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

68. ACS Flashcards by Seth Davis

4 classes of stable angina

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

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def unstable angina

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

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def variant (printzmetal) angina

o Coronary vasospasm at rest

o STE that is not possible to differentiate from STEMI

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Def acute MI

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

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5 types of MI

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

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traditional RFs for ACS

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

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non-traditional RFs for ACS

o RA
o Antiphospholipid
o HIV
o SLE

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list angina equivalents

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

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9 early complications of MI

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

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RFs for shock post MI

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

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14 causes of STE on ECG

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

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3 ECG changes in STEMI

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

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4 times ST depression seen in ACS

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

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2 abnormal T waves in ACS

wellens

2. De Winter

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define dewinter T wave

Anterior leads:
ST dep
hyperacute T waves

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Anatomic locations of leads

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

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perfusion of anterior wall

LAD

perfusion of lateral wall

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

perfusion of anterior/lat wall

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

perfusion of high lateral wall

 I and aVL

 L circ

perfusion of inferior wall

 RCA in 90%

 L circ in remainder

perfusion of post wall

	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

ECG for benign early repolarization

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

ECG for LV aneurysm

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

Scarbossa criteria

* 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

use of CXR in ACS

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

4 other cardiac causes of trop rise than ACS

 Myocarditis  Pericard  CHF  Trauma

4 non-cardiac causes of trop rise

 PE  Sepsis  Renal insuff  Extreme exertion

9 false positives for exercise stress test

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

4 Ds of delays to cath lab

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

ideal time to PCI

ideal: 30 max: 90

use of O2 in ACS

- Only for sats <95

3 contraindications to nitro

o Brady o Inferior wall stemi o RV stemi

when to start BB

- Early BB have higher rates of death | - Should within first 24 hours of management

when to start ACEi

within 24 hours

best anti-platelet

ASA

mech of ASA

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

2 main PSY inhibs

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

type of antithrombin

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

Contraindications to heparin

Allergy | ongoing hemorrhage

eligibility for lysis

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

contraindications to lysis

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