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STEP 2 > ACS + CAD pretest probability 06-29 > Flashcards

ACS + CAD pretest probability 06-29 Flashcards

1
Q

what are atypical anginal symptoms?

A

2 of the 3 characteristics of classic angina

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1
Q

3 classic anginal symptoms?

A

typical location (substernal), quality and duration

provoked by exercise or emotional stress

relieved by rest or nitroglycerin

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2
Q

what are non-anginal symptoms?

A

<2 of the 3 characteristics of classic angina

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3
Q

atypical anginal symptoms in what patients?3

A

elderly, women, diabetics

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4
Q

STEMI on ECG?

A

New ST elevation at the J point in two anatomically contiguous leads using the following diagnostic thresholds:

In leads V2–V3: ≥2.5 mm in men <40 years, ≥2 mm in men ≥40 years, or ≥1.5 mm in women regardless of age

and/or

≥1 mm in the other leads than V2 to V3.

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5
Q

NSTEMI ECG?

A

New or presumed new horizontal or down-sloping ST depression ≥0.05 mV (0.5 mm) in two anatomically contiguous leads

and/or

T wave inversion ≥0.1 mV (1 mm) in two anatomically contiguous leads.

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6
Q

what to do if inferior stemi detected?

A

Record right precordial leads (V3R and V4R) in order to assess for ST-segment elevation (aka right infarction)

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7
Q

what if detected posterior ischemia by prominent R waves and ST depressions in leads V1 and V2?

A

record the posterior leads V7, V8, and V9.

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8
Q

anteroseptal vessel and leads?

A

LAD (proximal) V1-V2

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9
Q

anteroapical vessel and leads?

A

LAD V3-V4

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10
Q

anterolateral vessel and leads?

A

LAD distal, LCX, RCA V5-V6 + I, aVL

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11
Q

lateral vessel and leads?

A

LCX, diagonal (LDA D1 branch)
I, aVL + V5-V6

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12
Q

Inferior vessel and leads?

A

RCA (90 proc.)
LCX 10 proc.

II, III, aVF

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13
Q

posterior vessel and leads?

A

RCA ir LCX
Is pradziu matysis:
ST depression in V1-V3

+ If RCA - depr. I, aVL
+ If LCX - elevated I, aVL
Sitie pokyciai yra prie reciprocal, tik is pradziu jie matosi, o papildomai, tikruosius ST pakilimus matysim uzrase papildomai V7-V9.
Jeigu yra kartu inferior MI, bus II, III, aVF pakilimas.

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14
Q

CAD (not acute). low risk criteria?

A

Asymptomatic all ages
Atypical in women < 50 age

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15
Q

CAD (not acute). Immediate risk criteria?

A

Atypical in men all ages
Atypical in women >= 50 years
Typical in women 30-50 age

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16
Q

CAD (not acute). High risk criteria?

A

Typical in amen age >= 40
typical in women >= 60

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17
Q

Asymptomatic all ages
Atypical in women < 50 age

A

CAD (not acute). low risk criteria

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18
Q

Atypical in men all ages
Atypical in women >= 50 years
Typical in women 30-50 age

A

CAD (not acute). Immediate risk criteria

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19
Q

Typical in amen age >= 40
typical in women >= 60

A

CAD (not acute). High risk criteria

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20
Q

CAD (not acute). low risk. What to do?

A

nothing

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21
Q

CAD (not acute). high risk? what to do?

A

Pharmacological therapy for CAD
(kokia cia ta terapija?)

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22
Q

CAD (not acute). intermediate risk? what to do?

A

First question to answer: if patient is able to EXERCISE?

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23
Q

CAD (not acute). intermediate risk? If patient is NOT able to exercise? (ex due to immobility, previous stroke, respiratory problems eg COPD etc)

A

Pharmacological stress imaging test

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24
Q

Pharmacological stress imaging test. What medications?

A

Adenosine, dipyridamole
Dobutamine echo

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25
Q

Pharmacological stress imaging test with adenosine and dipyridamole. 2 mechanisms?

A

Nonselective adenosine agonist

Dilates coronary arteries without increase in HR or BP

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26
Q

Pharmacological stress imaging test with adenosine and dipyridamole. Best for?

A

LBBB
Pacemaker
patients unable to reach tHR

27
Q

Pharmacological stress imaging test with adenosine and dipyridamole. not suitable for?

A

Reactive airway disease
Patients on dipyridamole or teophylline

28
Q

CAD (not acute). intermediate risk. Patient IS able to exercise. What evaluate then?

A

ECG

29
Q

CAD (not acute). intermediate risk. Patient IS able to exercise. ECG is normal. whats next?

A

Exercise ECG test.
* dar papildomai gali but exercise echo for those who can exercise.

30
Q

Exercise ECG test. mechanism?

A

increase HR and BP

31
Q

Exercise ECG test. Best for?

A

patients able to reach tHR (tHR = 85 proc. of 220 - age)

32
Q

Exercise ECG test. not suitable for?

A

LBBB
Pacemaker
Patients unable to reach tHR

33
Q

CAD (not acute). intermediate risk. Patient IS able to exercise. ECG is abnormal. whats next?

A

Exercise imaging test

34
Q

what is exercise imaging test and how is performed?

A

nuclear stress test.

Nuclear dye is injected while on treadmill. Makes photos of the heart, and compare different stages (before, at peak blabla).

35
Q

Pharmacologic stress test yra isskirta:
Dobutamine echo
and
Vasodilator stress testing i.e. Adenosine and Dipyridamole

A

.

36
Q

Pharmacological stress imaging test. Dobutamine echo. mechanism?2

A

B1 agonist
Incr. HR +/- BP

37
Q

Pharmacological stress imaging test. Dobutamine echo. Suitable for?

A

Reactive airway disease
Patients unable to reach tHR

38
Q

Pharmacological stress imaging test. Dobutamine echo. not suitable if present?

A

Tachyarrhythmias

39
Q

Signs of active ischemia in stress testing? 3

A

Angina, ST changes, decreased BP

40
Q

If intermediate risk and tests are positive, whats next?

A

Coronary angiography

41
Q

Anterolater, what reciprocals?

A

Gali būti II, III, aVF

42
Q

LATERAL reciprocals?

A

II, III, aVF

43
Q

Inferior reciprocals?

A

I, aVL

44
Q

Right ventricular infarction (in 50 proc of inferior MI). Vessel and leads

A

RCA

Uzrasyti desine puse:
V3R, V4R, V5R, V6R

45
Q

Inferior, posterior ir right MI gali buti kartu, nes tos pacios arterijos.
Arba RCA - dazniausiai, arba LCX.

Jeigu inferior, ka pagal gaires daryti?

A

IF detected inferior STEMI in II, III, and aVF: record right precordial leads (V3R and V4R) in order to assess for ST-segment elevation.

46
Q

Jeigu V1-V3 depression - ka daryt pagal gaires?

A

IF detected posterior ischemia by prominent R waves and ST depressions in leads V1 and V2: record the posterior leads V7, V8, and V9.

47
Q

Melhman. Inferior MI –> Artery answer?

A

answer probably will be RCA

48
Q

Melhman. Apex MI –> Artery answer?

A

answer LAD

49
Q

Melhman. lateral MI –> Artery answer?

A

answer LCX

50
Q

Right dominant. What gives rise to PDA?

A

RIGHT dominant system (> 85 proc. cases) implies, that RCA gives rise to PDA

51
Q

Left Right dominant. What gives rise to PDA?

A

LEFT dominant system (~ 10 proc. cases) implies, that LCA -> LCX gives rise to PDA

ANSWER LCX

52
Q

RIGHT MI. What is impaired?

A

RV filling

53
Q

RIGHT MI. What should be avoided?

A

Any drug that decreases preload should be avoided because they
cause abrupt decrease in RV preload and lead to profound hypotension.

54
Q

RIGHT MI. what are the drugs that should be avoided?

A

i. Nitrates (cause venodilation)
ii. Opiates (cause venodilation)
iii. Diuretics (cause volume depletion)

55
Q

RIGHT MI.

Patients who fulfill a certain criteria should be given IV fluids to increase RV preload

Criteria that should be if we want to manage right MI with iv infusion? 4

A

Hypotension

Low or normal JVP (=<3 cm H2O above the sternal angle at 30-45 degrees recumbency)

No pulmonary congestion

No evidence of right heart failure

56
Q

RIGHT MI.
First step –> gave IV infusion. If hypotension persists?

A

c. If hypotension persists despite adequate fluid resuscitation, inotropic agents can be considered

57
Q

RIGHT MI. General management apart infusion and inotropics?

A

Management
a. Dual antiplatelet therapy
b. Anticoagulation
c. PCI

58
Q

In what MI is prominent sinus bradycardia?

A

Inferior MI

59
Q

In inferior MI what is prominent symptom?

A

sinus bradycardia

60
Q

Why inferior MI is assoc. with sinus brady? 2

A

vagal tone predominates in the first 24h after infarction

RCA supplies the SA node (in inferior MI 90 proc. RCA)

61
Q

What supplies SA? 2 vessels

A

RCA 60 proc.
LCX 40 proc.

62
Q

What supplies AV? 2 vessels

A

RCA 90 proc.
LCX 10 proc.

63
Q

What supplies left bundle branch?

A

LAD

64
Q

What supplies right bundle branch?

A

Septal branches of LAD
Often collaterals from RCA/LCX (depending on dominance)

65
Q

Prominent symptom in case RCA is blocked?

A

Mobitz II AV Block (two P waves for every QRS complex)

BECAUSE RCA supplies AV node through AV nodal artery

66
Q

How to differentiate right MI vs PE?

A

Right MI is less likely to cause dyspnea or syncope (as in pulmonary embolism), and more likely to cause
bradycardia or arrhythmia

STEP 2 (9 decks)

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