Cardiology #7: ACS

Question 1

What is the MCC of Acute coronary syndrome (MI)?

Answer 1

Atherosclerosis

-Acute plaque rupture –> coronary artery thrombosis (occlusion)

Question 2

What are symptoms of ACS?

Answer 2

-Chest pain: pain at rest, not relieved with rest or Nitroglycerin, lasting > 30 minutes and may radiate to jaw, left arm, back, shoulders OR change from typical pattern
-Sympathetic stimulation: tachycardia, anxiety, n/v

Question 3

What are FOUR groups of people that can have a silent MI?

Answer 3

Diabetics, women, elderly, obese

Question 4

Explain the following elevations on ECG with the locations of the MI. Also give the artery that is affected with each part.

Anterior Wall:
Lateral Wall:
Anterolateral Wall:
Inferior Wall:
Posterior Wall:

Answer 4

-Anterior: ST elevations V1-V4: LAD; ST elevations in V1 and V2: Proximal LAD
-Lateral: I, avL, V5, V6 = circumflex artery
-Anterolateral: I, avL, V4-V6: LAD or Circumflex
-Inferior: II, III, aVF: RCA
-Posterior: ST depressions V1-V2 = RCA, Circumflex

Question 5

Regarding cardiac markers, which is the most sensitive and specific for an MI?

Which appears the FASTEST?

Answer 5

Troponin is the most sensitive and specific

Myoglobin appears the fastest

Question 6

Cardiac Markers:

-CK/CKMB: Appears, Peaks, Returns to Normal
-Troponin: Appears, Peaks, Returns to Normal
-Myoglobin: Appears, Peaks, Returns to Normal

Answer 6

-CK: Appears 4-6 hours, Peaks 12-24 hours, Normal in 3-4 days

-Troponin: Appears 4-8 hours, Peaks 12-24 hours, Normal in 7-10 days

-Myoglobin: Appears 2-4 hours, Peaks 4-6 hours, Normal in 1 day

Question 7

Regarding the management for ACS, these are the recommendations for testing and treatment times. Explain.

ECG
Door to Thrombolytics
Door to PCI

Answer 7

ECG within 10 minutes

Door to thrombolytics within 30 minutes

Door to PCI within 90 minutes

Question 8

Explain the MONA regimen as treatment for ACS

Answer 8

Morphine
Oxygen
Nitrates
Aspirin (chewed)

Morphine if no relief with Nitrates such as isosorbide dinitrate

Question 9

STEMI Treatment (think HAABRN)

Answer 9

Aspirin
ACEi
BB
Heparin
Nitroglyerin
Reperfusion!!!!

Question 10

NSTEMI or Unstable Angina Treatment

Answer 10

-Same as STEMI, but no emergent reperfusion!

Question 11

With cocaine induced MI, what is the treatment (remember, there’s one thing you should avoid!)

Answer 11

Heparin, Aspirin, Nitro

Avoid BB!!

Question 12

If the chest pain began > 12 hours ago and they do NOT have current CP and are low risk, what is the conservative treatment that can be done for ACS?

Answer 12

-Aspirin +/- Clopidogrel x 9 months
-Statin
-BB
-ACEi
-Nitro

Question 13

What are some complications of ACS

Answer 13

-Dressler Syndrome: Post MI Pericarditis + Fever + Pleural Effusion
-Heart Failure
-Ventricular Fibrillation

Question 14

Explain how a clot is formed

Answer 14

Factor Xa converts prothrombin (II) –> thrombin (Factor IIa). Thrombin activates fibrinogen –> fibrin clot

Question 15

What is the order in which a conduction is sent throughout the heart?

Answer 15

-SA node –> AV node –> Bundle of His –> Left bundle branch –> Right bundle branch –> Purkinje fibers

Question 16

Explain the MOA of anticoagulant Unfractionated Heparin

Answer 16

Binds and potentiates antithrombin III’s ability to inactivate Factor Xa, inactivates thrombin (Factor IIa), inhibits fibrin formation

Question 17

Explain the MOA of anticoagulant LMWH (Enoxaparin)

Answer 17

-More specific to Factor Xa than UFH
-Longer half life (12 hours) than UFH
-No need for PTT monitoring like UFH
-Thrombocytopenia side effect

Question 18

Myocarditis, inflammation of the heart muscle, is MC in _______.

The MCC of myocarditis is ______, but other causes include Autoimmune (SLE, RA), or Medications (Clozapine, Isoniazid, and Phenytoin)

Answer 18

young adults

Viral (Enteroviruses - Coxsackievirus B)

Question 19

Symptoms of Myocarditis include

Answer 19

-Viral prodrome followed by systolic dysfunction (dilated cardiomyopathy)
-HF symptoms (dyspnea, fatigue, S3 gallop)
-Megacolon, Pericarditis

Question 20

What is seen on the following diagnostics for myocarditis?

-CXR:
-ECG:
-Echo:

Answer 20

CXR: Cardiomegaly
ECG: May show pericarditis (diffuse ST elevations and PR depressions)
Echo: Ventricular systolic dysfunction

Question 21

However, what is the GOLD standard diagnostic for myocarditis?

Answer 21

Endomyocardial biopsy

Question 22

What is the treatment for myocarditis?

Answer 22

Supportive
-However, if systolic HF, use ACEi, Diuretics, and BB

Question 23

A Transient Ischemic Attack (TIA) is a transient episode of neuro deficits without acute infarction. What are the symptoms?

What is a TIA associated with a future….

Answer 23

-Deficits lasting < 24 hours
-Complete resolution in 1 hour
-Amaurosis fugax
-Carotid bruits

associated with increased future stroke risk

Question 24

What diagnostics are done for a TIA?

Answer 24

CT scan initially
CT or MR angiography, Carotid doppler
Conventional angiography is definitive

Question 25

Treatment for a TIA

Think both noncardiogenic and cardiogenic

Answer 25

-Supine position
-Only lower BP if > 220/120
-If a Noncardiogenic TIA:
–Antiplatelet: Aspirin, Clopidogrel
–Carotid endarterectomy if 50-99% stenosis of internal carotid
-If Cardiogenic due to A-fib
–Oral anticoagulation