ACS defintions, PCI

Question 1

signs and symptoms of ACS

chest pain and discomfort

Answer 1

Chest pain or discomfort
◦ Central or substernal, upper abdominal or
epigastric discomfort
◦ Pain radiating to the neck, jaw, shoulders, back,
one or both arms
◦ Sensation of pressure, crushing, tightness,
heaviness, cramping, burning, aching
◦ Accompanying dyspnea, indigestion, nausea,
vomiting, diaphoresis
◦ Associated hypotension or ventricular arrhythmias

Question 2

signs and symptoms of ACS

other sx (5)

Answer 2

◦ Isolated dyspnea
◦ Weakness
◦ Diaphoresis
◦ Light-headedness and/or syncope
◦ Nausea
The elderly, women and patients with DM may present with symptoms that are not typical of myocardial ischemia

Question 3

diagnosis of MI

Answer 3

At least one positive troponin PLUS one of the following:
◦ Symptoms or history
◦ ECG
◦ Imaging evidence of new loss of viable myocardium

Troponin
◦ Highly sensitive and specific test
◦ Not specific to plaque rupture

Question 4

ACS defintion

MI defn

Answer 4

ACS – any constellation of clinical symptoms
that are compatible with acute myocardial
ischemia
range of conditions associated with sudden, reduced blood flow to the heart.

Myocardial Infarction – any amount of
myocardial necrosis caused by ischemia

Question 5

NSTEMI

STEMI defn

Answer 5

NSTEMI – partial occlusion of infarct related artery resulting in necrosis
STEMI – total occlusion of infarct related artery resulting in necrosis

Question 6

what might you see in biomarker if ST-segment elevation is absent (slide 9)

Answer 6

ST-segment elevation is absent is due to partially occluding thrombus

no increase in biomarker lvl = unstable angina (thrombosis mediated)

increased biomarker lvl = Non-stemi

Question 7

what might you see in biomarker if ST-segment elevation is present (slide 9)

Answer 7

ST-segment elevation is present due to fullyoccluding thrombus

increased biomarker lvl = stemi

Question 8

STEMI, NSTEMI, UA hospital discharge status

Answer 8

death 7% for STEMI (highest)

87% home for UA, 77% for STEMI, 78% NSTEMI

at 6 mo fu, death, stroke, rehospitalization is similar

Question 9

describe the path from CV risk factors to death

Answer 9

CV risk factors - coronary atherosclerosis - ASx or Sx CHD - plaque rupture and coronary thrombosis

leads to ACS (MI, UA) which leads to death or arrhythmias

ACS can lead to ventricular dysfxna nd remodelling leading to congestive HF and ESHD

Question 10

phases of care - STEMI (3)

Answer 10

prehospital: id, intiial tx
hospital: • Diagnosis • Treatment • +/- Revascularization
community: med management

Question 11

goals for sTEMI and which phases of care they belong to

Answer 11

Rapid reperfusion to limit infarct size and
reduce mortality (prehospital)
◦ Prompt identification of STEMI
◦ Initiate reperfusion within recommended timeframe
◦ Maintain arterial patency (prehospital, hospital) being open, expanded, or unobstructed.

Prevent recurrent infarction
Limit adverse ventricular remodeling
Optimize long-term measures to reduce cardiovascular risk

Question 12

factors increasing ambulance for stroke or HA

Answer 12

older age, distance to hospital, low neighbourbood income quintile, females

less likely: young, short distance, high income quintile, males

Question 13

Reperfusion vs Revascularization

Answer 13

Reperfusion
◦ Restoration of blood flow within the infarct related
artery (in the setting of ACS
Infarction is tissue death (necrosis) due to inadequate blood supply to the affected area.

Revascularization
◦ Restoration of the blood flow to the heart when the
coronary arteries are blocked or narrowed by
atherosclerosis

Question 14

reperfusion strategies (2)

Answer 14

Fibrinolysis
◦ prehospital vs. ER administration
(medical contact to treatment time)
◦ adjunctive therapy to maintain arterial patency

Invasive Strategy
◦ access to cardiac catheterization facilities
(medical contact to balloon time)
◦ adjunctive therapy to maintain arterial patency

Question 15

pharmacotherapy for prehospital , hospital

what to se for coronary thrombus
supply-demand mismatch

Answer 15

Coronary thrombus
- ASA for antiplatelet effect
- P2Y12 inhibitor for antiplatelet effect
- Parenteral anticoagulant
Supply-demand mismatch
- Sublingual nitroglycerin for ischemia
- Intravenous nitroglycerin for persistent ischemia, heart failure or hypertension

Question 16

primary PCI in hospital

Answer 16

A procedure advancing a balloon tipped
catheter to an area of coronary narrowing,
inflating the balloon and then removing the
catheter after inflation done to provide initial
reperfusion in the setting of STEMI

Question 17

read on cardiac cath lab

Answer 17

nice to know

Question 18

stents and jargon
DES
BMS

Answer 18

DES = drug eluting stent
- slowly releases a drug to block cell proliferation.
} BMS = bare metal stent

Question 19

stent thrombosis

what is classified as acute vs subacute

Answer 19

Stent thrombosis = thrombotic occlusion of a coronary stent
◦ May result in ACS

Acute
◦ Within 24 hours
◦ Rare complication of procedure / stent deployment

Subacute
◦ Within 4 weeks for BMS
◦ Within ? weeks or months for DES
◦ Largely preventable with antiplatelet therapy

Question 20

bare metal stent

what is recommended?

Answer 20

} Risk of subacute stent thrombosis
} Dual antiplatelet therapy for 1 month
minimum

Question 21

in-stent restenosis (ISR)

Answer 21

} A gradual narrowing of the stent lumen due to neointimal proliferation
◦ Results in angina symptoms
} Principle cause of lack of long-term clinical success
} Not a complication – exaggerated response
to vascular injury
◦ Judged by frequency of subsequent revascularization procedures on target vessels after index procedure (TVR)

accumulation of smooth muscle cells and extra cellular matrix in the intima

Question 22

in-stent restenosis (ISR)

Answer 22

} DES incorporate zotarolimus, everolimus, etc. with a timed release polymer
} Inhibit neointimal hyperplasia with a locally delivered antiproliferative and anti-inflammatory agent
} Delay in re-endothelialization lengthens period of risk for sub-acute stent thrombosis

Question 23

} Risk of ‘late’ or delayed stent thrombosis
} Dual antiplatelet therapy for
at least 3 to 6 months - consensus
} Impact of newer technologies

Answer 23

drug-eluting stent

Question 24

what are predictors of DES thrombosis

Answer 24

advanced age, ACS, diabetes
low ejection fraction, prior brachytherapy, renal failure
long stents, multiple lesions, overlapping stents, small vesels, subolptimal stent results

Question 25

abs contra to fibrinolysis

Answer 25

} Prior intracranial hemorrhage
} History of structural CNS disease
} Ischemic stroke within 6 months
} Suspected aortic dissection
} Active bleeding or bleeding diathesis
} Significant closed head or facial trauma within 3 months
} Major surgery within last 3 weeks
} Internal bleeding within past 30 days

Question 26

relative contra to fibrinolysis

Answer 26

} Hx of chronic, severe, poorly controlled HTN
} SBP>180 or DBP>110 at presentation
} TIA within 6 months
} CPR of duration greater than 10 minutes
} Pregnancy
} Active peptic ulcer disease
} Oral anticoagulant therapy
} Advanced liver disease
} Infective endocarditis

Question 27

PCI can be performed in which settings?

Answer 27

the setting of ACS
◦ Primary PCI for STEMI
◦ Rescue PCI within 12 hours for failure of fibrinolytic
◦ Urgent PCI within 24 hours

OR as an elective procedure for stable angina

Duration of antiplatelet therapy is based upon
◦ the type of stent
◦ Whether or not the procedure is associated with an
acute coronary syndrome