Acute Coronary Syndrome

Question 1

Describe the classic and unclassic description of cardiac chest pain?

Answer 1

The classic description of cardiac chest pain is an intermittent, substernal chest pressure, usually on the left which radiates to the arm and neck, exacerbated with exertion and associated with shortness of breath, diaphoresis, nausea and palpitations.

These classic symptom are more often the exception than the rule. The pain can occur anywhere from the umbilicus to the neck and to the back. It can be sharp, burning (simulating gastric reflux). Diabetics and the elderly may have no chest pain at all. Women often present simply with fatigue, shortness of breath and generalized weakness.

Question 2

Distinguish stable angina from unstable angina

Answer 2

Distinguish stable angina (unchanged exertional pain lasting 5-15 minutes and relieved by rest or nitroglycerin) from unstable angina (increasing in frequency, at lower exertional levels or occurs at rest). Unstable Angina (UA) is a dynamic process which may lead to MI or death.

Question 3

criteria for diagnosing an acute MI

Answer 3

A consistent clinical history
EKG changes
Changes in cardiac enzymes (CK-MB)

Question 4

What kind of heart attack and what artery is most likely affected in a patient with ST elevations in V1-V6, and no reciprocal ST depressions?

Answer 4

Anterior MI, LAD (Left Anterior Descending)

Question 5

What kind of heart attack and what artery is most likely affected in a patient with ST elevations in V1-V3, and no reciprocal ST depressions?

Answer 5

Septal MI, LAD (Left Anterior Descending)

Question 6

What kind of heart attack and what artery is most likely affected in a patient with ST elevations in leads II, III, and aVF, and reciprocal ST depressions in leads I and aVL?

Answer 6

Inferior MI, RCA (80%) or Left Circumflex artery (20%)

Question 7

What kind of heart attack and what artery is most likely affected in a patient with ST elevations in leads I, aVL, V5, and V6 and reciprocal ST depressions in leads II, III and aVF?

Answer 7

Lateral MI, Left Circumflex

Question 8

What kind of heart attack and what artery is most likely affected in a patient with ST elevations in leads V7, V8 and V9 and reciprocal ST depressions in leads V1-V3?

Answer 8

Posterior MI, RCA or Left Circumflex

Question 9

What kind of heart attack and what artery is most likely affected in a patient with ST elevations in leads V1 and V4R and reciprocal ST depressions in leads V1 and aVL?

Answer 9

Right Ventricular MI, Right coronary artery

Question 10

Describe the typical elevation pattern for myoglobin

Answer 10

Initial Elevation 1-4 hours
Peak Elevation 6-7 hours
Return to Baseline 18-24 hours

Question 11

Describe the typical elevation pattern for CK-MB

Answer 11

Initial Elevation 4-12 hours
Peak Elevation 10-24 hours
Return to Baseline 48-72 hours

Question 12

Describe the typical elevation pattern for Cardiac Trop I

Answer 12

Initial Elevation 3-12 hours
Peak Elevation 10-24 hours
Return to Baseline 3-10 days

Question 13

Describe the typical elevation pattern for Cardiac Trop T

Answer 13

Initial Elevation 3-12 hours
Peak Elevation 12-48 hours
Return to Baseline 5-14 days

Question 14

Which cardiac enzyme marker is the most sensitive for heart?

Answer 14

The troponin I is the most sensitive cardiac marker, detectable in serum 3-6 hours after an MI, and its level remains elevated for 14 days.

Question 15

What is the ultimate way to diagnose ACS?

Answer 15

The diagnosis of ACS is ultimately made using cardiac catheterization.

Question 16

STEMI EK findings

Answer 16

For a ST-elevation MI (STEMI) look for ST-elevations of 1 mm or more in two contiguous limb leads (high lateral: I, aVL; inferior: II, III, aVF) or 2 mm elevations in the precordial leads (anterior: V1, V2, V3; lateral: V4, V5, V6).

Question 17

What is the TIMI Risk Score

Answer 17

TIMI Risk Score for UA/NSTEMI

65 or older?
 3+ CAD risk factors?
Known CAD?
Aspirin use in past week?
Severe angina?
ST segment changes?
Positive cardiac markers?

Question 18

Initial treatment for patient with concern for ACS

Answer 18

All potentially critical patients should get IV access, oxygen, and be placed on a cardiac monitor. MONA stands for morphine, oxygen, nitroglycerin and aspirin. Beta-blockers should be used to control the heart rate and blood pressure.

Antithrombin therapy (a heparin) and antiplatelet therapy (aspirin or a IIb/IIIa inhibitor) should be given to all patients with an ACS.

Question 19

Persistent and non-persistent ST elevation treatment and management

Answer 19

• Those with persistent ST-elevations will need some sort of revascularization procedure – either pharmacological (thrombolytic) or an angioplasty in the cardiac catheterization lab.
• Those without ST-elevations should get an angiogram when appropriately as determined by the interventional cardiologist.

Question 20

Will cardiac enzymes be positive in patients with only angina?

Answer 20

Cardiac enzyme testing will be negative in patients with angina! Functional testing is needed to discover any partially occluded coronary arteries.