68. ACS

Question 1

4 classes of stable angina

Answer 1

o 1 – none with physical activity
o 2 – minimal limitation
o 3 – severe limitation of physical activity
o 4 – unable to perform physical activity as angina at rest

Question 2

def unstable angina

Answer 2

• New in onset and with minimal exertion
• Or worsened from a previous stable pattern
• New onset must be of at least class 2

Question 3

def variant (printzmetal) angina

Answer 3

o Coronary vasospasm at rest

o STE that is not possible to differentiate from STEMI

Question 4

Def acute MI

Answer 4

either satisfies the criteria
1. Typical rise and gradual fall of markers and at least one of:
	Ischemic Sx
	ECG changes in TW or ST segment
	Imaging evidence
	Q waves
2. Pathologic findings of AMI

Question 5

5 types of MI

Answer 5

o 1. Spontaneous MI related to primary coronary event
o 2. MI secondary to ischemia caused by increased O2 demand or decreased supply
o 3. Sudden unexpected cardiac death with Sx suggestive of MI and new STE or LBBB
o 4. MI associated with coronary instrumentation, such as after PCI
o 5. MI associated with CABG
 Increase in biomarkers > 5x
 New q waves or LBBB

Question 6

traditional RFs for ACS

Answer 6

o	Male
o	DM
o	HTN
o	DLP
o	Family Hx
o	Early menopause
o	Cocaine

Question 7

non-traditional RFs for ACS

Answer 7

o RA
o Antiphospholipid
o HIV
o SLE

Question 8

list angina equivalents

Answer 8

o	Dyspnea
o	NV
o	Diaphoresis
o	Weak 
o	Dizzy
o	Anxiety

Question 9

9 early complications of MI

Answer 9

Brady and AV block
Tachycardias
Cardiogenic shock
LV free wall rupture
Septal rupture
Pericarditis
Dressler's syndrome
Stroke
Hemorrhagic stroke - if lysed

Question 10

RFs for shock post MI

Answer 10

	Large infarct
	Prior MI
	Low EF
	Older
	DM
	Pressors and ionotrops

Question 11

14 causes of STE on ECG

Answer 11

MI
LV hypertrophy
paced
normal variant
hyperK
PE
printzmetal angina
pericarditis
LV aneurysm
benign early repolarization
osborn wave of hypothermia
brugada
ICH
post cardioversion

Question 12

3 ECG changes in STEMI

Answer 12

o Begins with hyperacute T waves
o J point elevation
o ST elevation

Question 13

4 times ST depression seen in ACS

Answer 13

•	NSTEMI
•	Preceding STEMI
•	In posterior STEMI
•	Reciprocal changes
o	PAILS

Question 14

2 abnormal T waves in ACS

Answer 14

1. wellens

2. De Winter

Question 15

define dewinter T wave

Answer 15

Anterior leads:
ST dep
hyperacute T waves

Question 16

Anatomic locations of leads

Answer 16

Anterior: V1-V4
Lateral: I, AVL, V5-6
Inferior: II, III, AVF
RV: V4R
Posterior: V8-9 elevation
anterior depression

Question 17

perfusion of anterior wall

Answer 17

LAD

Question 18

perfusion of lateral wall

Answer 18

	First diag of LAD
	Often seen combined due to different perfusions
•	LAD
•	RCA
•	L circ

Question 19

perfusion of anterior/lat wall

Answer 19

 L main
 High risk
 ST in aVR has high risk for L main

Question 20

perfusion of high lateral wall

Answer 20

 I and aVL

 L circ

Question 21

perfusion of inferior wall

Answer 21

 RCA in 90%

 L circ in remainder

Question 22

perfusion of post wall

Answer 22

	Assoc with inf and inf/lat STEMIs
	RCA or L circ
	Look at V1-3
•	STD
•	Upright TWAVE
•	Talle wide R wave
•	R wave amplitude

Question 23

ECG for benign early repolarization

Answer 23

	Upward concavity
	Terminal notching
	Symmetric concordant T waves
	Diffuse STE
	Temporal stability
	< 3.5 mm J point elevation
	Should not be in limb leads

Question 24

ECG for LV aneurysm

Answer 24

 Hard to diff from STEMI
 Usually anterior V1-4
 May have q waves

Question 25

Scarbossa criteria

Answer 25

• STE > 1mm that is concordant with QRS
• ST dep > 1mm in V1-3
• STE > 5mm that is discordant
• Weight of 5,3,2 – need at least 3 points

Question 26

use of CXR in ACS

Answer 26

Look for CHF
o Evidence in 1/3 of AMI patients
o Heart size from determining chronicity

Question 27

4 other cardiac causes of trop rise than ACS

Answer 27

 Myocarditis
 Pericard
 CHF
 Trauma

Question 28

4 non-cardiac causes of trop rise

Answer 28

 PE
 Sepsis
 Renal insuff
 Extreme exertion

Question 29

9 false positives for exercise stress test

Answer 29

o	Aortic stenosis
o	Cardiomyopathy
o	Hemoglobinopathies
o	Low output states
o	Dig toxicity
o	PVH
o	Mitral valve prolapse
o	BBB

Question 30

4 Ds of delays to cath lab

Answer 30

Door – events before arrival
Data – ECG
Decisions – STEMI Dx
Drug – PCI vs lysis

Question 31

ideal time to PCI

Answer 31

ideal: 30
max: 90

Question 32

use of O2 in ACS

Answer 32

• Only for sats <95

Question 33

3 contraindications to nitro

Answer 33

o Brady
o Inferior wall stemi
o RV stemi

Question 34

when to start BB

Answer 34

• Early BB have higher rates of death

- Should within first 24 hours of management

Question 35

when to start ACEi

Answer 35

within 24 hours

Question 36

best anti-platelet

Answer 36

ASA

Question 37

mech of ASA

Answer 37

o Irreversible COX binding
o Stops thromboxane production
o Independent reduction in mortality

Question 38

2 main PSY inhibs

Answer 38

Plavix the tradition med
 Improved safety profile with thrombolytics
Ticagrelor
 Better outcomes that Plavix
 More expensive
Should receive loading dose of Plavix or ticagrelor with ASA
o If think CABG needed, hold for 24 hours

Question 39

type of antithrombin

Answer 39

o UFH
 60U/kg bolus
o Prefer UFH over LMWH for STEMI patients

Question 40

Contraindications to heparin

Answer 40

Allergy

ongoing hemorrhage

Question 41

eligibility for lysis

Answer 41

1. STEMI or equivalent within 12 hours
2. No PCI available
3. No contraindications

Question 42

contraindications to lysis

Answer 42

• BP > 200/120
• Retinopathic hemorrhage
• Bleeds
• > 10 minutes CPR
• Recent trauma or surgery