1 - ACS Flashcards

1
Q

Components of ACS:

A

STEMI
N-STEMI
Unstable angina

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Ischemia vs infarction

A

Ischemia = reversible

Infarction = irreversible

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the predominant symptom of CAD?

A

Chest pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Resting angina

A

At rest, prolonged (usually > 20 mins)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

New onset angina

A

Markedly limits physical activity

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Increasing angina

A

Previously dx’d

Now more frequent, longer duration, more limiting, etc

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Unstable angina

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

LAD

A

Anterior aspect of the heart

Main blood supply for the anterior and septal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Circumflex

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

RCA

A

Supplies the right side of the heart

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Right posterior descending artery

A

Inferior aspect of the LV

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

AV conduction system receives blood from

A

AV branch of the RCA

Septal perforating branch of left anterior descending coronary artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

RBB and the posterior LBB each get blood from

A

Both LAD and RCA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Coronary artery bloodflow is determined by

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Classic ACS pain:

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Things that can precipitate angina

A

Exercise
Stress
Cold environment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Duration of angina

A

Typically less than ten minutes

Sometimes up to 20

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Angina usually improves with:

A

Rest
NTG
O2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Atypical angina sxs

A

Fatigue
Weakness
Not feeling well
Vague discomfort

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Bradycardic rhythms are more common with:

A

Inferior wall MI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

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

A

Bradycardia or new heart block

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

If the ACS pt has an S3, could be:

A

Suggestive of a failing myocardium

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

The presence of JVD suggests

A

Right sided heart failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Diagnosis of STEMI?

A

EKG and clinical symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Diagnosis of NSTEMI?

A

Elevated cardiac biomarkers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

How long do you have to get the EKG?

A

10 mins

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

STEMI is defined as:

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

ST-elevation in V4R is highly suggestive of:

A

RV infarction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

Inferior wall AMI’s should have what performed?

A

A right-sided EKG

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Patients with RV STEMI should not receive:

A

NTG

BB’s

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Slide 28

A

KNOW IT!!

STEMI locations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

A NEW LBBB is considered:

A

STEMI equivalent

Bc it’s a predictor of increased mortality

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Slide 41

A

LBBB criteria examples

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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:

A

cTnT

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?

A

120 mins

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?

A

30 mins

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?

A

Alteplase

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?

A

ACEI’s

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?

A

A-fib

88
Q

Appx percentage of AMI pts that also already have HF?

A

15 - 20 %

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?>

A

Surgery

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?

A

Shock

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?

A

BB’s

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

A

Anterior

108
Q

ST-elevations in V1-V6, I and aVL

A

Anterolateral

109
Q

ST-elevations in I and aVL

A

Lateral

110
Q

ST-elevations in II, III, and aVF

A

Inferior

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