Cardio: Ischemia

Question 1

Periop PCI complications
How to recognize cholesterol embolization

Answer 1

purpura,
livedo reticularis
renal impairment
blue toes

Question 2

PCI complications Restenosis when does it happen ? How does it present

Answer 2

• first 3-6 months

Occurs 5-20% of pts

recurrence of angina symptoms

Question 3

PCI complications stent thrombosis
-When does it present and how

Answer 3

• first month
• occurs in 1-2% of patients,
• presents with acute MI

Question 4

Presentation of absent limb pulse.

Answer 4

Consider Takayasu’s arteritis is a large vessel vasculitis

Question 5

MI: How to manage
Glycaemic control in patients with diabetes mellitus

Answer 5

dose-adjusted insulin infusion with regular monitoring of blood glucose levels to glucose below 11.0 mmol/l

Question 6

Best marker for reinfarction

Answer 6

CK-MB

Question 7

ST elevation V1-V4
What artery?

Answer 7

Left anterior descending
Anteroseptal

Question 8

ST elevation II, III, aVF What artery?

Answer 8

Right coronary
Inferior MI

Question 9

Tall R waves V1-2

Answer 9

Posterior
Usually left circumflex, also right coronary

Question 10

ST elevation V4-6, I, aVL

Answer 10

Left anterior descending or left circumflex
Anterolateral

Question 11

angina-like chest pain on exertion
ST depression on exercise stress test
but normal coronary arteries on angiography

Answer 11

Syndrome X

Question 12

transient ST elevations
Which can occur at rest

Answer 12

Prinzmetal

Question 14

List the 3 components of Anginal pain
How is typical and Atypical angina defined

Answer 14

1. Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
2. Precipitated by physical exertion
3. Relieved by rest or GTN in about 5 minutes

Interpretation:
Pts with all 3 features = typical angina

pts w/ 2 of the above features = atypical angina

Pts with 1 or none=non-anginal chest pain

Question 15

If starting duel therapy for angina but cant have the addition of CCB/ β-blocker
What other drug should be considered (4)

Answer 15

Consider one of the following drugs: a
 long-acting nitrate,
 ivabradine,
 nicorandil or ranolazine

Question 16

If a further drug is needed after duel tx in angina
what should they be lined up for?

Answer 16

is awaiting assessment for PCI or CABG

Question 17

Criteria for PCI (3)

Answer 17

1. within 12 hours of the onset of symptoms + PCI can be delivered within 120 minutes
2. Pt presenting >hr12 but evidence of ongoing ischemia
   Or
3. Pts ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI

Question 18

Drug used in Fibrinolysis

Answer 18

Streptokinase/ Alteplase

Question 19

Indications for Fibrinolysis

Answer 19

Within 12 hours of the onset of symptoms + BUT PCI can’t be delivered within 120 minutes

Question 20

All MI pts get

Answer 20

All pt rx
300 Aspirin
morphine ONLY with severe pain
nitrates but not in hypotension

Question 21

Drug commenced prior to PCI
-on oral anticoagulant
- not on oral anticoagulant

Answer 21

Dual anti platelet therapy aspirin + another drug
Give

Prasugrel- if not taking an oral anticoagulant. Nb high bleeding risk

clopidogrel if already on oral anticoagulant

Question 22

Drug given during PCI

Answer 22

Radial access-unfractionated heparin w/bailout glycoprotein IIb/IIIa inhibitor (GPI)

femoral access: bivalirudin with bailout GPI

Question 23

During Fibrinolysis
What drug is given during

ECG should be repeated after 60-90 minutes to look for resolution. If not PCI

Answer 23

Give Antithrombin - unfractionated heparin (UFH),
LMWH,
fondaparinux
bivalirudin.)

Question 24

Drug give Post Fibrinolysis & when should ECG be repeated?

Answer 24

Post Fibrinolysis
-Ticagrelor
ECG should be repeated after 60-90 minutes to look for resolution. If not PCI

Question 25

Initial Rx of unstable angina/ NSTEMI if PCI is NOT planned immediately &
patients creatinine is <265 µmol/L

Answer 25

Aspirin
Fondaparinux
If > 265 give unfractionated heparin

Question 26

Initial Rx of unstable angina/ NSTEMI if PCI is planned or patients creatinine is >265 µmol/L

Answer 26

Aspirin
unfractionated heparin
Prasugrel or ticagrelor

Question 27

Indications for immediate angiography for NSTEMI/Angina

Answer 27

Clinically unstable

Question 28

Indications for angiography within 72 hours

Answer 28

Pt w/ Grace score >3 %

Question 29

5 or 6 Drugs started post MI

Answer 29

1. ACEi/ ARB - ( ramipril)
2. β-blocker - continued for at least 12 months after a MI.
3. Dual antiplatelet therapy ASPRIN + 2nd antiplatelet agent – clopidogrel/prasugrel/ ticagrelor; 2nd usually continued for up to 12 months following a MI
   - Cant tolerate aspirin- clopidogrel monotherapy
4. Statin-
5. Aldosterone antagonists - acute MI +HF(LVD); initiated within 3-14 days of the MI,

Question 30

After PCI What causes
* Eosinophilia
* purpura, livedo reticularis
* renal impairment
* blue toes

Answer 30

cholesterol embolization

Question 31

with in a month of PCI
presenting w/ MI

Answer 31

Stent Thrombosis
occurs in 1-2% of patients,

Question 32

After PCI when does Restenosis occur and how does it present?

Answer 32

• first 3-6 months

Occurs 5-20% of pts

usually presents with the recurrence of angina symptom

Question 33

What cause Cardiac arrest after MI

Answer 33

VF

Question 34

What arrhythmia occurs after inferior MI

Answer 34

Bradyarrhythmias/ AV block

Question 35

What often occurs within the first 48 hours following a transmural MI

Answer 35

Pericarditis

Question 36

What is Dressler’s syndrome? when is it likely to occur?

Answer 36

2-6 weeks following a MI-
autoimmune reaction

Raised ESR fever, pleuritic pain and pericardial effusion,

Question 37

Persistent ST elevation+ LVF after MI but no chest pain

Answer 37

Left ventricular aneurysm

Question 38

How and when does
Ventricular free wall rupture present
RX

Answer 38

1-2 weeks
acute HF 2dary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds).

Urgent pericardiocentesis and thoracotomy are require

Question 39

1st week After MI presents with
acute HF w/ a pan-systolic murmur

Answer 39

Rupture of the interventricular septum/ VSD