Acute coronary syndrome

Question 1

Canadian Cardiovascular Society Classification of Angina

Answer 1

Class I Angina occurs only with strenuous, rapid, or prolonged exertion. Ordinary physical activity does not cause angina.
Class II Slight limitation of ordinary activity. Angina occurs with climbing stairs rapidly, walking uphill, walking after meals, in cold, in wind, or under emotional stress.
Class III Marked limitations of ordinary physical activity. Angina occurs on walking one to two level blocks or climbing one flight of stairs at usual pace.
Class IV Inability to carry on physical activity without discomfort. Anginal symptoms may be present at rest.

Question 2

Reproducible chest wall tenderness is not uncommon, possibly because

Answer 2

the pericardium may become inflamed

Question 3

Bradycardic rhythms are more common with…. myocardial ischemia.

Answer 3

inferior wall

Question 4

Reciprocal ST-segment changes predict

Answer 4

1 larger infarct distribution,
2 an increased severity of underlying CAD,
3 more severe pump failure,
4 higher likelihood of cardiovascular complications,
5 increased mortality

Question 5

May have ST-segment elevation in the absence of acute myocardial infarction (9)

Answer 5

1 Early repolarization
  2 Left ventricular hypertrophy
  3 Pericarditis
 4 Myocarditis
  5 Left ventricular aneurysm
  6 Hypertropic cardiomyopathy
  7 Hypothermia
  8 Ventricular paced rhythms
  9 Left bundle-branch block

Question 6

May have ST-segment depressions in the absence of ischemia (7)

Answer 6

1 Hypokalemia
 2 Digoxin effect
 3 Cor pulmonale and right heart strain
 4 Early repolarization
  5 Left ventricular hypertrophy
  6 Ventricular-paced rhythms
  7 Left bundle-branch block

Question 7

May have T-wave inversions in the absence of ischemia

Answer 7

1 Persistent juvenile pattern
  2 Stokes-Adams syncope or seizures
  3 Post-tachycardia T-wave inversion
  4 Postpacemaker T-wave inversion
  5 Intracranial pathology (central nervous system hemorrhage)
  6 Mitral valve prolapse
  7 Pericarditis
  8 Primary or secondary myocardial diseases
  9 Pulmonary embolism or cor pulmonale from other causes
  10 Spontaneous pneumothorax
 11 Myocardial contusion
  12 Left ventricular hypertrophy
  13 Ventricular-paced rhythms
  14 Left bundle-branch block
  15 Right bundle-branch block

Question 8

Systems goals for reperfusion are PCI within … of ED arrival, or fibrinolysis within …. of ED arrival if PCI cannot be accomplished.

Answer 8

90 minutes

30 minutes

Question 9

Fibrinolytic therapy is indicated for patients with STEMI (as a reperfusion option) if time to treatment is … hours from symptom onset, and the ECG …

Question 10

Clinical variables that can be assessed in the ED and predict an increased risk of intracranial hemorrhage after fibrinolysis are (3)

Answer 10

1 age (>65 years old),
2 low body weight (

Question 11

Absolute contraindications to fibrinolysis (6)

Answer 11

1 Any prior intracranial hemorrhage
2 Known structural cerebral vascular lesion (e.g., arteriovenous malformation)
3 Known intracranial neoplasm
4 Ischemic stroke within 3 mo
5 Active internal bleeding (excluding menses)
6 Suspected aortic dissection or pericarditis

Question 12

Relative contraindications to fibrinolysis (13)

Answer 12

1 Severe uncontrolled blood pressure (>180/100 mm Hg)
2 History of chronic severe poorly controlled hypertension
3 History of prior ischemic stroke >3 mo or known intracranial pathology not covered in contraindications
4 Current use of anticoagulants with known international normalized ratio >2-3
5 Known bleeding diathesis
6 Recent trauma (past 2 wk)
7 Prolonged CPR (>10 min)
8 Major surgery (

Question 13

STEMI patients who have received fibrinolytics should receive full-dose… for a minimum of 48 hours.

Answer 13

anticoagulants

Question 14

Rescue PCI (after failed fibrinolytic administration) is recommended for the following groups:

Answer 14

1 patients in cardiogenic shock who are

Question 15

when used for patients with AMI, IV nitroglycerin should be titrated to …. rather than to symptom (chest pain) resolution.

Answer 15

blood pressure reduction

Question 16

Nitroglycerin or other nitrates should not be administered to patients with ACS who recently received …

Answer 16

a phosphodiesterase inhibitor for erectile dysfunction, within 24 hours of sildenafil, or within 48 hours of tadalafil use

Question 17

Temporary transcutaneous pacemaker indications (4)

Answer 17

1 Unresponsive symptomatic bradycardia
2 Mobitz II or higher AV blocks
3 New LBBB and bifascicular blocks
4 RBBB or LBBB with first-degree block

Question 18

Temporary transvenous pacemaker indications

Asystole

Answer 18

1 Unresponsive symptomatic bradycardia
2 Mobitz II or higher AV blocks
3 New or indeterminate-age LBBB
4 Alternating bundle-branch block
5 RBBB or LBBB with first-degree block
6 Consider in RBBB with left anterior or posterior hemiblocks
7 Overdrive pacing in unresponsive tidal volume
8 Unresponsive recurrent sinus pauses (>3 s)

Question 19

Generally hear blocks after AMI are associated with ….

Answer 19

Increased mortality

Question 20

….. , ….. and ….. have been linked to an increased likelihood of cardiac rupture.

Answer 20

Anti-inflammatory medications,
steroids,
and late administration of thrombolytic agents

Question 21

Rupture of the interventricular septum is more common in patients with …. and patients with …..

Answer 21

anterior wall MI

extensive (three-vessel) CAD

Question 22

….. rupture occurs in approximately 1% of patients with AMI, is more common with inferior MI, and usually occurs 3 to 5 days after AMI.

Answer 22

Papillary muscle

Question 23

….. occurs 2 to 10 weeks after AMI and presents as chest pain, fever, and pleuropericarditis. Treatment is symptomatic with aspirin up to 650 milligrams PO every 4 to 6 hours.

Answer 23

Dressler syndrome (post-AMI syndrome)

Question 24

To treat hypotension in the setting of RV MI (2)

Answer 24

1 volume loading (normal saline)

2 If cardiac output is not improved after 1 to 2 L of normal saline, begin inotropic support with dobutamine.

Question 25

(3) are associated with more atypical presentations.

Answer 25

Advanced age,
female gender,
and a history of diabetes mellitus

Question 26

In cocaine associated MI (3) are the mainstays of therapy for initial stabilization; …. are contraindicated.

Answer 26

Aspirin, nitrates, and benzodiazepines

Beta-blockers

Question 27

Patients with cocaine-associated STEMI are best managed with …..

Answer 27

PCI