided V4
54
Q

Criteria for AMI in the setting of pre-existing LBBB:

A
  1. ST-segment elevation of 1mm or greater and concordant with QRS complex
  2. ST-segment depression of 1mm or more in leads V1, V2, or V3
  3. ST-segment elevation of 5mm or greater and discordant
55
Q

Conditions in which ECG interpretation can be difficult:

A

Big list - slide 45

56
Q

Conditions that may present with T-wave inversion in the absence of ischemia

A

Slide 46 - big list

57
Q

I’ve got ST-elevations consistent with AMI - do i need to wait for the serum marker results to make txt decisions?

A

Only if you wanna see the patient die.

58
Q

Even low-level cardiac markers are strong indicators of:

A

The potential to develop unstable angina

59
Q

Conditions that that can cause elevated troponins in the absence of ischemic heart disease

A

Slide 49 - big list

60
Q

Pts with renal disease will often have elevated:

61
Q

Are BNP elevations specific to myocardial ischemia?

A

No, they can rise with any ventricular dysfunction

62
Q

If your chest pain pt has elevated BNP:

A

Worse outcomes

63
Q

Standard care for the ACS patient

A

IV
ASA
ECG
O2 (maybe)

Then:
Cath lab or fibrinolytics (fix the problem)

64
Q

I work at a hospital with a cath lab - STEMI patient walks in - how long do I have to get them on the table?

A

90 mins or less

65
Q

I work at a hospital that does not have a cath lab - STEMI pt walks in - how long do I have to get that pt transferred and ON THE TABLE at another facility?

66
Q

I work at a hospital without a cath lab and the nearest hospital with one is really far away - how long do I have to start fibrinolytics for my STEMI patient?

67
Q

Most STEMI pts will receive what meds in the ED?

A

Antiplatelet agents (i.e. ASA)

Antithrombins (i.e. UFH/LMWH)

Nitrates (i.e. SL-NTG)

If heading to cath lab, may be beneficial to administer GP-IIb/IIIa antagonists, as well (Abciximab, Ebtifibatide, Tirofiban)

68
Q

Which NSTEMI patients should most likely receive PCI: (long list)

A 
Recurrent angina/ischemia with or without sxs of CHF
Elevated troponins
New or presumably new ST-depression
High-risk findings on non-invasive stress testing
Depressed LV function
Hemodynamic instability
Sustained v-tach
PCI within previous 6 mos
Prior CABG
69
Q

What is the preferred txt for NSTEMI?

A

PCI (as long as the time from first medical contact to balloon is less than 90 to 120 mins)

70
Q

What is the most common type of PCI?

A

Coronary angioplasty with or without stent placement

71
Q

What are coronary stents?

A

Fenestrated stainless steel tubes that are expanded by a balloon to provide scaffolding within the coronary arteries

72
Q

What adjunctive txt is recommended with stent placement?

A

Anti-platelet therapy

73
Q

ASA dose

A

162-325 mg

74
Q

Clopidogrel dosing

A

600mg loading dose PO

Followed by 75mg/d

75
Q

Enoxaparin dosing

A

30mg IV bolus

Followed by 1mg/kg SQ q 12h

76
Q

Most commonly used fibrinolytic in STEMI?

77
Q

NTG dosing

A

0.4mg SL q 5mins x3 PRN (as long as SBP > 90mmHg)

78
Q

You can get fibrinolytics for STEMI as long as your sxs started less than ____ hrs ago, and the ECG has:

A

6 to 12

At least 1mm ST-elevation in two or more contiguous leads

…lots of other considerations, we’ll get to ‘em

79
Q

Which type of STEMI’s do fibrinolytics work best in?

A

Larger, anterior infarctions

80
Q

Who is rescue PCI (failed fibrinolytic therapy) recommended for?

A

Cardiogenic shock <75 yrs old

Severe heart failure

Pulmonary edema

Hemodynamically compromising ventricular arrhythmias

81
Q

Biggest complication of fibrinolytic therapy in STEMI?

A

Intracranial bleeding

82
Q

My patient has relative CI’s to fibrinolytic therapy but the cath lab is like 8 hours away…

A

The benefits may outweigh the risks

83
Q

Absolute CI’s to fibrinolytic therapy in STEMI?

A

Any prior intracranial hemorrhage

Known structural cerebral vascular lesion (e.g. AV malformation)

Known intracranial neoplasm

Ischemic stroke within 3 mos

Active internal bleeding (excluding menses)

Suspected aortic dissection or pericarditis

84
Q

Relative CI’s to fibrinolytics in STEMI?

A

BP >180/100, uncontrollable

HX of severe, chronic, or poorly controlled HTN

Ischemic stroke ever

Any intracranial pathology

Current anticoagulant use with INR >2-3

Known bleeding diathesis

Trauma in the last 2 weeks

Prolonged CPR (> 10mins)

Major surgery in the last 3 weeks

Non-compressible vascular punctures (i.e. central lines)

Recent internal bleeding

Ever had streptokinase? Use a different fibrinolytic this time

Pregnancy

Active peptic ulcer disease

Other medical conditions likely to increase risk of bleeding (i.e. diabetic retinopathy)

85
Q

What med can help reduce LV dysfunction and slow the development of CHF during an MI?

86
Q

Best treatment for hemodynamically unstable SVT / a-fib / a-flutter?

A

Cardioversion

87
Q

What dysrhythmia commonly occurs transiently within the first 24hrs of AMI?

88
Q

Appx percentage of AMI pts that also already have HF?

89
Q

Mechanical complications of AMI usually involve:

A

Tearing or rupture of infarcted tissue (papillary muscles, interventricular septum, or ventricular free wall)

90
Q

What might kill a patient up to a week after the actual MI?

A

Ventricular free wall rupture (leads to rapid pericardial tamponade)

91
Q

Sxs of ventricular free wall rupture?

A

Sudden onset severe, tearing pain

HOTN

Tachycardia

AMS

JVD

Pulsus paradoxus

92
Q

Txt for ventricular free wall rupture?>

93
Q

Sxs of interventricular septal rupture?

A

CP
Dyspnea
Sudden, NEW holosystolic murmur

94
Q

TOC for interventricular septal rupture?

A

Doppler echo (shows flow)

95
Q

Pericarditis is a common complication of which type of AMI?

A

Transmural

96
Q

TOC for pericarditis?

A

ASA 650 PO q 4 to 6 hrs (holy high dose, Batman)

OR

Colchicine 0.6mg BID

NOT IBUPROFEN

97
Q

Dressler’s Syndrome?

A

Late post-MI syndrome

Occurs 2 to 10 weeks post-AMI

Sxs - CP, fever, pleuropericarditis

Txt - ASA / colchicine

98
Q

If you give NTG to your suspected AMI patient and they get worse, they just might have:

A

RV infarction

Seen by doing a r-sided ECG - V4R ST-elevation

99
Q

Most serious complication of RV infarction?

100
Q

Since i can’t give NTG to my right-sided MI patient, what’s my txt goals?

A

Maintain preload (bolus 1 or 2 liters of saline - if that doesn’t work, run dobutamine)

Reduce RV afterload

Inotropic support

Early reperfusion

101
Q

CP after PCI?

A

Abrupt vessel closure, until proven otherwise

Txt aggressively for ACS, emergency cardiology consult

102
Q

Most sensitive finding for cocaine-associated MI?

A

Cardiac troponin

103
Q

Mainstay of txt for cocaine-associated MI?

A

ASA
NTG
Benzos

104
Q

What is CI’d for the first 24hrs of cocaine-induced MI?

105
Q

Treatment of Choice for cocaine addiction?

A

More cocaine

106
Q

ST-elevations in V1, V2, and possibly V3

A

Anteroseptal

107
Q

ST-elevations in V1, V2, V3, and V4

108
Q

ST-elevations in V1-V6, I and aVL

A

Anterolateral

109
Q

ST-elevations in I and aVL

110
Q

ST-elevations in II, III, and aVF

111
Q

ST-elevations in II, III, aVF, and V5 and V6

A

Inferolateral

112
Q

Initial R waves in V1 and V2 > 0.04 seconds and R/s ratio > or = to 1

A

True posterior

113
Q

ST-elevations in II, III, and aVF and ST elevation in right-side V4

A

Right ventricular

Senior - EMED 2 (10 decks)

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