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RACP Written 2018 > Cardiology - Acute Coronary Syndrome > Flashcards

Cardiology - Acute Coronary Syndrome Flashcards

1
Q

Acute ACS Management

What do you give at SAAS level?

A
  • Aspirin
  • O2 if sats <94%
  • nitrates
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2
Q

Why don’t we give O2 to everyone with ACS?

A

AVOID Study:

If sats >94% infarcts are BIGGER and MORE RECURRENT INFARCTS

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3
Q

Cardiac Biomarkers:
Myoglobin

Rise?
Peak?
Normalises?

A

Rises: 1-2 hours
Peaks: 6-8 hours
Normalises: 1-2 days

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4
Q

Cardiac Biomarkers:
CKMB

Rise?
Peak?
Normalises?

A

Rises: 2-6 hours
Peaks: 16-20 hours
Normalises: 2-3 days

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5
Q

Cardiac Biomarkers:
CK

Rise?
Peak?
Normalises?

A

Rises: 4-8 hours
Peaks: 16-24 hours
Normalises: 3-4 days

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6
Q

Cardiac Biomarkers:
Trop T

Rise?
Peak?
Normalises?

A

Rises: 4-6 hours
Peaks: 12-24 hours
Normalises: 7-10 days

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7
Q

Cardiac Biomarkers:
AST

Rise?
Peak?
Normalises?

A

Rises: 12-24 hours
Peaks: 36-48hrs
Normalises: 3-4 hours

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8
Q

Cardiac Biomarkers:
LDH

Rise?
Peak?
Normalises?

A

Rises: 24-48hrs
Peaks: 72hours
Normalises: 8-10 days

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9
Q

Of the cardiac biomarkers what order do they appear?

A 
Myoglobin
CKMB
CK and Troponin
AST
LDH
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10
Q

STEMI presents WITHIN 12 hours of symptoms

What management?

A

PCI within 90 minutes!!

BUT if you can’t, then give fibrinolysis

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11
Q

Given fibrinolysis in a non-PCI hospital. Should we transfer?

A

Transfer to PCI capable hospital within 24 hours to get either angiography or PCI

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12
Q

Given fibrinolysis in a non-PCI hospital, when would we transfer IMMEDIATELY?

A
  • haemodynamic instability

- <50% ST recovery by 60-90 minutes

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13
Q

What is the PharmacoIntemsive approach to STEMI? What benefits?

A

In HIGH RISK STEMI within 12 hours of symptoms then give FULL DOSE THROMBOLYSIS followed by PCI within 3-24 hours

Benefits:

  • lower infarction rates
  • lower recurrent ischaemia
  • lower 1yr composite endpoints

BUT more intracranial haemorrhage than just PCI and POTENTIALLY JUST AS EFFECTIVE AS PCI ALONE

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14
Q

How many people don’t reperfuse when given thrombolysis?

A

30%

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15
Q

Absolute contradictions to thrombolysis?

A

1) Any previous ICH
2) Known cerebral AVM
3) Ischaemic stroke within past 3 months
4) Active bleeding or bleeding diathesis
5) significant closed head or facial trauma within last 3 months
6) suspected aortic dissection

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16
Q

When should you repeat the ECG after thrombolysis and what should you look for?

A

At 90 minutes

If there is <=50% ST resolution then NEED IMMEDIATE PCI

17
Q

Indication for thrombectomy in STEMI?

A

Do NOT do thrombectomy as NO BENEFIT and INCREASED STROKE

18
Q

Culprit versus Complete Revascularisation?

A

Treat culprit at a later date.

DO NOT open a totally occluded artery in 1 or 2 vessel disease if >24 hours post STEMI

19
Q

When is a CABG superior to PCI?

A
  • 3 vessel disease
  • Left Main Disease
  • diabetes and >1 vessel disease
20
Q

Benefits of radial access in STEMI compared to femoral access?

A
  • lower composite MI/death/stroke
  • decreased overall MORTALITY
  • decreased bleeding
  • decreased length of stay
  • less painful
21
Q

Risks of radial access in STEMI compared to femoral access?

A
  • longer

- more contrast

22
Q

At what sized infarct is there a significantly higher rate of death or heart failure?

A

Infarct size >17%

23
Q

Complications post STEMI: What is the impact of arrythmia <24 hours post STEMI

A

NO IMPACT on PROGNOSIS if ventricular arrythmia in first 24 hours

24
Q

Complications post STEMI: What is the impact of recurrent ventricular arrythmia >24 hours post STEMI

A
  • Indicate larger infarcts

- Higher short AND long term mortality

25
Q

Complications post STEMI: Role of lidocaine in arrythmias?

A

Lidocaine reduces INCIDENCE of VT
BUT not mortality!
AND predisposes to asystole and bradycardia

26
Q

Complications post STEMI: RV infarct results in what pathophysiological impact? How do you manage initially to avoid shock?

A

Decreased pulmonary blood flow and LA repair
Results in decreased preload and impaired LV filling

Treatment:

  • reperfusion
  • aggressive IVT
  • Inotropes until RV function improves (usually 2-3 days)
27
Q

Complications post STEMI: Ventricular Septal Defect
? when do they occur
? signs
? management

A

HIGH MORTALITY!!
Occur 3-7 days post MI

Signs: new HD compromise and new HOLOSYSTOLIC MURMUR

Treat with vasopressors and intra-aortic balloon pump

28
Q

Complications post STEMI: Mitral regurgitation
? most common after which type of infarct
? when do they usually occur

A

More common post INFERIOR-POSTERIOR INFARCTION

If due to papillary muscle rupture then usually 3-7 days post MI

29
Q

Complications post STEMI: LV Free Wall Rupture
? most common after which type of infarct
? when do they occur
? commonly present with what

A

HIGH MORTALITY
More common post ANTERIOR MI
Occur 3-7 days post MI

Often present with pericardial tamponade, PEA and death

30
Q

Complications post STEMI: LV Thrombus
? most common after which type of infarct
? treatment

A

More common post ANTERIOR MI

Treat with warfarin 3-6 months

31
Q

What is the use of TIMI score in NSTEMI?

A

If score 0-2 then use ischaemia guided strategy. Only use invasive if medical fails.

32
Q

Components of TIMI score in NSTEMI?

A
  • Age >65yrs
  • > 3 traditional risk factors
  • Known CAD with stenosis >50%
  • Aspirin use in past week
  • > 2 angina episodes in 24 hours
  • ST deviation >0.5mm
  • Elevated cardiac biomarkers (CKMB/Troponin)
33
Q

When is an AICD indicated post ACS?

A

AICD indicated if LVEF <35% at 40 days post MI

34
Q

Which CLINICAL factors increase risk of stent thrombosis? (7)

A
  • Age >80yrs
  • ACS indication for stent insertion
  • Diabetes
  • Renal impairment
  • Low EF
  • Previous brachytherapy
  • Previous stent thrombosis
35
Q

Which ANATOMICAL factors increase risk of stent thrombosis? (6)

A
  • bifurcation stenting
  • ostial stenting
  • left main stem stenting
  • small (<3mm) stent
  • long (>18mm) stent
  • multiple stents
36
Q

Which surgeries have an UNACCEPTABLE risk of bleeding?

A
  • intracranial
  • spinal
  • eye
  • TURP
  • plastic reconstructive
37
Q

How long to defer elective non-cardiac surgery post stenting

A

Post BMS: Defer >6 weeks (ideally 3 months)

Post DES: Defer 12 months

38
Q

Poor Prognostic Features post ACS

A
  • Age
  • Hx of heart failure
  • Peripheral vascular disease
  • Reduced systolic BP
  • Killip Class
  • Initial serum Cr
  • Initial cardiac biomarker elevation
  • Cardiac arrest on admission
  • ST segment deviation
39
Q

Killip Class post ACS

A

Increased mortality with increased class

Killip 1: No clinical signs of heart failure
Killip 2: Crackles / S3
Killip 3: Frank APO
Killip 4: Cardiogenic shock

RACP Written 2018 (167 decks)

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