ACS, STEMI

Question 1

what is an absolute contraindication for FT (fibrinolytic therapy) in STEMI

Answer 1

acute ischemic stroke in the last 3 months. Prior history of intracranial hemorrhage (time unlimited) is another absolute contraindication.

Ok to do fibrinolytic therapy if INR>2.

Question 2

Reciprocal lead changes in STEMI

Answer 2

In a STEMI should see STE elevation and some reciprocal lead ST segment depressions. Anterior MI see inferior wall depression only 70% of time. Can have MI without reciprocal lead changes.

Question 3

where do we not look for reciprocal changes in STEMI

Answer 3

don’t look at AVR or V1 as they will have negative T waves

Question 4

How can we miss an acute MI on EKG?

Answer 4

if the computer doesn’t look at AVL. If there’s STE in inferior leads look to AVL (100% of reciprocal changes here in STEMI) and if there’s a depression or no depression it could still be a stemi. Won’t see reciprocal changes if it’s a left circumflex

Question 5

Management of STEMI

Answer 5

oxygen for arterial sat<90%
nitrates (caution with hypotension, RV infarction and severe aortic stenosis)
anti platelet therapy with ASA + P2Y12 receptor blocker

AC- unfractionated heparin, low molecular weight heparin, or bivalirudin

Beta blockers - should be started within 24 hrs but contraindicated in overt HF
high risk for cardiogenic shock

Prompt reperfusion with PCI
-first ideal medical contact to PCI <90 minutes

Statin therapy - as soon as possible.
bradycardia.

Question 6

how do inferior wall MI present?

Answer 6

they can have cardiogenic shock due to acute right Ventricular myocardial infarction

see hypotension, JVD, clear lung fields

Question 7

EKG in right ventricular MI will show

Answer 7

> 1 mm ST segment elevation in right sided precordial leads V4R to V6R.

Question 8

what should be avoided in right ventricular wall infarction?

Answer 8

appropriate antiplatelet and AC and no nitrates as this can decrease RV preload and cause profound hypotension. LEss preload and so see low cardiac output.

Question 9

Treat hypotension and low cardiac output from RV MI

Answer 9

treat with bolus of IVF

Question 10

what medication to start after hypotension doesn’t resolve with IVF in a RV MI?

Answer 10

start dopamine.

don’t use dobutamine as this can worsen hypotension (decreased peripheral vascular resistance)

Question 11

if pt comes in with NSTEMI and not on a beta blocker what do you do?

Answer 11

start beta blocker it helps decrease size of infarct

remember only hold if he’s bradycardiac or has decompensated HF.