AMI Flashcards
ACS ACUTE CORONARY SYNDROME
(ACUTE MYOCARDIAL INFARCTION) (it’s in the name)
Lack of oxygen to myocardium causing necrosis
What is the most common cause of Acute Coronary Syndrome??
Atherosclerosis
patho
Normal vessel
Lipid (cholesterol core starts) around the lumen
Large lipid core forms and becomes Atherosclerosis
Note - diameter is smaller.
Fibrous cap thins (capsule where the cholesterol is)
CAD: AMI PATHOPHYSIOLOGY (cap the AMI)
Atherosclerotic plaque develops in coronary vessel
Vessel narrows
Fibrous cap thins
Cap tears & ruptures
Blood clot forms and occludes blood vessel
Thin fibrous cap develops
fissure/tear and ruptures
Thrombus immediately forms and occludes the vessel
CLINICAL SIGNS AND SYMPTOMS OF AMI - pain on what side? where does it radiate? (NJAB a heart attack)
Left chest pain. Not relieved by rest or nitro
Described as heaviness, tightness, constricting, crushing pain in the sternal area.
May radiate to the neck, jaw, arms, or back.
Signs and Symptoms of Women and CAD
CAD is the number 1 killer of American Women
Women manifest sx’s of CAD 10 yrs later than men
Treadmill test less sensitive in women (35% false +)
Exercise echocardiogram more accurate in women
Women have a 42% chance of dying 1 yr after MI (vs) men who have a 23% chance - has to do w/ not catching it in time w/ women
Diagnostic Work up for AMI (same for CAD)
HPI (history) c/w AMI
Adult c/o left chest pain
Serial ECG’s
Serial Troponin levels (CK MB)
EKG’s
Serial EKG 75 - 80% specific for diagnosing MI’s.
Only 50% of initial EKG’s are abnormal*** that’s why we need cereal EKGs
Demo… 12 lead EKG
PQRST (won’t test on EKGs)
P= atrial depolarization / contraction
QRS = Vent depolarization /contraction (QRS is ischemia)
ST = repolarization of Vent
Atrial repolarization during QRS
12 lead ECG c/w acute MI - elevation? (the number)
ST elevation > 1mm in at least 2 consecutive leads
EKG CHANGES - are they immediate?
IMMEDIATE
STEMI (ST elevation MI)
S-T segment ↑ in leads over the infarct
Note: 75% of all MI’s are in which ventricle?
Left Ventricle
LAB TESTS FOR AMI (just the main one)
enzymes & proteins are released from dead cardiac cells, that ‘s where TROPONINs come from. some ppl have naturally elevated troponin - so re-check a few hours later if high.
CAD: DIAGNOSTIC TESTS – SERUM MARKERS AFTER AN ACUTE MI - CK-MB (crete is 6, 15, 3)
Serum Marker First appears
CK-MB 4 – 6 hrs
Peaks 15 – 24
Normalizes 3 – 4 days
COMPLICATIONS OF AMI - most common one
ARRHYTHMIA’s (Most common complication)
80% of MI’s go into ARRHYTHMIA’s: such as:
(may precede V-Tach, V-fib)- COMPLICATIONS OF AMI - PVCs may precede…
(may precede V-Tach, V-fib
COMPLICATIONS OF AMI- Cardiogenic shock - what % of loss of function?
assoc with > 40% loss of Left Ventricle function.
GOALS OF TREATMENT FOR AMI
Preserve Myocardium (reperfusion)
Control pain
Manage and prevent complications
Cardiac Rehabilitation
ACS Chest Pain Protocol - Symptoms suggest MI CHEST PAIN, what do you do? (time…)
Activate EMS (Emergency Med System)
Time CP (chest pain) began (< 12 hrs or > 12 hrs?)
ABC’s, VS, CPR, Defibrillation
Cardiac Monitor
IV access, Labs (Troponin, Coags, lytes, CBC, Chem..)
Focused Exam, Hx, Fibrinolytic Checklist
Initiate ED TX MONA BT
If STEMI < 12 hr.. (ST Elevation Myocardial Infarct)
MONA B + (and how much?)
O2 4L/min np
ASA 160 to 325mg chew tablet
Nitro SL 0.4 q5min X 3 doses (Caution - don’t give nitro w/ an inferior MI can cause hypotension)
Morphine if pain not relieved with NTG
Beta Blocker (Metropolol 5mg to 15mg)
PCI/Thrombolytics
BEST OUTCOMES WITH PCI - when can you use it?
Percutaneous coronary intervention with angioplasty and stent (preferred treatment for ST-elevation MI) (for a STEMI less than 12 hours***)
Start MONA B
Treat or transfer to hospital with PCI capability
Door to Balloon < 90min
PCI WITH PTCA
Percutaneous Coronary Intervention with Percutaneous Transluminal Angioplasty with Stent
If PCI NOT Available AND CP (chest pain) is < 12 HOURS, give…
THROMBOLYTICS, an
IV Medication that dissolves the Blood Clot
Reduces mortality ↓ 2.5 – 5%
Must be used with CP less than 6-12 hours
Goal: Door to Needle less than 30 min
What if it the patient has had Chest Pain for more than 6 to 12 hours??
Need to consult with Cardiology
AMI > 12 hours - STABLE MI - what meds (ace is older than 12 hours)
Admit CCU, Continuous Monitoring
Ace Inhibitor, Morphine, beta blocker, NTG
Echocardiogram
AMI > 12 hours - UNSTABLE MI (the cabbage is severe)
Possible..Cardiac Cath
Possible PCI or CABG (Coronary Artery Bipass graft)
Possible IABP (Intra-aortic balloon pump)
MEDICATIONS for AMI - ASA
160 – 325mg (best to chew tablet)
23% reduction in 30-day mortality
In patients with unstable angina yields 50% reduction in mortality.
(Thrombolytics 2.5 - 5 % reduction)
MEDICATIONS for AMI - heparin (everyone loves hepburn)
Should be used in all suspected AMI’s without contraindications
2.4% reduction in death
Also given to pts who get Thrombolysis tx.
meds for AMI - morphine (how much)
↓ Pain, anxiety, ↓ cardiac workload
1 – 5 mg q 5 minutes until pain controlled. (√ hypotension, ↓RR)
meds for AMI - nitro - what does it do? (nitro before and after)
↓ Pain, ↓ preload and afterload
0.3 – 0.4 SL (subligual or Nasal q 5 min X 3 doses then IV 10 – 20mcg/min
meds for AMI - Antiarrhythmics (Mi Am a Pro Lid)
prn (Amiodarone, Lidocaine, Procainamide..)
meds for AMI - Beta Blocker - what do they do? (not HR, but…)
Metoprolol (Lopressor)
Give in ED, ↓ pulse and O2 demand
↑ survival rate (saves 1 in 140 lives) IV/ PO
meds for AMI - ACE inhibitors - when to start? and for how long? (6 Aces)
Start within 6 - 12 hrs of MI and continue for at least 6 weeks.
Studies show better survival rates
Treat arrhythmias - when to defib?
Defibrillate
V-fib, and pulseless V-Tach
SUDDEN CARDIAC DEATH - usually from what?
Sudden Cardiac Arrest and Death usually from V Fib during AMI
In spite of aggressive CPR in the field, few who develop out-of-hospital cardiac arrest will survive.
ETIOLOGY of Sudden Cardiac Death - what does it usually start with? (sudden cardiac death is tacky)
Most pts have pre-existing multi-vessel dz
75% have occlusive atherosclerosis
Sudden Cardiac arrest usually begins with V-Tach to V-Fib, then Asystole.
Sudden Cardiac Death - medical management
DEFIBRILLATION
CAD: FACTS ABOUT SUDDEN CARDIAC ARREST - what do they die from? (Gabrielle has Sudden cardiac death)
ALMOST ALL PEOPLE WITH SUDDEN CARDIAC ARREST DIE FROM V-FIB.
FROM THE TIME A PERSON GOES INTO CARDIAC ARREST UNTIL THEY ARE DEFIBRILLATED IS CRUCIAL TO THEIR SURVIVAL RATE.
90% SURVIVAL RATE IF DEFIB IN 1 MINUTE FROM ARREST
10% SURVIVAL RATE IF DEFIB AFTER 9 MINUTES
most dangerous plague is a
thin fibrous cap and large lipid core
20 minutes after ischemia (die in 20 min)
necrosis begins in the heart
Non-stemi
non ST elevated MI
troponin T - levels (T is a very low 1)
normal is less than 0.01. MI is 0.1
troponin I - levels (I am just a zero less)
normal less than 0.1. MI is 1.
if MI is suspected…door to balloon time and door to needle time
Door to Balloon (PCI with Stent) 90 min for Percutaneous Coronary Intervention -OR-
Door to Needle (Fibrinolytics) 30 min
if PCI is not available…
start Fibrinolytics w/in 30 min
memorize slide
41 ACS powerpoint
AMI - symptoms - when does it occur? how long does it last? (Am I having a heart attack for 20 min?)
Can occur while active or at rest
Usually lasts longer than 20 minutes or >
AMI - stomach issues?
Associated sx’s: N/V, diaphoresis, anxiety
Can present atypically especially in woman, diabetics and the elderly. - know something is wrong, but can’t really describe it.
GI upset
mid to upper back pain
indigestion
AMI - breathing?
SOB
diagnostics for AMI - CONSIDER
Portable CXR (chest x-ray) to check for (Aneurysms, PE, CHF)
Cardiac Cath, coronary angiography (isolate the occlusion)
EKG - Areas of ischemia and infarct can be noted on the EKG where? (all of them)
lateral, anterior, posterior, inferior….
EKG - Area of infarct can correlate with the possible complications like
CHF, arrythmias, cardiogenic shock..
3-5 leads are not enough
EKG w/ MI - NSTEMI - what will be elevated?
NSTEMI Non-ST elevation MI Troponins will be elevated
(double check placement if you only see elevation in one lead)
diagnostics after an acute MI - Troponin I (isn’t normal right away basically)
Serum Marker First appears
Troponin I 3 – 6 hrs Peaks 14 - 18
Normalizes 5 – 7 days
GET SERIAL TROPONIN LEVELS and SERIAL ECG’S
complications of AMI - what types of arrhythmias (AMIs can go either way)
Tachycardia
Bradycardia
Heart Block
If no PCI available…(fiber to the rescue)
use Fibrinolytics (t-PA)
when is nitro contraindicated? (Nitro is not right, it’s inferior)
Contraindicated in right vent infarct
Suspect if Inferior MI and get Right sided EKG
when are beta blockers contraindicated?
Contraindicated in CHF, hypotension, bradycardia, HB
arrhythmias - what meds? (Octavia arrhythmias)
Amiodarone, Lidocaine
