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ACS Clinical Features Flashcards

1
Q

Why is diagnosing ACS in the prehospital setting difficult?

A

Chest pain is a poor predictor of the diagnosis of AMI and adjunctive diagnostic tools are limited.

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2
Q

What is the specificity percentage of a prehospital 12-lead ECG for STEMI in patients with atraumatic chest pain?

A

99%

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3
Q

What is the positive predictive value percentage of a prehospital 12-lead ECG for STEMI?

A

93%

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4
Q

How much additional time does a prehospital ECG increase paramedic scene time?

A

1 to 3 minutes

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5
Q

What advantages does the EMS diagnosis of STEMI via prehospital ECG offer? List them.

A
  • Earlier detection of STEMI
  • Ability to select patient destination based on PCI availability
  • Hospital-based preparation prior to patient arrival
  • More rapid initiation of hospital-based reperfusion therapy
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6
Q

What factors should be considered in the history evaluation of chest discomfort in the emergency department?

A

Character, onset, location, duration, and associated symptoms

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7
Q

What does the term ‘angina’ refer to?

A

A tightening sensation, not pain.

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8
Q

How can angina pectoris be described?

A

Discomfort with squeezing, pressure, tightness, fullness, heaviness, or burning sensation.

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9
Q

Where is angina pectoris typically located?

A

Substernal or precordial

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10
Q

Which areas can the discomfort of angina pectoris radiate to?

A
  • Neck
  • Jaw
  • Shoulders
  • Either arm
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11
Q

What symptoms are characteristically associated with angina pectoris? List them.

A
  • Dyspnea
  • Nausea
  • Vomiting
  • Diaphoresis
  • Weakness
  • Dizziness
  • Excessive fatigue
  • Anxiety
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12
Q

What are anginal equivalent symptoms?

A

Symptoms that arise without chest discomfort in a presenting pattern of known ischemic coronary disease.

Most commom -Dyspnea

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13
Q

What might indicate a consideration of ACS if the heartburn is different from the patient’s usual gastroesophageal reflux?

A

Lack of reproducible pain on abdominal palpation

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14
Q

What is a nontraditional presentation of ACS?

A

Atypical features of pain or presence of anginal equivalent symptoms

Examples include dyspnea and pain that is pleuritic, positional, or reproduced by palpation.

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15
Q

What percentage of ED patients diagnosed with AMI did not have chest pain on presentation?

A

One-third

This highlights the variability in symptoms associated with AMI.

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16
Q

What are some risk factors for presentations of ACS without classic anginal pain?

A
  • Diabetes mellitus
  • Older age
  • Female sex
  • Nonwhite ethnicity
  • Dementia
  • No prior history of MI or hypercholesterolemia
  • No family history of coronary disease
  • Previous history of CHF or stroke
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17
Q

In patients under 85 years old, what is the common symptom found in most AMI cases?

A

Chest pain

Although dyspnea, stroke, weakness, and altered mental status are also present.

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18
Q

What symptoms are more common than chest pain in patients older than 85 years?

A

Anginal equivalent complaints, especially dyspnea

60% to 70% of patients older than 85 years experience this.

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19
Q

How does diabetes mellitus affect the risk of ACS presentations?

A

Patients with diabetes are at heightened risk for ACS and may present with anginal equivalents

Medically unrecognized AMI occurs in 40% of patients with diabetes.

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20
Q

What percentage of women report typical chest discomfort at the time of their AMI?

A

Fewer than 60%

Women often report dyspnea, indigestion, or vague symptoms instead.

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21
Q

What disparities exist in the treatment approaches for ACS related to race and ethnicity?

A

Nonwhite populations may have underrecognized symptoms in ACS

This can lead to worse outcomes due to delayed diagnosis and treatment.

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22
Q

What is the in-hospital mortality risk for patients with AMI without chest pain?

A

Two- to three-fold increased compared to patients with chest pain

They are also more likely to experience stroke, hypotension, or heart failure requiring intervention.

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23
Q

What is the hospitalization death risk for patients 65 years or younger with NSTEMI?

A

1%

This risk increases to 10% for patients aged 85 years and older.

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24
Q

What are traditional risk factors for CAD?

A
  • Age
  • Tobacco smoking
  • Hypertension
  • Diabetes mellitus
  • Hyperlipidemia
  • Family history of AMI at an early age
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25
What additional risk factors should be considered for CAD?
* Markedly elevated body mass index * Artificial or early menopause * Cocaine (or other sympathomimetic agent) use
26
How does the presence of individual risk factors affect the diagnosis of ACS in the ED?
They have a limited impact; history of presenting illness is more critical ## Footnote The presence of risk factors does not dictate evaluation strategy.
27
What are some less-common risk factors for CAD?
* Antiphospholipid syndrome * Rheumatoid arthritis * HIV * Systemic lupus erythematosus (SLE)
28
How much more likely are women with SLE aged 35 to 44 to have an MI compared to a similar population?
More than 50 times more likely ## Footnote This illustrates the significant impact of SLE on cardiovascular risk.
29
Key Entities in the Differential Diagnosis of Chest Pain
Acute myocardial infarction Aortic dissection Angina-Unstable angina,Stable angina, Prinzmetal angina Boerhaave syndrome Cholecystitis or biliary colic Esophageal spasm Gastroesophageal reflux Gastritis or esophagitis or PUD Herpes zoster Pericarditis Mallory-Weiss syndrome Myocardial or pulmonary contusion Pancreatitis Pleurisy Pneumonia Pneumothorax Pulmonary embolism Pulmonary hypertension
30
What is the focus of the physical examination in ACS patients?
The focus is on cardiac, pulmonary, abdominal, and neurologic examinations, looking for complications of ACS and alternative diagnoses for chest pain.
31
What are frequent findings in patients with severe forms of UA and AMI?
Pale appearance, anxiety, and diaphoresis.
32
What are common manifestations of ACS complications in AMI patients?
Bradycardia, tachycardia, hypotension, and pulmonary edema.
33
What percentage of patients diagnosed with AMI exhibit reproducible chest wall tenderness?
Up to 15%.
34
True or False: Patients with pleuritic, positional, or reproducible chest pain are at no risk for ACS.
False.
35
What are the types of dysrhythmias that can occur in AMI patients?
Bradycardias and tachycardias.
36
What is the estimated occurrence of primary ventricular fibrillation in AMI patients?
4% to 5%.
37
What defines cardiogenic shock?
End-organ hypoperfusion resulting from decreased cardiac output unresponsive to restoration of adequate preload.
38
What are the risk factors for cardiogenic shock?
* Large infarctions * Prior MI * Low ejection fraction (<35%) * Older age * Diabetes mellitus
39
List some therapeutic measures for cardiogenic shock.
* Vasopressor support * Inotropic support * Mechanical circulatory support * Early revascularization
40
What mechanical complications can occur post-AMI?
* Left ventricular free wall rupture * Interventricular septum rupture * Papillary muscle rupture
41
When does left ventricular free wall rupture most commonly occur?
One-third of cases occur in the first 24 hours, and the remainder occur 3 to 5 days after large MIs.
42
What are the clinical presentations of left ventricular free wall rupture?
* Sudden death * Pulseless electrical activity * Hemodynamic deterioration
43
How can the diagnosis of interventricular septum rupture or papillary muscle rupture be confirmed?
Echocardiography with color flow Doppler imaging.
44
What is infarct-related pericarditis?
Pericarditis that occurs early after an MI, associated with transmural insult.
45
What are the clinical features of Dressler syndrome?
* Fever * Malaise * Pleuro-pericardial pain * Presence of a rub on auscultation
46
What is the rate of stroke in the setting of MI compared to non-MI patients?
Approximately 1.0% in MI patients vs. 0.01% in non-MI patients.
47
What is the risk of hemorrhagic stroke in patients undergoing fibrinolytic therapy?
Less than 1%.
48
What complications can arise from ACS therapy?
Hemorrhage as a major complicating issue.
49
What are common procedural complications related to percutaneous interventions?
Arterial injury with hemorrhage, typically a pseudoaneurysm of the femoral artery.
50
What physical examination findings suggest a pseudoaneurysm of the femoral artery?
* Pain * Swelling * Ecchymosis in the thigh
51
What diagnostic imaging can confirm a pseudoaneurysm of the femoral artery?
Ultrasonography or CT of the thigh and retroperitoneal area.
52
What is the differential diagnosis of ACS?
Includes both life-threatening and benign conditions such as: * Pulmonary embolism * Aortic dissection * Aortic aneurysm with perforation * Pneumothorax * Esophageal perforation * Myopericarditis * Myocarditis * Pneumonia * Costochondritis * Musculoskeletal chest pain * Herpes zoster infection * Various gastrointestinal maladies ## Footnote Significant morbidity can occur with non-life-threatening causes.
53
What role does the 12-lead ECG play in evaluating patients with chest discomfort?
Assists in: * Establishing diagnosis * Determining candidacy for therapies * Performing risk assessment ## Footnote In the setting of STEMI, the ECG is diagnostic.
54
What are the ECG findings consistent with STEMI according to the Fourth Universal Definition of Myocardial Infarction?
New ST elevation of greater than 1 mm in at least two contiguous leads, with specific cut-offs for leads V2 and V3: * 1.5 mm or greater in females of any age * 2.5 mm or greater in males < 40 years * 2 mm or greater in males > 40 years ## Footnote These findings establish candidacy for emergent reperfusion therapy.
55
What electrocardiographic findings may indicate increased cardiovascular risk?
Findings include: * Total ST segment deviation * LBBB * Left ventricular hypertrophy (LVH) * QT interval prolongation ## Footnote These findings may influence risk assessment in ACS.
56
What can the ECG suggest regarding alternative diagnoses in ACS?
Can suggest: * Pulmonary embolism (PE) * Acute myopericarditis ## Footnote ECG analysis is essential for determining possible alternative conditions.
57
What morphologic changes may occur in the ECG during ACS?
Changes may occur in: * T wave * ST segment * QRS complex * PR segment ## Footnote The current clinical use of PR segment abnormalities remains uncertain.
58
What limitations exist for the diagnostic abilities of the ECG?
Limitations include: * Individual variations in coronary anatomy * Preexisting coronary disease (e.g., previous MI) * Poor view of posterior, lateral, and apical left ventricular walls * Potential for normal or nonspecifically abnormal ECG in early ACS ## Footnote A single ECG is neither 100% sensitive nor specific for AMI.
59
True or False: A normal ECG in an asymptomatic patient with a history of intermittent anginal chest pain is always reliable.
False ## Footnote It can be misleading and should not be overemphasized.
60
What is the negative predictive value of a normal ECG after symptom onset?
High but not 100%, even up to 12 hours after onset of chest symptoms. ## Footnote The patient's reported history remains the most important diagnostic study.
61
Fill in the blank: The patient's reported history and the _______ of that history by the emergency clinician is the most important diagnostic study.
interpretation ## Footnote This context is crucial for accurate ECG interpretation.

Chest pain (3 decks)

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