ACS Rogers Part 1 and 2

Question 1

which is not considered an acute coronary syndrome? SELECT ALL THAT APPLY

a. silent ischemia
b. unstable angina
c. NSTEMI
d. STEMI
e. SIHD

Answer 1

a. silent ischemia
e. SIHD (stable ischemic heart disease)

Question 2

what would we see on an ECG for a STEMI?

Answer 2

persistent ST elevation

Question 3

on an ECG for a STEMI, what causes the “electrical hole” from the P wave to the Q wave?

Answer 3

caused by scar tissue that cannot conduct electricity

Question 4

what molecule is released from necrotic myocytes (injured heart cells) when the heart is under damage?

Answer 4

troponin

Question 5

units for high sensitivity troponin

a. ng/mL
b. ng/L

Answer 5

b. ng/L

Question 6

units for conventional troponin

a. ng/mL
b. ng/L

Answer 6

a. ng/mL

Question 7

gold standard test for myocardial injury

Answer 7

troponin test

Question 8

normal value for high sensitivity troponin is < ___ ng/L

Answer 8

< 14 ng/L

Question 9

normal value for conventional troponin is < ___ ng/mL

Answer 9

< 0.05 ng/mL

Question 10

true or false: unstable angina would have an elevated troponin level

Answer 10

false

Question 11

true or false: an NSTEMI would lead to an elevated troponin level

Answer 11

true

Question 12

main difference between stable and unstable angina

Answer 12

stable angina has chest pain during exertion and lasts a short time, unstable angina has chest pain that occurs at rest or with very little exertion (last longer)

Question 13

true or false: a STEMI would lead to an elevated troponin level

Answer 13

true

Question 14

A 68 year old female calls 9-1-1 twenty minutes after sudden onset of severe, substernal, radiating chest pain. Over the past several days she has been experiencing chest discomfort with exertion and dyspnea. Troponin is 3.2ng/mL and ECG shows no ST elevation or Q wave changes. Which of the following is correct?

a. Signs and symptoms are consistent with stable angina
b. Signs and symptoms are consistent with unstable angina
c. Signs and symptoms are consistent with NSTEMI
d. Signs and symptoms are consistent with STEMI

Answer 14

c. Signs and symptoms are consistent with NSTEMI

Question 15

what is a TIMI risk score?

Answer 15

thrombolyis in myocardial infarction (TIMI) score: the risk of experiencing death, MI, or urgent need for revascularization within 14 days

Question 16

what is it called when there is change in size, shape, and function of the left ventricle after an ACS?

Answer 16

ventricular remodeling

(this can lead to heart failure; preventing this is an important therapeutic goal)

Question 17

get an ECG within _____ minutes of arrival at an emergency facility; if the initial ECG is not diagnostic but the pt remains symptomatic, we should perform serial ECGs every _____-_____ minutes for the first hour

Answer 17

10; 15-30

Question 18

troponin levels should be obtained at presentation and ___-___ hours after symptom onset

Answer 18

3-6

Question 19

What does MONA stand for? What are the roles of all the components?

Answer 19

morphine -> relieves chest pain
oxygen -> maintains O2 saturation > 90%
NTG -> inc blood flow to heart
aspirin -> thins blood and prevents clots

Question 20

what is the dose for morphine in MONA?

Answer 20

4-8 mg IV, followed by 2-8 mg IV q5-15 mins

Question 21

why do we avoid NSAIDs (except aspirin) during hospitalization for UA/NSTEMI/STEMI?

Answer 21

they lead to sodium and water retention = inc risk of MACE

Question 22

what is the dose for NTG in MONA? (for sublingual and IV)

Answer 22

-sublingual NTG: 0.3-0.4 mg q5 min x 3 for ischemic pain
-IV NTG: start at 10 mcg/min and titrate by 5 mcg/min q5 min (MAX: 200 mcg/min)

Question 23

can we use transdermal NTG when hospitalized for UA/NSTEMI/STEMI?

Answer 23

no, the onset of action is not rapid enough (15-60 min)

Question 24

what is the dose range for aspirin in MONA?

Answer 24

162-325 mg chewable aspirin x 1 dose

(we normally just see 325 mg)

Question 25

can we use enteric coated aspirin in MONA?

Answer 25

yes, it must be chewed in order to be absorbed quickly

Question 26

if a pt is hospitalized for UA/NSTEMI/STEMI and already took a baby aspirin in the morning, would you still give a loading dose (325 mg)?

Answer 26

yes, give an additional 3 tablets to get 324 mg total for loading dose

Question 27

3 reperfusion strategies

Answer 27

PCI; CABG; fibrinolytic therapy

Question 28

a "heart cath" is also known as ?

Answer 28

coronary angiography

Question 29

for STEMI, reperfusion therapy should be administered to all eligible STEMI pts whose symptoms began in the past _____ hours

Answer 29

12

Question 30

door-to-needle time for reperfusion therapy for STEMI

Answer 30

within 30 min of hospital arrival

Question 31

door-to-balloon time for reperfusion therapy for STEMI

Answer 31

within 90 min of hospital arrival

Question 32

__________ therapy is recommended for STEMI pts at non-PCI-capable hospitals

Answer 32

fibrinolytic

Question 33

if we are over _____ min away from a PCI-capable hospital, we can start fibrinolytic therapy at a non-PCI-capable hospital

Answer 33

120 min

Question 34

tenecteplase dosing: < 60 kg: ___ mg 60-69 kg: ___ mg 70-79 kg: ___ mg 80-89 kg: ___ mg 90+ kg: ___ mg

Answer 34

30 mg 35 mg 40 mg 45 mg 50 mg

Question 35

reteplase dosing

Answer 35

10 units x 2 doses 30 min apart

Question 36

A 63 YOM presents to your ED complaining of chest pain that began 1 hour ago. He is found to be having a STEMI. Your hospital is not able to perform a PCI. He does not have any contraindications to fibrinolytics and weighs 50 kg. Which of the following recommendations would you make? SELECT ALL THAT APPLY a. give a fibrinolytic within 30 min b. give a fibrinolytic within 90 min c. transfer the pt to a PCI-capable hospital d. no intervention at this time, as it is too late to give a fibrinolytic

Answer 36

a. give a fibrinolytic within 30 min c. transfer the pt to a PCI-capable hospital (a is best option if the closest PCI-capable hospital is 120 minutes away or more; c is best option if the hospital is less than 120 minutes away)

Question 37

what drug class is not recommended for NSTEMI/UA?

Answer 37

fibrinolytics