AMI

Question 1

What post-AMI event should you be on alert for in someone who has recently had an MI?

Answer 1

• Free wall rupture occurs in 10% of AMI fatalities, usually 1 to 5 days after infarction. Rupture of the left ventricular free wall usually leads to pericardial tamponade and death (in >90% of cases).
• Papillary muscle rupture occurs in approximately 1% of patients with AMI, is more common with inferior MI, and usually occurs 3 to 5 days after AMI.
• Rupture of the interventricular septum is more common in patients with anterior wall MI and patients with extensive (three-vessel) CAD.

Question 2

What percent of AMI presents with cardiogenic shock, and what percentage of those are due to mechanical failures?

Answer 2

6-8% of AMI has associated cardiogenic shock.

25% of cardiogenic shock in AMI is due to mechanical failures.

Question 3

RV infarction occurs in conjunction with what?

What is a common finding with RV infarction that is contradictory to normal MI management?

Answer 3

30% of inferior MI have RV infarction.

Hypotension and

Question 4

Doing what to a RV infarction will be bad?

Answer 4

Factors that reduce preload (volume depletion, diuretics, and nitrates) or decrease right atrial contraction (atrial infarction and loss of AV synchro- ny) and factors that increase RV afterload (left ventricular failure) can lead to significant hemodynamic derangements.

Question 5

RV infarction treatment should include what?

When LV dysfunction occurs simultaneously, what can be done?

Answer 5

Patients with marginal preload or hypotension should be treated with volume loading (normal saline). The increased preload will improve RV cardiac output. If cardiac output is not improved after 1 to 2 L of normal saline, begin inotropic support with dobutamine.

• Addition of nitroprusside to decrease LV afterload or a balloon pump may be of benefit. Reduction in left ventricular afterload may help passive movement of blood through the right ventricle.

Question 6

Cocaine induced MI management should include what?

Answer 6

Troponin (most sensitive to detect MI in cocaine induced MI)

Nitrates, ASA and benzos are best therapies to stabilize. Beta blockers are contraindicated.

PCI is the primary therapeutic strategy.

Question 7

Cardiogenic shock is what?

Answer 7

Evidence of tissue hypoperfusion and volume overload.

HD criteria are:

1) sustained hypotension (systolic BP <90 mm Hg),
2) reduced cardiac index (<2.2 L/ min per m2),
3) an elevated (>18 mm Hg) pulmonary artery occlusion pressure

Question 8

What is the DDx for cardiogenic shock?

Answer 8

Question 9

Management of cardiogenic shock is what? (in order)

Answer 9

ECG, +/- V4R if inferior MIABG (6% vs 31% mortality if RV infarction)

ABG

CXR

ED ECHO

ASA, heparin, and very careful IV nitro and morphine.

β-Blockers should not be given to cardiogenic shock pts.

Small fluid bolus (250ml), if not responsive or develops edema, then

In the absence of profound hypotension, dobutamine is a mainstay of initial pharmacologic treatment. With systolic BP <70 mmHg, dopamine is preferred as a single agent or in combination with dobutamine.

Question 10

Cardiogenic shock with acute MR or acute VSD (septal wall blowout) should be treated with what?

Answer 10

Dobutamine and nitroprusside, as a temporizing measure to aortic balloon pump and PCI/bypass surgery.

Question 11

How do you risk stratify MI?

Answer 11

Question 12

What are the contraindications to ASA?

Answer 12

Contraindications to aspirin include: HARP GAS

Hemophilia

Bleeding

Ulcer

Severe HTN

Allergy