All about the heart Flashcards
ACS definition
Unstable angina through AMI
Three principals of UA
At rest, <20 minutes usually
New-onset which limits walking 1-2 blocks or 1 flight of stairs
Diagnosed increasing in frequency or duration or threshold is lower
Angina precipitators
Exercise, stress, cold
Angina typically lasts
<10 mins, up to 20, improves within 2-5 minutes or after nitro
Atypical AMI symptoms
Fat beeties woman
S3
Present in 15-20% of AMI, may indicate a failing myocardium
TIMI - Thrombosis in Myocardial Infarction
0-2 have 2-9% 30 day risk of death, MI, or revascularization
Age 65+
3 or more traditional risk factors
Prior stenosis of >50%
ST segment deviation
2 or more anginal events in 24 hour prior
Aspirin use within 7 days prior to presentation
Elevated cardiac markers
isobar
Introduce Situation/status Observations Background Actions/assessment Responsibility
AHS inclusion criteria
2mm in at least 2 of V1-V6
1mm in 2 of inferior or V4R
1mm in 2 of V5,V6 aVL
1mm depression V1-V2 and 1mm elevation V8, V9
Exclusion criteria (SIBBS)
Structural anomaly of brain vessels
Ischemic stroke within 3 months (except within last 3 hours)
Brain tumor
Brain bleed
Significant closed head or face trauma in 3 months
Relative contras ask about
BP, strokes, CPR, surgery in 3 weeks, internal bleeding, non-compressible bleeding from IV attempts
Preggo, active ulcers, pts on coumadin
Where da clot?
Elevation III > II plus depression of >1mm in I and or aVL
RCA PPV 94%
Where da clot?Elevation III > II plus depression of >1mm in I and or aVL PLUS V1 and or V4R elevation
Proximal RCA PPV 100%
Where da clot?
ST elevation in L, aVL, V5 V6 and depression in V1, V2, V3
LCA PPV 91%
Where da clot?
Elevation V1, V2, V3 +
>2.5mm V1 and/or RBBB with q wave
Proximal LAD PPV 100%
Where da clot?
Elevation V1, V2, V3 +
St depression >1mm in II, III and aVF
Proximal LAD PPV 93%
Where da clot?
Elevation V1, V2, V3 +
<1mm depression / elevation in inferior leads
Distal LAD PPV 78%
Reciprocal changes
From subendocardial ischemia, means larger area of injury risk, worse underlying CAD, more severe pump failure, increased mortality
One of V5, V6, aVL with isoelectric or elevated ST in I
strongly suggestive of left circumflex lesion
Tins nitro
WILL dilate atherosclerotic vessels if they have intact vascular smooth muscle
Inhibits platelet aggregation
If not treated with thrombolytics, it will reduce infarct size and improve regional function
Mortality rate is lowered by 35% with nitrates.
SHOULD be titrated to 10% reduction in MAP, or 30% if baseline is hypertensive NOT symptom resolution
B blockers in AMI
Antidysrhythmic, anti-ischemic and anti hypertensive properties. Diminish MVO2 from decrease in hrt rate, arterial BP and myocardial contractility. Prolongs diastole for better perfusion
When to use B-blockers
Increases risk of cardiogenic shock Don't give if: Signs of heart failure Evidence of low CO Age over 70, SBP<120, tachy >110 or brady <60
Atrial kick in AMI
Normally lose 10-20% CO when kick is eliminated, lose up to 35% with reduced LV compliance when kick is eliminated
Sinus tach in AMI
Poor prognosis, common in anterior. Treat anxiety, pain, pump failure etc
Complete heart block
Anterior/inferior AMI as RCA and septal perforating branch of LAD supply AV conduction system
15% mortality without RV involvement, 30% with
Poor prognosis is due to how much is involved, not the block itself. Still pace though yo
Mortality rates from CO in AMI
10% no heart failure
15-20% mild failure
40% frank pulmonary edema
50-80% cardiogenic shock
Ventricular free wall rupture
Pericardial tamponade (90% death rate) Severe acute tearing pain. Hypotensive, tachy, possibly confusion and agitation, Becks triad
RV infarcation
Usually not isolated to RV From RCA or if left dominant LCX Use V4R if inferior Right ventricle becomes kinda useless, left ventricle bulges into RV and moves blood that way, so if LV is involved thats pretty fucked up I guess Tins says 1-2L of fluid
Post PCI
Assume chest pain is abrupt vessel closure until proven otherwise, occurs in 4% of pts 2-14 days postprocedure
Cardiogenic shock
A combo of damage to myocardium, and inflammatory response which depresses pump function and dilates peripheral vasculature
Average ejection fraction
Above 50-55%
Virchow’s triad
Hypercoaguability
Hemodynamic changes - stasis/turbulence
Endothelial injury/dysfunction
Cardiogenic shock physical presentation
Usually <90SBP (higher if baseline is htn PP <20 Sinus tach (check if pt is on BB) Tachypnea Rales (unless isolated RV) JVD Hepatojugular reflex Murmur
