Acute Coronary Syndrome

Question 1

Describe Unstable Angina

Answer 1

Chest pain at rest
Unpredictable 
May be relieved with NTG 
Troponin Neg
ST depression or T wave inversion

Question 2

Describe NSTEMI

Answer 2

Troponin pos
ST depression or T wave inversion
Unrelenting chest pain

Question 3

Describe STEMI

Answer 3

Troponin positive
ST elevation in 2 or more contiguous leads
Unrelenting chest pain

Question 4

Describe Variant or Prinzmetal’s Angina

Answer 4

A type of unstable angina associated with transient ST segment elevation

• Coronary artery spasm with or without atherosclerotic lesions
• occurs at rest
• may be precipitated by nicotine, ETOH, cocatine
• trop neg
• NTG resolves chest pain; STs turn to normal

Question 5

Changes in II, III, aVF

Answer 5

RCA, inferior LV

Question 6

Changes in V1, V2, V3, V4

Answer 6

LAD, anterior LV

Question 7

Changes in V5, V6, I, aVL

Answer 7

circumflex, lateral LV

Question 8

Changes in V5, V6

Answer 8

low lateral LV

Question 9

Changes in I, aVL

Answer 9

high lateral LV

Question 10

Changes in V1, V2

Answer 10

RCA, posterior LV

Question 11

Changes in V3R, V4R

Answer 11

RCA, RV infarct

Question 12

Door to balloon time

Answer 12

90 minutes

Question 13

Door to drug time

Answer 13

<30 minutes

Question 14

S/S of vasovagal reaction

Answer 14

hypotension with or without bradycardia, absence of compensatory tachycardia, pallor, yawning, nausea, diaphoresis

Question 15

Signs of retroperitoneal bleed

Answer 15

sudden hypotension, severe low back pain

Question 16

Contraindications for fibrinolytic therapy

Answer 16

• any prior intracranial hemorrhage
• known structural cerebral vascular lesion (AV malformation)
• known malignant intracranial neoplasm (primary or metastatic)
• ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours
• Suspected aortic dissection
• Active bleeding or bleeding diathesis
• Significant closed-head or facial trauma within 3 months

Question 17

What are some signs and symptoms of reperfusion?

Answer 17

• chest pain relief: due to fibrinolysis of clot
• resolution of ST segment deviations
• Myocardial stunning when vessel opens –> Marked elevation of troponin/CK-MB, Reperfusion arrhythmias (VT, VF, AIVR)

Question 18

Inferior MI: what artery is occluded?
What rhythm changes do you expect to see?
What kind of murmur do you expect to hear? Explain
What drugs do you need to use with caution?

Answer 18

• RCA occlusion
• Associated with AV conduction disturbances (2nd degree type 1, 3rd degree heart block, SSS, SB
• development of systolic murmur: Mitral valve regurgitation secondary to papillary muscle rupture
• use beta blockers and NTG with caution

Question 19

Right Ventricular Infarct: 
How do you assess?
What do you expect to see in your patient assessment?
What drugs do you use to treat?
What drugs do you want to avoid?

Answer 19

• 30% of inferior wall MI patients also have a RV infarct
• Right sided ECG can show ST changes
• JVD at 45 degrees, high CVP, hypotension, clear lungs, bradyarrhythmias
• use positive inotropes to treat and IVF
• avoid preload reducers (nitrates and diuretics)

Question 20

Anterior MI: 
What artery is occluded?
What EKG changes do you see?
What rhythm changes do you see?
What murmur do you expect to hear?
Is it more or less serious that inferior MI?

Answer 20

• LAD occlusion
• ST elevation in V1 -V4
• reciprocal changes in inferior wall
• May develop 2nd degree type 2 heart block or RBBB (ominous sign)
• development of systolic murmur: possible VSD
• higher mortality than inferior (Heart Failure)

Question 21

Lateral MI

• What EKG changes do you expect to see?
• What artery is occluded?

Answer 21

• ST elevation in V5, V6 (low lateral)
• ST elevation in I, aVL, (high lateral)
• generally involves circumflex artery