- T wave inversions or tall/symmetric "peaked" T-waves - presence of Q-waves - ST segment depression - ST segment elevations - new LBBB

Acute Coronary Syndrome Flashcards by Gold Xiong

angina

chest discomfort not necessarily in the chest, relieved with rest or nitroglycerin

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relief with nitroglycerin

does not always mean cardiac in origin

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unstable angina

angina that increases with frequency and intensity, lasting longer than 20 min, not necessarily a heart attack

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acute myocardial infarction

presence of positive cardiac enzymes suggestion myocyte death AND presentation of ischemic-type chest pain or changes in EKG

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How many types of myocardial infarction (MI) are there?

5 (type 4 has two sub types)

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Type 1 MI

spontaneous MI due to plaque erosion, rupture, or dissection

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Type 2 MI

secondary to ischemia from increased oxygen demand or decreased supply

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Type 3 MI

sudden, unexpected cardiac death (or cardiac arrest) with symptoms suggestive of MI, accompanied by STEMI, new LBBB, or evidence of a fresh thrombus in coronary artery by angiography or autopsy –> vtach, ACLS

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Type 4 MI

associated with coronary angioplasty or stents
- 4a: MI associated with PCI
- 4b: MI associated with stent thrombus evident by angiography or autopsy

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Type 5 MI

associated with CABG

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Can you have a MI without EKG changes?

Yes, 5-10% of pts having an active MI can have a normal EKG

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EKG findings in MI

T wave inversions or tall/symmetric “peaked” T-waves
presence of Q-waves
ST segment depression
ST segment elevations
new LBBB

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atypical MI

active MI without chest pain; 1/3 - 1/2 of pts present this way; mainly in elderly, diabetics with neuropathy, females

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risk factors for atypical MI

women
non-Caucasian
diabetes
uncontrolled or long-standing HTN
hyperlipidemia
smokers
family h/o CAD

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Physical exam consistent with decreased cardiac output

anxious
diaphoretic
presence of rales
hypotension
presence of an S3
new or worsening mitral regurgitation

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What are the cardiac markers?

myoglobin
CK-MB
troponin

Initial rise of cardiac markers

myoglobin: 1-2 hrs
CK-MB: 3-4 hrs
troponin: 3-6 hrs

Peak levels of cardiac markers

myoglobin: 4-6 hrs
CK-MB: 12-24 hrs
troponin: 12-24 hrs

Duration of cardiac markers

myoglobin: 24 hrs
CK-MB: 2 days
troponin: 7 days

How is troponin cleared in the body?

renally

When to give oxygen? (MONA)

if O2 saturation is < 94%, start O2 at 4L per nasal canula and titrate as needed

What effect does nitroglycerin have on preload and afterload?

decreases which decreases workload

When is reducing the preload bad?

in patients that have R sided MI since they are preload dependent

Which of the P2Y12 inhibitors is reversible?

ticagrelor

In which patients is nitroglycerin recommended?

pts w/ persistent ischemia, heart failure, HTN, or anterior MI

Contraindications to using nitroglycerin

- Hypotension (<90 SBP or >30 decrease from baseline) - Brady or tachy - cardia - Recent use of PDE5 inhibitor (can cause profound hypotension and shock)

If medium or high risk and invasive surgery is indicated, what antiplatelet therapy to give upon presentation?

DAPT

With initial conservative strategy and diagnostic angiography not indicated, what antiplatelet therapy to give?

- aspirin - anticoagulant + clopidogrel or ticagrelor - low risk: continue ASA forever, cont clopidogrel or ticagrelor up to 12 months

With initial conservative strategy and presence of recurring symptoms, what antiplatelet therapy to give?

- ASA - anticoag - Glycoprotein IIb/IIIa Inhibitors (tirofiban or eptifibatide) OR P2Y12 inhibitors (clopidogrel or ticagrelor) - diagnostic angiography * PCI: cont ASA, loading dose of P2Y12, stop anticoag * CABG: cont ASA, stop gp IIb/IIIa 4 hr b4 CABG, cont UFH or stop enoxaparin 12-24 hr or fonda 24 hr B4 CABG and start UFH,

Pros and cons to using beta blockers in ACS

- Pros: mortality benefit, decrease rate of reinfarction and ventricular fibrillation - Cons: increased risk of cardiogenic shock

Risk factors for increased risk of shock of using beta blockers in ACS

- Age > 70 y/o - SBP < 120 - Bradycardia or sinus tachycardia - Increased time since onset of symptoms

When is heparin indicated in ACS?

- High-risk unstable angina (troponin positive) - NSTEMI - PCI - No evidence or concern for aortic dissection (can open up and bleed)

Reperfusion time goal

- Door to balloon (PCI): 90 min - Door to needle (fibrinolysis): 30 min

Thrombolytic mechanism of action

converts plasminogen to the proteolytic enzyme plasmin, which lyses fibrin as well as fibrinogen

What type of MI are thrombolytics indicated?

STEMI

Thrombolytic fail rate

20% of infarcted arteries --> PCI

Half-life of thrombolytics

- Alteplase: 3-6 min - Reteplase: 13-16 min - Tenecteplase: 22 min

Absolute contraindications to thrombolytics

- Prior intracranial bleeding - Known structural cerebral vascular lesion - Malignant intracranial neoplasm - Ischemic stroke previous 3 mos - Aortic dissection - Active bleeding or bleeding disorder - Significant head trauma in last 3 months

Relative contraindications to thrombolytics

- Severe or poorly controlled HTN (SBP > 180 or DBP > 110) - Ischemia stroke > 3 months ago or dementia - Traumatic or prolonged CPR (> 10 min) - Major surgery in last 3 wks - Recent internal bleed in last 2-4 wks - Active peptic ulcer - Chronic anticoag w/ high INR