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)