Cardiac review part 2

Question 1

stable angina

Answer 1

chest pain with activity, predictable

lesions are usually fixed and calcified

Question 2

What is the spectrum of Ischemic heart disease?

Answer 2

1. asymptomatic coronary artery disease (CAD)
2. Stable angina

Question 3

Acute coronary syndrome

Answer 3

includes: 1. unstable angina 2. NSTEMI (non-st elevation myocardial infarction) 3. STEMI (st elevation MI)

due to platelet mediated thrombosis

may result in sudden cardiac death

Question 4

unstable angina

Answer 4

chest pain at rest, unpredictable

ST depression or T wave inversion on ECG

troponin negative

relieved with nitroglycerin

Question 5

NSTEMI

Answer 5

unrelenting chest pain

st depression, t wave inversion on ECG

troponin positive

Question 6

STEMI

Answer 6

unrelenting chest pain

ST elevation in 2 or more contiguous leads

troponin positive

Question 7

prinzmetal’s or variant angina

Answer 7

unstable angina associated with transient ST elevation

troponin negative

due to coronary spasm

treat with nitroglycerin

may be precipitated by nicotine, ETOH, cocaine

Question 8

management of acute chest pain includes:

Answer 8

1. Stat ECG (within 10 mins)
2. Aspirin
3. Anticoagulant (hepain or lovenox)
4. antiplatelet agent (plavix, abciximab, eptifibatide, tirofiban)
5. Beta blocker (unless ACS d/t cocaine)
6. treat pain (nitroglycerin and/or morphine)
7. risk factor assessment (cardiac biomarkers)

Question 9

cardioselective beta blocker

Answer 9

metoprolol

Question 10

Inferior MI

Answer 10

associated with RCA occlusion, ST elevation in II, III, and aVF

associated with AV conduction disturbances: 2* type 1 AV block (Weinkebach), 3* AV block, Sick Sinus Syndrome (SSS), sinus bradycardia

development of systolic murmur (mitral valve) s/t papillary muscle rupture

tachycardia associated with mortality

USE beta blockers and NTG with CAUTION

Question 11

Right Ventricular (RV) infarct

Answer 11

RCA supplies the inferior wall of the LV and the RV, so about 30% also have a RV infarct

Right sided ECG

s/s: JVD, high CVP, hypotension, clear lungs, bradyarrythmias, ECG with ST elevation in V3R, V4R

treatment: fluids, positive inotropes

avoid: preload reducers (nitrates, diuretics), caution with beta blockers

Question 12

Anterior MI

Answer 12

associated with LAD (left anterior descending) occlusion, ST elevation in V1-V4

may develop 2* type II AV block (mobitz II) or RBBB (OMINOUS SIGN as the LAD supplies the bundle of HIS)

HEART FAILURE: higher mortality than inferior MI

Question 13

Lateral MI

Answer 13

ST elevation in V5, V6 (low lateral)
ST elevation in I, aVL (high lateral)
Generally involves left circumflex artery

Question 14

Treatment of STEMI

Answer 14

goal is REPURFUSION

PCI (door to balloon in 90 mins)
Fibrinolytic therapy (door to drug 30 mins)

criteria: ST elevation in 2+ leads, onset of chest pain < 12 hrs, chest pain of 30 mins duration, chest pain unresponsive to NTG

Question 15

adverse reaction to STEMI treatment

Answer 15

vasovagal reaction (hypotension, absence of reflex tachycardia) - give fluids, atropine

sheath site bleeding - apply pressure 20 mins

retroperitoneal bleeding (hypotension, back pain) - fluids, blood products

vascular complications - assess pulses