Cardiovascular Medicine: Acute Coronary Syndromes Flashcards
what are the classical anginal sxs?
- substernal CP w/ exertion
- CP relief w/ rest or nitroglycerin
what are anginal equivalents?
- exertional dyspnea
- fatigue
- N/V
in which pts are anginal equivalents most commonly found?
- DM pts
- females
signs of cardiac ischemia
- new MR murmur
- new S3 gallop
- new S4 gallop
what distinguishes the 3 types of ACS?
- 12-lead ECG and cardiac markers
what might an echocardiogram show in ACS?
regional wall motion abnormalities
in which pts might an echocardiogram be especially useful if ACS is suspected?
pts w/ LBBB
which ACS?
- normal cardiac biomarkers
- no characteristic ECG changes
unstable angina
which ACS?
- positive cardiac biomarkers WITHOUT STE or STE equivalents
- STD and nonspecific changes may be seen
NSTEMI
which ACS?
- positive cardiac biomarkers WITH STE in 2 or more contiguous leads
- STE equivalents include new LBBB or posterior MI (tall R waves and STD in V1-V3)
STEMI
what are STE equivalents?
- new LBBB
- posterior MI (tall R waves and STD in V1-V3)
ECG localization of AMI:
- anatomic location: INFERIOR
- ST-segment change: elevation
- what are the indicative ECG leads?
2, 3, aVF
ECG localization of AMI:
- anatomic location: ANTEROSEPTAL
- ST-segment change: elevation
- what are the indicative ECG leads?
V1-V3
ECG localization of AMI:
- anatomic location: LATERAL and APICAL
- ST-segment change: elevation
- what are the indicative ECG leads?
V4-V6, possibly 1 and aVL
ECG localization of AMI:
- anatomic location: POSTERIOR WALL**
- ST-segment change: depression
- what are the indicative ECG leads?
(often a/w inferior and/or lateral STE infarctions)
tall R waves in V1-V3
ECG localization of AMI:
- anatomic location: RIGHT VENTRICLE**
- ST-segment change: elevation
- what are the indicative ECG leads?
(often a/w inferior and/or lateral STE infarctions)
V4R-V6R; tall R waves in V1-V3
why is the TIMI score used?
estimate risk in pts w/ unstable angina/NSTEMI to guide therapy
TIMI risk score components
- age 65 or more
- 3 or more CAD risk factors
- prior coronary obstruction 50% or more
- ST-segment changes
- 2 or more episodes of angina w/i 24 hours
- aspirin use in past week
- elevated biomarkers
management strategy if TIMI risk score is 0-2
- start aspirin,
- BB,
- nitrates,
- heparin,
- statin,
- clopidogrel
- predischarge stress test and angiography if significant myocardial ischemia
management strategy if TIMI risk score is 3-7
- start aspirin,
- BB,
- nitrates,
- heparin,
- statin,
- GP 2b/3a inhibitor
- clopidogrel
- EARLY angiography
when is immediate angiography also indicated in ACS?
- hemodynamic instability
- HF
- recurrent REST angina despite therapy
- new or worsening MR murmur
- sustained VT
DON’T BE TRICKED
besides STEMI, what are other causes of STE’s??
- acute pericarditis
- LV aneurysm
- takotsubo (stress) CM
- coronary vasospasm (Prinzmetal angina)
- normal variant
other causes of acute chest pain:
- vignette: young woman w/ /o migraines, acute CP, and STE
- possible dx
- test/therapy
- coronary vasospasm (Prinzmetal angina, variant angina)
- CCB
other causes of acute chest pain:
- vignette: young person w/ CP following a party
- possible dx
- test/therapy
- cocaine
- CCB (avoid BB)
other causes of acute chest pain:
- vignette: tall, thin person w/ long arms w/ acute chest and back pain, normal ECG, and aortic diastolic murmur
- possible dx
- test/therapy
- Marfan syndrome w/ aortic dissection
- MRI, contrast CT, or TEE
- immediate surgery for type A dissection
other causes of acute chest pain:
- vignette: a pt who recently traveled or w/ immobility, sharp or pleuritic CP, and nondiagnostic ECG
- possible dx
- test/therapy
- PE
- UFH or LMWH
- CTA
other causes of acute chest pain:
- vignette: tall, thin young man who smokes w/ sudden pleuritic chest pain and dyspnea
- possible dx
- test/therapy
- spontaneous PTX
- CXR
other causes of acute chest pain:
- vignette: postmenopausal woman w/ substernal CP following severe emotional/physical stress has STE in the anterior precordial leads, troponin elevation, and unremarkable coronary angiography
- possible dx
- test/therapy
- stress-induced (takotsubo) CM
- look for characteristic apical ballooning on ventriculogram
- BB
other causes of acute chest pain:
- vignette: young man w/ substernal CP, deep T-wave inversions in V2-V4, and a harsh systolic murmur that increases w/ Valsalva maneuver
- possible dx
- test/therapy
- HCM
- echocardiography
- BB
STEMI goal time
- first medical contact to PCI time 90 minutes or LESS
- 120 minutes or less IF transferred from non-PCI capable facility
other indications for PCI
- failed thrombolysis (continued CP, persistent STE’s)
- fibrinolysis contraindicated
- STEMI w/ continued chest pain or STE 12-24 HOURS AFTER ONSET
- new HF or cardiogenic shock
if PCI is NOT available, tx for STEMI
thrombolysis
MC CI’s for thrombolysis tx in STEMI
- active bleeding
- high r/o bleeding (recent major surgery)
- BP > 180/110 on presentation
indications for acute CABG
- failure of thrombolysis
- failure of PCI
- mechanical complications (papillary muscle rupture, VSD, free wall rupture)
presentation of RV/posterior MI
- hypotension or hypotension after nitroglycerin or morphine
tx for hypotension in setting of RV/posterior MI
IVF
signs of RV/posterior MI
- elevated CVP w/ clear lungs
- hypotension
- tachycardia
most predictive ECG finding for RV/posterior MI
STE in lead V4R on right-sided ECG
when should place an IABP in STEMI pts?
- cardiogenic shock
- acute MR
- acute VSD
- intractable VT
- refractory angina
DON’T BE TRICKED
when should you ONLY transfer a STEMI pt for PCI instead of thrombolytic therapy?
ONLY if PCI can be done 120 minutes or less
DON’T BE TRICKED
when should you NOT use thrombolytic therapy?
- pts w/ NSTEMI
- asymptomatic pts w/ onset of pain > 24 hours
DON’T BE TRICKED
what is the typical reperfusion arrhythmia that can occur after thrombolytic therapy?
transient accelerated idioventricular arrhythmia
DON’T BE TRICKED
should you tx referfusion arrhythmias following thrombolytic therapy?
NO
drug therapy for MI:
- indication for aspirin
- ASAP for all pts w/ ACS
- continue indefinitely as secondary prevention
drug therapy for MI:
- indication for P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel)
- ASAP for all pts w/ ACS
- continue for 1 year following MI
drug therapy for MI:
- indication for AC (UFH, LMWH, bivalirudin)
- ASAP for definite or likely ACS
drug therapy for MI:
- indication for GP 2b/3a antagonists (abciximab, eptifibatide, tirofiban)
- ASAP for HIGH-risk NSTEMI
- give prior to PCI
drug therapy for MI:
- indication for BB (metoprolol, carvedilol)
- give w/i 24 hours
- continue indefinitely as secondary prevention
drug therapy for MI:
- indication for CCB (NOT nifedipine)
- use BB is CI
drug therapy for MI:
- indication for ACEI
- give w/i 24 hours
- continue indefinitely in pts w/ reduced IVEF or clinical HF
drug therapy for MI:
- indication for ARB
- give if can’t take ACEI
drug therapy for MI:
- indication for nitroglycerin
- give if ongoing chest pain or HF
drug therapy for MI:
- indication for statin
- given high-intensity statin early
- continue indefinitely as secondary prevention
drug therapy for MI:
- indication for eplerenone
- give 3 to 14 days after MI if LVEF 40% or less and clinical HF or DM
when does stent thrombosis occur?
24 hours to 1 year after placement
how does stent thrombosis present?
- recurrent angina
- sudden death
- MI, usually w/ STE
how to prevent stent thrombosis?
DAPT
indication and duration of DAPT
- stable angina pectoris
- if NO stent
- if bare-metal stent (BMS)
- if drug-eluting stent (DES)
- clopidogrel, only if can’t take aspirin
- aspirin and clopidogrel for 1 month, then only aspirin
- aspirin and clopidogrel for 1 year, then only aspirin
indication and duration of DAPT
- unstable angina/NSTEMI
- if NO stent
- if bare-metal stent (BMS)
- if drug-eluting stent (DES)
- aspirin and clopidogrel or ticagrelor for 1 year, then only aspirin
- aspirin and clopidogrel, prasugrel, or ticagrelor for at least 4 weeks to 1 year, then only aspirin
- aspirin and clopidogrel, prasugrel, or ticagrelor for 1 year, then only aspirin
indication and duration of DAPT
- STEMI
- if NO stent
- if bare-metal stent (BMS)
- if drug-eluting stent (DES)
- aspirin and clopidogrel or ticagrelor for 1 year, then only aspirin
- aspirin and clopidogrel, prasugrel, or ticagrelor for at least 4 weeks to 1 year, then only aspirin
- aspirin and clopidogrel, prasugrel, or ticagrelor for 1 year, then only aspirin
DON’T BE TRICKED
which med’s effectiveness is unknown in pts w/ AMI?
spironolactone
when should you temporarily pace a pt w/ AMI?
- asystole
- symptomatic bradycardia (including complete heart block)
- alternating LBBB and RBBB
- new or indeterminate-age bifasicular block w/ 1st-degree AVB
what are the mechanical complications of MI?
- VSD
- papillary muscle rupture
- LV free wall rupture
when do mechanical complications of MI occur?
2-7 days after MI
what are the physical exam findings of VSD and papillary muscle rupture?
- abrupt pulmonary edema
- hypotension
- loud holosystolic murmur and thrill
what are the physical exam findings of LV free wall rupture?
- sudden hypotension
- sudden cardiac death w/ PEA
how to stabilize pts w/ VSD and papillary muscle rupture?
- IABP
- afterload reduction w/ sodium nitroprusside
- diuretics
- emergent surgical intervention
how to stabilize pts w/ LV free wall rupture?
- emergent pericariocentesis
- emergent surgery
when is cardiac catheterization indicated in pts w/ postinfarction angina or following post-MI stress test results?
- exercise-induced STD or STE
- can’t achieve 5 METs during testing
- can’t increase SBP by 10 to 30 mmHg
- can’t exercise (arthritis)
when are ICDs indicated?
- > 40 days since MI
- > 3 months since PCI or CABG
- EF < 35%
- h/o demodynamically significant ventricular arrhythmia or cardiac arrest (secondary prevention)
what should all post-MI pts be screened for?
depression
