269 STEMI Flashcards
(157 cards)
1
Q
Classification of Myocardial infarction. Troponin I positive. Post 2 vessel stentt
A
Tupe 4A: PCI
Type 4B: Stent Thrombosis
Type 5: CABG
2
Q
Not associated with CAD A. Age B. Inflammation C. Systemic huper D. Metabolic syndrome
A
Age
3
Q
OASIS 7. Superior to placebo in STEMI not receiving reperfusion therapy
A
Fondaparinux
4
Q
Less common presentations of STEMI
A
Loss of consciousness Confusional state Sensation of profound weakbess Appearance of arrhythmia Evidence of peripheral embolism Unexplained drop in arterial pressure Breathlessness
5
Q
Pain in STEMI typically radiates in what areas but never in what area?
A
Pain may radiate to occipital area but not below umbilicus and the trapezius
6
Q
Temporal stages in STEMI
A
Acute: hours to days
Healing: 7-28 days
Healed: more than 29 days
7
Q
*Pathologic change in myocardial infarction 24 hours from onset
A
band necrosis
*still to find actual page in Harrison
8
Q
CK rises within and returns to normal by?
A
CK rises in 4 to 8 hours and returns to normal by 48 to 72 hours
9
Q
Cardiac Troponin remains elevated for how long after STEMI
A
7 to 10 days
10
Q
Universally present in STEMI on cardiac imaging
A
Abnormalities in wall motion
11
Q
ECG findings candidate for reperfusion
A
ST segment elevation at least 2 mm in two contiguous precordial leads and 1 mm in two adjacent limb leads
12
Q
Time from FMC to device time in PCI capable hospital
A
less than 90 minutes
13
Q
Door in Door out time from non PCI capable hospital
A
less than 30 minutes
14
Q
FMC to device time in non PCI capable hospital
A
less than 120 minutes
15
Q
When to administer fibrinolysis when anticipated FMC to device is long
A
within 30 minutes of arrival
16
Q
Reason why glucocorticoids and NSAIDS not given to STEMI patients
A
They can impair infarct healing and increase risk of myocardial rupture
17
Q
Treatment of choice of ventricular tachycardia if heart failure is present
A
Digoxin
18
Q
Cause of LV wall rupture
A
*Few hours from myocardial infarction
19
Q
When goes LV aneurysm occur in patients with STEMI
A
Weeks to months after STEMI
20
Q
Dykinesia or local expansile paradoxical wall motion; composed of scar tissue; most common location
A
ventricular aneurysm; apical aneurysm is most common
21
Q
Class 1 A recommendation for …
A
Sustained Vtach
Recurrent chest pain
*from exam; still to find actual Harrison page
22
Q
Pivotal diagnostic and Triage tool because it is at the center of the decision pathway for management
A
12 Lead ECG
23
Q
Stages of STEMI
A
Acute few hours to 7 days
Healing 7- 28 days
Healed more than 29 days
24
Q
Laboratory test for confirmation of STEMI
A
ECG
Serum cardiac biomarkers
Cardiac imaging
Nonspecific indices of tissue necrosis and inflammation
25
Why does slowly developing high grade coronary artery stenoses do not typically precipitate STEMI
development of rich collateral network over time
26
what causes STEMI in most cases
atherosclerotic plaque becomes disrupted and conditions favor thrombogenesis
27
characteristic of plaque prone to rupture
rich lipid core and thin fibrous cap
28
the amount of myocardial damaged caused by coronary occlusion depends on what factors
1. territory supplied 2. whether or not the vessel becomes totally occluded 3. duration of coronary occlusion 4. quantity of blood supplied by collateral vessels 5. demand of oxygen of the myocardium whoes blood supply has been limited 6. endogenous factors that produce spontaneous lysis of occlusive thrombus 7. adequacy of myocardial perfusion in the infarct zone when flow is restored in occluded epicardial coronary artery
29
most common presenting symptom in STEMI
pain
30
cluster where STEMI often commence
morning within a few hours of awakening
31
typical pain in STEMI
central portion of the chest and or epigastrium and on occasion it radiates to the arms
32
pain in STEMI can radiate as high as where but not below the what?
radiate as high as the occipital area but not below the umbilicus
33
differentials of the pain in STEMI
acute pericarditis, pulmonary embolism, acute aortic dissection, costochondritis, and gastrointestinal disorders
34
True or false. Radiation of discomfort to the trapezius is not seen in patients with STEMI
True.
35
Proportion of painless STEMI is greater in what subset of patients
elderly, patients with diabetes mellitus
36
less common presentation of STEMI
loss of consciousness, confusional state, sensation of profound weakness, appearance of an arrhythmia, evidence of peripheral embolism or a merely unexplained drop in arterial pressure
37
duration of substernal chest pain and diaphoresis that strongly suggest STEMI
more than 30 mins
38
manifestation of anterior infarction
sympathetic nervous system hyperactivity like tachycardia and or hypertension
39
manifestation of inferior infarction
parasympathetic hyperactivity like bradycardia and or hypotension
40
True or false. In patients with anterior wall infarction, an abnormal systolic pulsation casued by dyskinetic bugin fo the infarcted myocardium amy develop in the periapical area within the first days of the illness and then may resolve
True.
41
decline in systolic pressure in patients with transmural infarction
systolic pressure declines by 10-15 mmHg from the preinfarction state
42
True or false. Most patients initially presenting with ST segment elevation ultimately evolve Q waves on the ECG
True.
43
Levels of cardiac troponin may remain elevated for how many days after STEMI
7-10 days
44
CK rises within how many hours and generally returns to normal by how many hours
CK rises within 4-8 hrs and generally returns to normal by 48-72 hr
45
True or false. Nonspecific reaction to myocardial injury is associated with polymorphonuclear leukocytosis with WBC count reaching levels of 12,000- 15, 000/ uL
True.
46
Elevated WBC and ESR may occur for how long in STEMI
leukocytosis for 3-7 days, and ESR may remain elevated for 1-2 weeks
47
universally present on cardiac imaging for patient with STEMI
abnormalities of wall motion
48
True or false. Although perfusion scanning is extremely sensitive, it cannot distinguish acute infarcts from chronic infarcts
True.
49
technique to detect MI on high resolution cardiac MRI
late enhancement
50
two general classes of complications for STEMI
electrical complications (arrhythmias) and mechanical complications (pump failure)
51
most common cause of death in the first 24 hr of STEMI
ventricular fibrillation
52
greatest cause of delay for the treatment of STEMI
onset of pain and patient's decision to call for help
53
criteria for AMI
detection of a rise and or fall of cardiac biomarker values, symptoms of ischemia, new ST wave changes of new LBBB, development of pathologic Q waves on ECG, imaging evidence of new loss of viable myocardium, or new regional wall motion abnormality, identification of intracoronary thrombus by angiography or autopsy
54
AMI in PCI
cTn 5x in patients with normal baseline or rise of cTn values 20% from baseline if elevated
55
AMI in CABG
cTn 10x in patient with normal baseline
56
Criteria for prior myocardial infarction
any one of the ff. 1. pathologic Q waves with or without symptoms in the absence of nonischemic causes 2. imaging evidence of a region of loss of viable myocardium that is thinned and fails to contract, in the absence of nonischemic cause, 3. pathologic findings of a prior MI
57
goal of initiating PCI
Within 120 mins of first medical contact
58
Classification of Myocardial infarction. Spontaneous
Type 1
59
Classification of Myocardial infarction. Secondary to an ischemic imbalance
Type 2
60
Classification of Myocardial infarction. Resulting in death when biomarker values are unavailable
Type 3
61
Classification of Myocardial infarction. Related to PCI
Type 4a
62
Classification of Myocardial infarction. Related to stent thrombosis
Type 4b
63
Classification of Myocardial infarction. Related to CABG
Type 5
64
when hypoxemia is present how to give oxygen supplementation
oxygen nasal prong or face mask 2-4 L/min for the first 6-12 h after infarction
65
in addition to diminishing or abolishing chest discomfort, it also capable to decreasing myocardial oxygen demand and increasing myocardial oxygen supply
nitroglycerin
66
how to reverse hypotension from ingestion of nitrates and PDE5 inhibitor
atropine
67
very effective analgesic for pain associated with STEMI
morphine
68
when is nitrates avoided
SBP less than 90 mmHg and in whom there is clinical suspicion of RV infarction
69
True or false. Morphine also has a vagotonic effect and may cause bradycardia or advanced degrees of heart block esp in patients with inferior infarction
True.
70
conditions prior to giving metoprolol IV
HR more than 60 bpm, SBP more than 90 mmHg, PR interval less than 0.24 s
71
how to give metoprolol IV
5 mg every 2-5 mins for a total of 3 doses
72
how to transition to metoprolol oral
50 mg every 6h for 48 hr then 100 mg every 12 hr
73
contraindication to oral beta blocker therapy
1. signs of heart failure 2. low output state 3. increased risk of heart failure 4. PR more than 0.24 s, 2nd or 3rd degree heart block, active asthma or reactive airway disease
74
True or false. Unlike beta blockers, calcium antagonist are of little value in the acute setting
True.
75
ECG of STEMI
2 mm in two contiguous precordial leads and 1 mm in adjacent limb leads
76
true or false. In the absence of ST segment elevation, fibrinolysis is not helpful and evidence even suggesting that it may be harmful
True
77
why are glucocorticoids and NSAIDs avoided in patients with STEMI
they can impair infarct healing and increase risk of myocardial rupture
78
When is PCI generally preferred over fibrinolysis
diagnosis is in doubt, cardiogenic shock is present, bleeding risk is increased, symptoms have been present for at least 2-3 hr
79
why is PCI done when the symptoms has already been present for 2-3 hrs
clot is mature and less easily to be lysed by fibrinolytic drugs
80
when should fibrinolysis ideally be initiated
Within 30 mins of presentation
81
what is the principal goal of fibrinolysis
prompt restoration of full coronary arterial patency
82
fibrinolytic agents approved by US FDA
tpa, streptokinase, tenecteplase and reteplase
83
what is the mechanism of action of these fibrinolytic agents
promote the conversion of plasminogen to plasmin which subsequently lyses fibrin thrombi
84
Meaning of TIMI score 0
complete occulusion of the infarct related artery
85
Meaning of TIMI score 1
some penetration of the contrast media beyond point of obstruction
86
Meaning of TIMI score 2
perfusion of the infarct vessel into the distal bed but flow is delayed compared to that of normal
87
Meaning of TIMI score 3
full perfusion of the infarct vessel with normal flow
88
What is the TIMI goal of reperfusion therapy
TIMI 3
89
more effective than streptokinase at restoring full perfusion
tpa, rpa, TNK
90
how to give tpa
15 mg bolus followed by 50 mg IV over the first 30 mins then 35 mg over the next 60 mins
91
how to give streptokinase
1.5 MU IV over 1 hr
92
how to give rPa
10 MU bolus over 2-3 mins then 10 MU bolus 30 mins after
93
how to give TNK
0,53 mg/kg over 10 s
94
contraindication to use of fibrinolytic agents
history of crebrovascular hemorrhage at any time, nonhemorrhage stroke or cerebrovascular event within the past year, BP more than 180/110 mmHg, suspicion of aortic dissection and active internal bleeding
95
relative contraindication of fibrinolytic agents
INR more than 2, less than 2 weeks invasive or surgical procedure, more than 10 mins cardiopulmonary resuscitation, known bleeding diasthesis, pregnancy, hemorrhage ophthalmic condition, active peptic ulcer disease, severe hypertension that is currently under adequate control
96
because of risk of an allergic reaction, patients should not receive streptokinase if the agent had been received within the preceding
5 days to 2 years
97
most frequent and potentially most serious complication of fibrinolytic agents
hemorrhage
98
cardiac catheterization and coronary angiography should be carried out after fibrinolytic therapy if there is
1. failure of reperfusion (persistent chest pain and ST segment elevation more than 90 mins) 2. coronary artery re occlusion ( re elevation of ST segments or recurrent chest pain)
99
True or false. Patient who have confirmed STEMI but low risk (no persistent chest pain, no CHF, no hypotension or no cardiac arrhythmias) may be transferred out to coronary care unit within 24 hours
True.
100
STEMI patient should be kept on bed rest for how long
First 6-12 hrs
101
what is the activity of STEMI patient within the first 24 hrs
upright position and dangle legs over side of the bed, then sitting in a chair
102
when can STEMI patient start ambulating in room
by the second or third day
103
after day 3, what is the goal distance of ambulating in STEMI patients
185 ms (600 ft) at least 3x a day
104
what is the diet of STEMI patient
NPO or clear liquids only in the first 4-12 hrs
105
what is the calorie for fat and cholesterol in STEMI patient
less than 30% of calories as fat and cholesterol less than 300 mg/day
106
what is the proportion of carbohydrates in STEMI patients
50-55% of total calories
107
what the choice and dose of sedation in STEMI patient
Diazepam 5 mg or oxazepam 15-30 mg or lorazepam 0.5- 2 mg given three to four times a day
108
what is the goal of anticoagulation therapy
maintain patency of the infarct related artery in conjunction with reperfusion strategy and to reduce tendency to thrombosis
109
how is UFH administered in STEMI
initial bolus of 60 U/kg then 12 U/kg per hour
110
what is the goal APTT during the maintenance therapy of UFH
1.5 – 2 times the control value
111
Individuals who are for prolonged therapy with anticoagulatnts
anterior location of infarct, severe LV dysfunction, heart failure, history of embolism, mural thrombbus, atrial fibrillation
112
how long should individuals with increased risk of systemic or pulmonary thromboembolism receive anticoagulant
full therapeutic levels of LWH or UFH then 3 months of warfarin
113
what is the mechanism of ACEI leading to reduced mortality in STEMI
reduction in ventricular remodeling after infarction
114
how long should ACEI be given
indefinitely
115
contraindication to ARBs in STEMI patients
creatinine more than 2.5 in male and more than 2.0 in female or hyperkalemia of more than 5.0 meq/L
116
how long can a patient be on intravenous nitroglycerin
24-48 hrs
117
refers to the series of changes in shape, size and thickness in both the infarcted and noninfarcted segments in the left ventricle
ventricular remodelling
118
medications to the prescribed in patients with ejection fraction of less than 40% regardless of whether or not heart failure is present
ACEI or ARB
119
primary cause of in hospital death from STEMI
pump failure
120
most common clinical signs of pump failure
S3 and S4 gallop sounds and pulmonary rales
121
Killip I
no signs of pulmonary or venous congestion
122
Killip II
moderate heart failure as evidence by rales at the lung bases, S3 gallop, tachypnea, signs of failure of the right side of the heart,
123
Killip III
severe heart failure and pulmonary edema
124
Killip IV
shock with systolic pressure less than 90 mmHg
125
Mortality rate. Killip I
0-5%
126
Mortality rate Killip II
10-15%
127
Mortality rate Killip III
35-45%
128
Mortality rate Killip IV
85-95%
129
infarction of how much of the left ventricle leads to cardiogenic shock
more than 40%
130
patients who may benefit from diuresis based on LV filling pressures
LV filling pressure more than 22 mmHg and normal cardiac indices
131
patients who may benefit from volume expansion based on LV filling pressure
LV filling pressure less than 15 mmHg and reduced cardiac indexes
132
optimal LV filling pressure or pulmonary artery wedge pressure
About 20 mmHg
133
True or false. Benefits of digitalis administration to patients with STEMI are unimpressive
True.
134
True o false. Nitrates in various forms may be used to decrease preload and congestive symptoms
True,
135
True or false. 1/3 of patients with inferior infarction demonstrate at least minor degree of RV necrosis
True
136
ST segment elevation in V4R means
RV infarction
137
hemodynamic pattern on catheterization in RV dysfucnction
steep rigth atrial Y descent, and an early diastolic dip and plateau in RV waveforms
138
True or false. Infrequent sporadic ventricular premature depolarizations occur in almost all patients with STEMI and do not require therapy
True.
139
when is pharmacologic therapy in arrhythmias given
sustained ventricular arrhythmias
140
True or falsse. Prophylactic antiarrhythmic therapy is contraindicated
True.
141
target serum potassium and magnesium in STEMI patient to avoid ventricular fibrillation
serum potassium 4.5 mmol/L and magnesium 2.0 mmol/L
142
how to deal with sustained ventricular tachycardia
Amiodarone 150 mg over 10 mins followed by infusion of 1.0 mg/min for 6 hr and than 0.5 mg/min
143
if ventricular tachycardia does not stop and there is hypotension, what should be done
synchronized cardioversion of 200-300 J
144
what to do if ventricular tachycardia or fibrillation is refractory to electroshock
intracardiac epinephrine 1 mg or 10 ml of 1:10,000 dilution or amiodarone 75-150 mg bolus
145
primary response to acute ischemia that occurs during the first 48 hr
ventricular fibrillation
146
True or false. Patient who develop ventricular fibrillation after the first 48 hrs have increased mortality rate
True.
147
ventricular rhythm with rate of 60-100 beats/min often occurs transiently during fibrinolytic therapy at the time or reperfusion
accelerated idioventricular rhythm
148
True or false. AIVR that occurs in association with fibrinolytic therapy is benign and does not presage the development of classic ventricular tachycardia
True.
149
most common supraventricular arrhythmia
sinus tachycardia
150
if heart failure is absent, alternative to managing supraventricular arrhythmias
beta blockers, verapamil or diltiazem
151
what to do if bradycardia is persistent despite atropine
electrical pacing
152
True or false. Recurrent or persistent ischemia often heralds extension of the orignal infarct or reinfarction
True.
153
how is pericarditis in STEMI managed
Aspirin 650 mg 4x a day
154
most common aneurysm post STEMI
apical aneurysm
155
usual duration of hospitalization of uncomplicated STEMI
3-5 days
156
when can sex be resumed in patients with STEMI
After 2 weeks
157
when can STEMI patients return to work
Within 2-4 weeks
