ACS Flashcards
To call STEMI ST segment elevation should persist more than
20 mts
The normal MI due to plaque rupture we see is Type
1
In TMT ST depression in V1 indicates
Lcx disease-100% specific (but low sensitivity)
CK MB assays to avoid Macrokinase
Mass assays avoid detection of Macrokinase . Usually used is activity assay
If CK MB is > 20% of total CPK Suspect Macrokinase
Chronic skeletal muscle disease like DERMATOMYOSITIS/POLYMYOSITIS CK MB fraction may be as high as 50%
MC side effect of Ticagrelor
Dyspnea- More than 10%
RV is supplied by a single coronary artery and flow in diastole is ____%
50% in Diastole
In LV 90% flow occurs in Diastole
Stage 3 ECG change in Acute pericarditis
Diffuse T inversions :: usually after ST has become isoelectric
Stage 4 :is normal ECG
Stage 2 ECG change in acute pericarditis
Seen in First week
Normalization of ST and PR segments
ST elevation pattern in acute pericarditis
Diffuse ST elevation
ST depression in V1and aVR
PR elevation in aVR
PR depression in other limb leads and left chest leads ( esp V5& 6)
PR& ST change in opposite directions
Treatment of peri infarct pericarditis
Avoid using NSAID for 7-10 days
Then Aspirin 650-1000mg TID for 1-2 weeks
Colchicine may be given..
When to stop anticoagulation in PIP
If effusion more than 1 cm or if effusion increases 3 mm or more may consider stopping anticoagulation
M guard stent is
Stent with a micronet to prevent distal embolisation
In thrombotic lesions
Higher restenosis rates
Dose of tenecteplase in acute MI
30-50 mg over 5 sec
<60kg– 30 mg
>90 kg–50 mg
Stent thrombosis mortality rate
Upto 40%
Clinical and diagnostic picture of acute MI was first described in
1910
LV function doesn’t normalize in……% of patients after coronary reperfusion
30%
Re perfusion injury is responsible for ….% of infarct size
50%
Microvascular obstruction occurs in …..% of patients after PAMI
40%
Precordial Electrography was first described in
1944
Wilson and Rosenbaum
Introduction of enzymes into clinical practice was in
1955
by La Due
…..% of hospital deaths in first 72 hours is due to arrhythmias
70%
Intensive monitoring for AMI was first started in …… to prevent arrhythmic deaths
1962
Benefit of streptokinase in opening coronaries were first documented in
1976 by Chazov
Though streptokinase was used from 1950s the results were inconsistent
With intracoronary STK
First angioplasty was done in
1977 by Gruntzig
Stunned myocardium was first demonstrated in
1980 in dogs
Hibernating myocardium was first described in
1978
due c/c ischemia
In stunned myocardium blood flow is normal but in hibernating it is reduced
Both are viable myocardium
With coronary re perfusion in AMI … of area at risk is saved
50%
The rest will be scar
But strategies to reduce reperfusion will reduce the scar to 25% from the 50%
Factor Leiden V is
Type of Factor V which is inactivated less efficiently by Protein C
Inherited thrombophilias means
Factor V Leiden- most common
ProteinC,S,AT-III def
Prothrombin gene mutation
Total 5 inherited thrombophilias
Arterial thrombosis and inherited thrombophilias relation
Testing is NOT justified as they principally cause only Venous thrombosis
Further review there may be some association
Uptodate
MINOCA
MI with No Obstructive Coronary Atherosclerosis (<50% stenosis)
The 3 main antiphospholipid antibodies are
- aCL-anticardiolipin
- LA- lupus Anticoagulant
- Anti Beta 2 Glycoprotein antibody
aCLAB GP
The concept of microvascular obstruction was first posited in
1980
Canakinumab is
IL 1-beta monoclonal Ab- a cytokine in inflammatory pathway
Used in CANTOS study.Reduced hscrp, cardiac events and Cancer without reducing cholesterol
COMPASS trial is
Rivaroxaban in Stable CAD and PAD along with Aspirin
Studies which showed LDL reduction below 70 in STEMI is useful
IMPROVE-IT , FOURIER
Study suggesting to give Cangrelor in STEMI if P2Y12 inhibitors are not given
CHAMPION
Study suggesting Tica for 36 months in STEMI
PEGASUS-TIMI 54
Study which showed routine use of deferred stenting not useful in STEMI
DANAMI -DEFER
When to switch to potent P2Y12 inhibitors after fibrinolysis
After 48 hrs Expert opinion
ESC 2017
Role of routine revasc of Asymptomatic CAS 70-99% before CABG
Not indicated
The clock for the 90 minute target to treat with PCI in STEMI starts at
The time of ECG diagnosis of STEMI
In ESC DTB has been replaced with
FMC- first medical contact.—
If fibrinolysis is planned for STEMI it should be given within
10 mts.
ESC 2017
Before it was 30 mts in 2012
Deferred Stenting is
Open the Artery and wait for 48 hours to implant stent
In setting of primary PCI. ( Open the vessel with minimum manipulation and wait)
Not recommended.ESC2017
Cut off for administering Oxygen therapy in STEMI
<90%
ESC 2017
Before it was 95%
LBBB And RBBB is given equal consideration for URGENT CAG when Pt is having ischemic symptoms-as per
ESC 2017
MINOCA forms—
14%
Complete revasc recommendations in 2012 and 2017 ESC difference
2012-Not recommended
2017- To be considered at index procedure or before discharge
But CULPRIT-PCI trial which came later in 2017 showed it is not the correct strategy 😃😃🤣🤣😂🤣🤣
hSTroponin levels -limit of detection by Roche diagnostic
Below 5ng/L not detected
99th percentile is 14 ng/L ie 0.014ng/ml in routine Trop units
Study which showed immediate multivessel PCI is not useful in shock
CULPRIT-SHOCK 2017
Came at a time when ESCs new recommendations where for complete revasc!!!🤣🤣
A trial which showed DCB non inferior to DES in Stent restenosis
DARE 2017 Used a paclitaxel coated balloon
Infarct related artery in IWMI with ST elevation in III>II and ST depression in I, aVL
Prox/Mid RCA
Infarct related artery in IWMI with ST elevation inII>III and ST depression in V1-3 (OR )ST elevation in I And aVL
LCx
or
Distal occlusion of a dominant RCA
Absence of ST depression in V1-3 has high negative predictive value for LCx
Infarct related artery in IWMI with ST elevation in V1 and V4R
Prox RCA
ECG findings in LAD occlusion proximal to first septal
complete RBBB, ST elevation in V1>2.5mm, ST elevation in aVR,ST depression in V5
Infarct related artery if Q only in V4-6
LAD distal to S1
IRA if Q in aVL
LAD prox to D1
ST depression inaVL- LAD distal to D1
AWMI with inferior ST depression and ST elevation in aVL
LAD proximal to S1 and D1
If ST depression is absent lesion will be more distal
ST elevation in aVR >or equal to V1 suggests
LMCA occlusion
T wave changes in early STEMI
Tall and Broad based T waves
Wellens syndrome is deeply inverted or biphasic T waves in
V2 /3 suggestive of critical LAD stenosis
May extend from V1-6
Type A - biphasic T
Type B- inverted T( first A then becomes B)
AHA guidelines For thrombolysis in non PCI Hospital
Anticipated FMC to device time if > 2 hours give thrombolysis
Tenecteplase is incompatible with
Dextrose solution
Flush IV lines with Saline if dextrose was used before
STEMI in Hospital mortality change from 1997 to 2016
9.8 to 5.5% in men and 18.3 to 6.9 in females
NSTEMI corresponding rates are 7 to 2% and 11 to 4%
ESC 2017
Studies supporting complete revasc in STEMI
PRAMI and CvLPRIT.
2017
Cut off for Oxygen administration in ACS
<90% saturation. ( it was 95% before ESC 2017)
MINOCA forms ——% of all MI
14%
First LARGE scale randomized Trial of O2 therapy in suspected MI
2017 DETO2X-AMI
Pts with symptoms s/o AMI account for ———% of EMS consultations
10%
ESC 2017
ESC 2017 Guidelines for NSTEMI fast diagnosis
0/1 hour algorithm with Hs Troponin ( still u can miss 0.2-0.4%)
Around 30% will be false positives
Previous was 0/3 hour
Percentage of AMI or ACS missed
2-10%
2005 JAMA
The immediate life threatening causes of chest pain other than MI
Tension PnTx, PE, Dissection
Sensitivity of the initial ECG in diagnosing AMI
20-60%
2005 JAMA
Duration of classical angina pectoris according to classical teaching is
2-10 mts
MI pain vs Aortic Dissection pain
MI pain- Crescendo pattern—ie maximum intensity after several minutes
Dissection- Maximal intensity at onset. Worst pain in life
Pericardial pain is reduced by
Leaning forward
Classical teaching on NTG response in MI and Esophageal disease
CAD- pain relieved in less than 5 mts
Esophageal- Takes more than 10 mts
Likelihood ratio of Stabbing, pleuritic, positional or palpatory chest pain for ACS
0.2-0.3- means less likely.
Radiation to shoulder or arm- Likelihood ratio is 4
If cardiac hs-Troponin changes
20%.
> 20% is likely ACS
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