Cardiovascular 2

Question 1

Acute coronary syndrome (ACS): Definition

Answer 1

Acute coronary syndrome (ACS) refers to a spectrum of clinical presentations ranging from those for ST-segment elevation myocardial infarction (STEMI) to presentations found in non–ST-segment elevation myocardial infarction (NSTEMI) or in unstable angina. It is almost always associated with rupture of an atherosclerotic plaque and partial or complete thrombosis of the infarct-related artery.

Question 2

ACS: 3 types

Answer 2

STEMI, NSTEMI, unstable angina (UA)

Question 3

ACS Tx: priority for all ACS

Answer 3

ASA
Nitroglycerin SL q5 min. (use caution w/ inferior MI since it may cause severe HoTN)
O2 if SaO2 < 90%
Morphine IV (relieves pain, anxiety, lower BP at the cost of preload)

Question 4

ACS Tx: STEMI specific

Answer 4

Anticoagulation: heparin
Revascularization: PCI (within 3 hrs of recognition of STEMI) or thrombolytic Thx (Alteplase)
Lifelong anticoagulation

Question 5

Percutaneous intervention (PCI): 4 types

Answer 5

1. PTCA
2. Stenting
3. Laser/rotational atherectomy
4. Brachytherapy

Question 6

ACS Tx: NSTEMI/UA specific

Answer 6

Anticoagulation: heparin
Cardiac imaging (for evaluation of myocardial function)
Coronary angiography

Question 7

Inflammatory myocarditis: causes

Answer 7

Insect borne infections (Borrelia burg or Trypanosoma cruzi)
Viruses (Parvovirus-B19, Coxcackie)
Hypersensitivity post Strep pyogenes infection

Question 8

Inflammatory myocarditis: S/Sx

Answer 8

Presents as CHF w/ systolic dysfunction

**If you see CHF in a Pt w/ no MI risk factors, ask if the Pt had some other S/Sx before he got CHF

Question 9

Inflammatory myocarditis: Tx

Answer 9

Abx if bacterial infection

Supportive care for CHF

Question 10

Inflammatory myocarditis: Pearls

Answer 10

Poor prognosis for Pts w/ a high-degree AV block or RV dysfunction
Can occur simultaneously w/ pericarditis

Question 11

Endocarditis: definition

Answer 11

infection of the endocardial surface of the heart (see the image below), which may include one or more heart valves

Question 12

Endocarditis: causes (long- and short- incubation)

Answer 12

Long-incubation (subacute): often Strep spp., forms over wks to months. Less destructive and does not metastasize.
Short-incubation (acute): often Staph spp., forms over days to wks. Often metastasize and frequently fatal.

Question 13

Endocarditis: S/Sx

Answer 13

• Persistent fever, new/changing heart murmur, wt loss, cough
• Subungual (splinter) hemorrhages
• Osler nodes and/or Janway lesions
• Roth spots (rare)

Question 14

Endocarditis: Dx

Answer 14

Dx w/ Duke Criteria

IE is definite in the presence of 2 major criteria, or 1 major + 3 minor criteria, or 5 minor criteria

Question 15

Duke Criteria: Major criteria

Answer 15

1. Microorganisms consistent w/ IE from 2 separate/persistently positive blood cultures
2. Echo is IE positive
   New valvular regurgitation

Question 16

Duke Criteria: Minor criteria

Answer 16

1. Predisposing heart condition, injection drug use
2. Temp > 38
3. Vascular phenomena
4. Immunologic phenomena
5. Microbiological evidence

Question 17

How to recognize an inferior STEMI: EKG

Answer 17

• ST elevation in leads II, III and aVF
• Progressive development of Q waves in II, III and aVF
• Reciprocal ST depression in aVL (± lead I)