Acute Coronary Syndrome

Question 1

1 Cause of death worldwide

Answer 1

Ischemic Heart Disease

Question 2

RF (HD)

Answer 2

Age
Male
Fm Hx
DM
HTN
HLD
Smoking
Obesity/Sedentary lifestyle

Question 3

Chest discomfort (pressure, squeezing, tightness, heaviness) 2/2 ischemia
Exacerbated c exertion; Alleviated c rest
Atypical sxs c DM, Elderly, Female

Answer 3

Angina

Question 4

Anginal pain at rest or upon waking
Young women
2/2 anxiety, stress, coronary VASOSPASM
ST elevation

Answer 4

Variant / Prinzmetal’s Angina

Question 5

Tx Prinzmetal’s

Answer 5

CCB (Dihydropyridines) & Nitrates
Avoid caffeine, nicotine, ergots
NO BB

Question 6

Atypical angina (DM, Elderly)

Answer 6

SOB, DOE, Dizzy, Fatigue, (Near) Syncope
Epigastric pain
Dec appetite
Asx - Silent

Question 7

Predictable pattern to angina
Precipitated by: Exertion, Emotion, Eating
Lasts 5-15 min
Pain, no EKG chng, no elev enzymes

Answer 7

Stable (Demand) angina

Question 8

Tx (Stable angina)

Answer 8

Rest

NTG

Question 9

New onset angina; angina at rest
Changing pattern: freq, duration, intervention
“Pre-infarct”
Pain, no EKG chng, no elev enzymes

Answer 9

Unstable (Supply) angina
“Pre-infarction”

…longer periods of rest; more NTG req.

Question 10

T-wave inversion
“Non-completed” MI
Pain, min EKG chng, elev enzymes

Answer 10

NSTEMI

Question 11

ST elevation (depression in opp. leads)
Tombstones
Pain, maj EKG chng, elev enzymes

Answer 11

STEMI

Question 12

Myocardial cell death
Usually coronary artery thrombus
More severe form of anginal pain
Q-wave

Answer 12

Myocardial Infarction

Question 13

Tx (AMI)

Answer 13

MONA   B
ASA - right away (reduces mortality)
Oxygen
Morphine and Nitro (CP relief, but will dec BP)
BB only after fluid off lungs

Question 14

Anticoagulation (AMI)

Answer 14

ASA - always
Plavix - reduced mortality in STEMI
Heparin/Lovenox - red mortal in STEMI
Thrombolytics in STEMI (best if within 70 min)
…Cath lab/PCI most efective (within 90 min)

Question 15

Post-MI Tx

Answer 15

BB (within 24 hrs); not with CHF, low EF
ACEI - affects remodeling
Statins
ASA - 81 mg
Plavix - 12 months if use DES

Question 16

Avoid… in post-MI

Answer 16

NSAIDS
Nifedipine (short-acting)

Question 17

Surgery for:
Single vessel or mult discrete lesions =
Left main, diffuse dz, failure of balloon/stent =

Answer 17

= PTCA

=CABG

Question 18

F/U (AMI)

Answer 18

Smoking cessation
Lipid eval
Diet & exercise
Mngt comorbid dz

Question 19

ST segment:
depression =
elevation =

Answer 19

= subendocardial ischemia

= transmural ischemia

Question 20

Which leads are:
anteroseptal = 
anteroapical = 
lateral = 
inferior = 
posterior =

Answer 20

= V1-2
= V3-4
= V5-6, I, aVL
= II, III, aVF
= V1-2 (?)

Question 21

Which leads affect the:
LAD =
RCA =
Circumflex =

Answer 21

= V1-4
= V1-2, II, III, aVF
= V5-6, I, aVL

Question 22

ANS activation in AMI

Answer 22

SNS - diaphoresis, vasoconstriction

PSNS - Nausea (comm infer wall MI), weak

Question 23

Sharp, pleuritic CP worse c inspiration
Relieved leaning forward
Friction RUB
Odynophagia
DIFFUSE ST elevation; PR depression
EKG - electrical alternans (QRS size)
Dyspnea, rales, tachypnea, fever, myalgias

Answer 23

Acute Pericarditis

Question 24

Acute onset dyspnea
Pleuritic pain
RF: Virchow’s triad (stasis, endothelial damage, hypercoagulability)
Widened As gradient

Answer 24

PE

Question 25

Intimal tear
Abrupt onset ripping/tearing (back, shoulder blades)
Unequal pulses
Cardiac tamponade c Beck’s triad (hypotension, JVD, muffled heart sounds)

Answer 25

Aortic dissection

Question 26

Causes of Pericarditis (inflamm of sac)

Answer 26

Idiopathic
Virus - Coxsackie...
Bact - H. flu
Fungal
Neoplastic - Lung, breast , lymphoma
Autoimmune - SLE, RA
Meds - Procainamide, Hydralazine

Question 27

Develop pericarditis 1-8 wks after AMI

Answer 27

Dressler’s Syndrome

Question 28

Pulsus paradoxus (SBP drops > 10 with insp)
Dyspnea, cyanosis
JVD, hypotension, thready pulse, quiet / muffled pericardium (Beck’s triad)
Ewart’s sign - dullness and bronchial breathing

Answer 28

Pericardial tamponade

Question 29

Tx (Pericarditis)

Answer 29

NSAIDS