Acute Coronary Syndromes And Cardiac Conditions Dr. Ross Exam 4 Flashcards
Acute coronary syndrome is which of the following: A. Unstable angina B. Acute myocardial infarction C. STEMI D. NSTEMI E. All of the above
E. All of the above
Is stable angina part of acute coronary syndrome? Y/N
No, not acute
What is good for predicting population risks for coronary artery disease? A. Chest pain B. Upper abd pain C. Past history D. EKG in isolation
C. Past history
Label the following as acute or non-acute: 1. Unstable angina 2. Stable angina 3. Aortic dissection 4. Pericarditis
- Acute 2. Non-acute 3. Acute 4. Non-acute
What non-cardio things can cause chest pain?
Pulmonary embolism Pneumonia Spontaneous pneumothorax (tall white dudes) GERD Peptic ulcer Pancreatitis Costrochondritis/broken rib Anxiety
Clinical description of stable vs unstable angina:
Stable angina is when you get chest pain symptoms during moderate physical activity or when you are pushing yourself physically. These symptoms go away with rest/nitro. Unstable angina is chest pain while doing very little or resting and it intensifies.
Name this cause of acute chest pain: Usually >30mins duration Assoc. symptoms include dyspnea, weakness, diaphoresis
Myocardial infarction (MI) heart attack
Name the cause of this acute chest pain: Chest pain that occurs during moderate physical exercise
Stable angina
Name the cause of this acute chest pain: Chest pain occurs at rest or with minimal exertion
Unstable angina
Name this cause of acute chest pain: Sudden, severe pain, may radiate to back Commonly associated with HTN or connective tissue disease
Aortic dissection
Name the cause of this acute chest pain: Pleuritic pain, worse in supine position Fever, pericardial friction rub
Pericarditis
Name the cause of this acute chest pain: Sudden onset of pain, dyspnea, tachypnea, tachycardia
Pulmonary embolism PE
Name the cause of this acute chest pain: May be assoc. with localized pleuritic pain Cough, fever, crackles
Pneumonia
Name the cause of this acute chest pain: Unilateral pleuritic pain assoc. with dyspnea and sudden onset
Spontaneous pneumothorax
Name the cause of this acute chest pain: Burning retrosternal and epicanthic discomfort Aggravated by large meals and post-radial recumbency
GERD/esophageal reflux
Name the cause of this acute chest pain: Atypical symptoms for any organ system Symptoms may persist despite negative evaluations of multiple organ systems
Psychological (like anxiety: saw this a lot in the ED)
A heart score of 0-3:
2.5% chance of major acute coronary event (MACE) in next 6 weeks, discharge home
A heart score of 4-6:
20.3% chance of MACE over next 6 weeks, admit for clinical obs
Heart score of 7-10:
72.7% chance of MACE over next 6 weeks, early invasive strategies (cath lab for stents; surgery for bypass)
Which of the following is not a risk factor for ACS: A. Male B. Over 65 C. Tobacco smoking D. HTN E. DM F. HLD G. Being physically active and dieting
G. Being active and dieting
Who gets an EKG? Pt’s who present with:
CP SOB Dizziness Palpitations Syncope Epigastric pain
Initial risk stratification for ACS includes what 4 things?
- History and physical exam 2. EKG 3. Troponin 4. Heart score
SxS for high likelihood of CAD/ACS include: Hx: PE: ECG: Cardiac biomarkers:
Hx: chest or left arm discomfort as chief complaint; known hx of CAD PE: hypotension, signs of heart failure, transient MR murmur ECG: New ST-segment deviation (1mm or greater); T-wave inversion in multiple precordial (V1-6) leads Cardiac biomarkers: elevated troponin (normal is 0-0.4; > 0.4 is probably MI)
Higher risk: Do not ignore! Pain that radiates where? Pain associated with what 4 things?
Radiates bilaterally Pain associated with exertion, diaphoresis, nausea, vomiting
Lower “gestalt” for MI:
Pleuritic pain provoked by respiration or cough Pain in middle to lower abdomen Pain localized by the tip of 1 finger instead of widespread crushing pain Pain reproduced with movement or palpation of the chest wall or arms Brief episodes of pain lasting a few seconds Pain radiating to lower extremities
Lower risk in HPI: 3 P’s
- Pleuritic pain, sharp, stabbing 2. Palpation reproducible (rib fx?) 3. Pain based on position (lying/sitting) Also 4. Younger age 5. Pain lasting seconds or more than 24hrs
What’s the first step for a pt with CP after getting basic triage of vitals and CC?
EKG
Second step after EKG?
History and “gestalt”, Take best guess assessment at very low, low, or intermediate
Third step after Hx?
Troponin and bloodwork Heart score
Very low risk:
Obvious non-ischemia etiology to pain Normal EKG Normal troponin
Low risk:
History not suggestive of MI EKG normal x2 Troponin negative Heart score low
Intermediate risk:
Hx suggestive of ischemia Pain at rest New onset pain Crescendo pain Ongoing pain Ischemic EKG or arrhythmia Positive Troponin > 0.4
If you are in any setting besides an ED, you need to arrange transport to hospital and treat for ischemia w/ ____ and ____.
ASA Oxygen
Cardiac markers
Troponin I (2-6 hours, peaks at 12) CK-MB (creatine kinase, 4-8hrs, peaks at 24hrs) LDH (lactate dehydrogenase, or just lactate to us dumb ED folk) CRP (C-reactive protein, inflammatory marker)
Check hsT (high sensitivity Troponin) at _ hour and _ hour.
0 hour 1 hour
Need two hsT levels. Multiply the 1st hsT by ___. The 2nd hsT should be less than that.
1.4
Don’t use hsT if: (exclusion criteria)
Unstable angina/MI Concerning EKG findings Hospitalization already planned ( hsT detects much lower conc. Of troponin, but up to 50% of pt’s without ACS will have a detectable but not abnormal hsT)
Troponin is also elevated in what 8 things?
Acute heart failure Cardiomyopathy Pericarditis LVH A-fib Renal failure Sepsis Stroke
MI criteria on EKG (gender discriminate)
Male w/ >2mm ST segment elevation in 2 consecutive precordial (V1-6) leads Female w/ > 1.5mm ST elevation in 2 consecutive precordial leads >1mm ST segment elevation in Limb leads (I and aVL or II, III and aVF ST segment depression in V1-V3= posterior infarction New LBBB with symptoms and sgarbossa criteria
Early EKG findings for ischemia: Earliest sign is hyper acute ___ wave (tall and peaked)
Peaked T waves
What is Wellen’s sign?
Bi-phasic T waves in V2-5 w/ or w/o pain (Commonly have LAD ischemia)
Areas of an EKG represent coronary arteries: 1. II, III, aVF: 2. I, aVL, V5, V6: 3. V1-2: 4. V3-4:
- Inferior (RCA) 2. Lateral (circumflex) 3. Septal (LAD) 4. Anterior (LAD)
Tx of ACS: Step 1: ASA, oxygen, nitro only if ___ established Step 2: Step 3:
IV Heparin (anti-coagulant) Platelet inhibitors
30-50% of Inferior infarcts also have ____ _____ infarction as well: think about blood supply
Right ventricle
Right coronary artery (RCA) supplies bloody to ____ node, _____ _____, and middle segment supplying the lateral and inferior ___, inferior ___ wall, and ___ node.
SA node Right atrium Right ventricle Inferior left ventricle wall AV node
A posterior left ventricle wall infarction can be missed as there are no specific leads for it. Look at the ______ leads of V__ and V__ for ST_______.
Anterior V3, V4 Depression
When looking for an inferior wall MI look at ___ and ___. You are looking for ___ depression.
V1 and V2, ST
*can look further with right-sided EKG
What treatment approach is different with an inferior wall MI w/ RV involvment?
Avoid reducing preload aka do NOT give nitrates. You may have to use multiple bolus fluids to maintain stable BP.
*Since the RV is affected LV filling will be diminished = reduced stroke volume = reduced BP.
Why would an inferior MI with posterior LV involvment be missed?
There are no leads specifically for posterior LV. So look at anterior leads for ST depression/inversion
What are the two types of plaques?
a) fibrous and lipid
b) fibrous and fibrolipid
c) atherosclerosis and arteriosclerosis
d) calcium and collagen
b) fibrous and fibrolipid
fibrous = fibrin
fibrolipid = fat, cholesterol and calcium
When a plaque ruptures it releases potent ____ substances that cause platelet ____ (glycoprotein 1b), ____ and ____.
thrombogenic, activation, adhesion and aggregation
What is the cause of Prinzmetal’s angina?
Coronary spasm without thrombus ALMOST ALWAYS at rest
*caused by cold weather, vasoconstricting meds, cocaine
*usually occurs between midnight and early morning in younger patients
In Prinzmetal’s angina, an EKG would show ST ____, but no ST ____ in reciprocal leads.
elevation, depression
Unstable angina is characterized by
a) small plaque rupture that is self-limiting
b) Varying triggers
c) A fixed deficit that occurs with certain exertional level
d) chest pain occuring mostly after eating
c) A fixed deficit that occurs with certain exertional level
T/F: Unstable angina can have pain at rest and with exertion.
True
Unstable angina can have which of the following?
a) mild chest pain that is the same every episode
b) new or typical pain with increased severity
c) pain only at rest
d) Specific EKG findings
b) new or typical pain with increased severity
*EKG may be normal
Would you have an elevated troponin w/ unstable angina?
a) Yes
b) No
c) depends on severity
b) No
*There is no troponin leak with unstable angina
What are the four steps you should always do with chest painers?
- History/ PE
- Myocardial marker labs
- EKG
- Scoring system (i.e. TIMI or Heart)
What should you do with a high risk chest painer?
a) Start aggressive fluids
b) Get your attending involved
c) Chest xr
b) Get your attending involved early on, high probability to call cath lab
*also start immediate measures i.e. ASA/heparin/O2
What lab would you be drawing regardless of low risk chest painer?
Troponin immediately after EKG (even if EKG is reassuring)
*2nd EKG 30-60 min later
You have a low-risk chest pain in your ED, their 1st and 2nd EKG and troponin are reassuring and their HEART score is 4. You have done the proper charting, given strict ED return precautions which the patient agrees to and agrees to come back for a 72 hr f/u. Are you able to safely discharge?
NO!
*Everything is there for a discharge EXCEPT their HEART score (4-10) = admit/further eval
HEART 0-3 only passes go and collects $200
You have a chest pain pt with a concerning hx/PE and an EKG non-diagnostic w/ ST depression. Medications you will administer next are?
O2, ASA, NTG, morphine, beta blockers, heparin
*not exactly sure what she is getting at on this slide except confirming EKG is going to cath lab
You have a 55 yr. male w/ CP radiating to back duration 60 min that ocurred earlier today. He is in great shape and runs daily, but recently he only runs 2 miles b/c he gets tired. No family hx, non smoker, no concerning PMH, 0/10 pain. Do you discharge him?
NO!
ACS risk due to VERY concerning history
Depending on your facility what testing would you do for intermediate risk chest pain?
a) Exercise tress test w/ adenosine
b) nuclear imaging study w/ or w/o chemical stress (thallium/technitium)
c) Coronary CTA (triple threat scan)
d) PCI
e) Duel source CTA
You may do any of those listed depending on facility EXCEPT duel source CTA (not until status change)
What is your first step in risk stratification of chest pain patient?
First step: get rapid EKG as this will catch high risk patients quickly
What is your 2nd step in risk stratification of chest pain patient?
Second: Hx and the ol’ gestalt (very low, low or intermediate risk)
What is your 3rd step in risk stratification of chest pain patient?
Three: Cardiac marker labs (except for very low risk) and HEART score
And finally, what is your fourth step in risk stratification of a chest pain patient?
Secondary evalutation/disposition, if low risk use accelerated diagnostic protocol (ADP). Two attached are both ADPs
*consider observation admission
Chest pain onset is less than 6 hours, your TIMI score is zero. What do you do next?
One additional trop 2 hrs after first or 6 hrs after chest pain has resolved. If trop negative and you still have concern for CAD you can order an outpatient stress test or coronary CTA.
You have a chest painer with sxs ongoing for more than 6 hrs, neg hx, normal EKG, neg trop, TIMI is 0-1. What is required to rule out MI?
After six hours from sxs, a single neg trop rules out MI
What are the contraindications to thrombolytic therapy for MI?
- active bleed
- ICH anytime
- ischemic stroke last 3 mos
- spine surg last 2 mos
When would you start thrombolytics for MI?
- CP >30 min and no PCI within 90 min
- acute MI or new left bundle with scarbossi criteria
What is rescue PCI?
PCI performed after failed thrombolysis. Still needs to be performed in time windwo of < 6 hrs and at the most 12 hrs for STEMI. After this no muscle to save.
When do you initiate PCI?
- within 90 min
- STEMI within 12 hrs
- failed or contraindicated thrombolytics
What are some pitfalls to avoid with chest painers?
- failure to review EKG quickly
- women can present differently (post-menopausal risk)
- failure to review old studies (especially EKG looking for changes)
- New BBB
- DM frequently have silent MI
You have a diabetic patient come into your ED for dizziness. An EKG is ran and you note diagnostic changes indicative of an MI, but the patient has no pain whatsoever. Why would you continue to work this up?
Diabetics frequently have silent MI due to altered pain perception
You have a 51 yr patient with abdominal pain. What should you be considering?
Not considering, doing. Get EKG >50 if you are considering GI disorder to look for MI.
Why does a GI cocktail not r/o MI?
Because they can help MI pain and GERD
What are early complications of MI?
- Inferior wall > bradydysrhythmia
- AV block (i.e. mobitz 2/ complete block)
- tachydysrhythmia
- cardiogenic shock due to muscle loss
What are some complications of an MI not caught until ~7 days?
Can cause structural damage/rupture of interventricular septum/papillary muscles
What are late complication of MI (~2 weeks)?
- pericarditis
- Dressler syndrome
- aneurysm rupture
What are some benign rhythms you may find after an MI?
- afib
- PVCs
- Mobitz 1
What are some bad juju rhythms you don’t want to find after an MI?
- Mobitz 2
- complete block
What could be on your ddx for chest pain?
- pericardial tamponade
- aortic dz
- pneumonia
- pneumothorax
- PE
You have a 40 yr male with 3 days sharp, pleuritic CP radiating to left shoulder/neck that is worse when laying down. EKG shows diffuse ST elevation w/o reciprocal changes. What is this hx classic for?
Pericarditis
What are findings with pericarditis?
- EKG does not have convex (tombstone) shape
- EKG goes through 4 stages
- Look for ST elevation in 2 and 3, if 3 > 2 then MI
- recent or current coxackie virus?
- Get echo looking for effusion, if large admit and drain
- tx w/ high dose ASA and colchicine (prevents recurrent attacks)
What are some causes of myocarditis in the young?
- enterovirus (especially)
- parvovirus
- coxsackie
*Need contrast MRI for dx but echo can be helpful
*Hx of viral illness several wks prior
When do cardiac abnormalities in neonates usually present?
Within 3 wks
You have a neonate that is cyanotic and not responding to O2, what would you treat with next?
Prostaglandin
*cyanosis secondary to cardiac abnormality will not respond to O2
Abnormalitites include:
- truncus arteriosus
- transposition of great vessels
- tricuspid atresia
- tetrolog of fallot
- tontal anomolus pulmonary circulation
Why do we care about hypertensive patients?
-increased risk for CV and renal disease
Memorize HTN classifications with attached pic
How do you treat asymptomatic HTN in ED setting?
No right or wrong.
- Maybe work up, maybe not
- EKG looking for LVH
- Do not have 2 elevated readings on 2 sep occasions
- If BP >140 sys or > 90 diastolic could refer for outpatient
62 yr male in ED sudden onset severe chest and back pain. Earlier syncopal episode of unknown length. Now awake with c/o CP.
PMH: HTN
Vitals BP 190/110 pulse 98
2nd Vitals 150/80 pulse 101
What are you concerned for?
Aortic dissection
A patient with hypotension you must immediately consider what?
Cardiogenic shock (arrythmia)
- aortic dissection
- aortic aneurysm
**aortic dissection and aneurysm will have:
- Pulse deficits
- Abdominal mass
- hematuria
What is Beck’s triad referring to and what are the 3 signs?
Cardiac tamponade
- JVD
- Hypotension
- Muffled heart sounds
Which is more common an aortic dissection or aneurysm?
Dissection
Patients with aortic dissection may present with what?
- Pain out of proportion w/ exam
- Normal EKG
- ill appearing
- ripping or tearing pain
- Initially hypertensive then hypotensive
Tx: IV X 2, fast US and CXR, labs
Risk w/ middle age males with HTN, pregnant females or Marfans
You have a patient with complaints of chest pain and nuero complaints. What must you consider and why?
Aortic dissection. Start thrombolytics thinking stroke then will bleed out = clean kill
*Get CXR or CTA
An abdominal aortic aneurysm is characterized by?
dilation of all layers of arterial wall. Usually catastrophic when ruptures.
Tx: IV X 2, blood products, vascular surgeon
How would you dx a thoracis aneurysm?
CXR followed w/ CT chest with contrast
Findings:
widened mediastinum
- left pleural effusion
- calcium sign
- left apical capping
- tracheal deviation
How would you dx an AAA?
Ulstrasound f/u with CT chest with contrast
When is an AAA considered pathological? At what size?
> 3 cm = pathological
> 5.5 cm = need surgery
ED tx for AAA?
Lower HR then BP
-beta blocker then arterial dilator (labetalol then nitroprusside)
Which of the following drugs was the only one shown in studies to improve mortality in the setting of AMI?
a) ASA
b) NTG
c) High flow O2
d) beta blockers
a) ASA
*23% mortality improvement
