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Board Basics Review > Cardiovascular Medicine: Acute Coronary Syndromes > Flashcards

Cardiovascular Medicine: Acute Coronary Syndromes Flashcards

1
Q

what are the classical anginal sxs?

A
  • substernal CP w/ exertion

- CP relief w/ rest or nitroglycerin

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2
Q

what are anginal equivalents?

A
  • exertional dyspnea
  • fatigue
  • N/V
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3
Q

in which pts are anginal equivalents most commonly found?

A
  • DM pts

- females

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4
Q

signs of cardiac ischemia

A
  • new MR murmur
  • new S3 gallop
  • new S4 gallop
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5
Q

what distinguishes the 3 types of ACS?

A
  • 12-lead ECG and cardiac markers
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6
Q

what might an echocardiogram show in ACS?

A

regional wall motion abnormalities

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7
Q

in which pts might an echocardiogram be especially useful if ACS is suspected?

A

pts w/ LBBB

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8
Q

which ACS?

  • normal cardiac biomarkers
  • no characteristic ECG changes
A

unstable angina

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9
Q

which ACS?

  • positive cardiac biomarkers WITHOUT STE or STE equivalents
  • STD and nonspecific changes may be seen
A

NSTEMI

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10
Q

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)
A

STEMI

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11
Q

what are STE equivalents?

A
  • new LBBB

- posterior MI (tall R waves and STD in V1-V3)

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12
Q

ECG localization of AMI:

  • anatomic location: INFERIOR
  • ST-segment change: elevation
  • what are the indicative ECG leads?
A

2, 3, aVF

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13
Q

ECG localization of AMI:

  • anatomic location: ANTEROSEPTAL
  • ST-segment change: elevation
  • what are the indicative ECG leads?
A

V1-V3

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14
Q

ECG localization of AMI:

  • anatomic location: LATERAL and APICAL
  • ST-segment change: elevation
  • what are the indicative ECG leads?
A

V4-V6, possibly 1 and aVL

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15
Q

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)

A

tall R waves in V1-V3

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16
Q

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)

A

V4R-V6R; tall R waves in V1-V3

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17
Q

why is the TIMI score used?

A

estimate risk in pts w/ unstable angina/NSTEMI to guide therapy

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18
Q

TIMI risk score components

A
  • 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
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19
Q

management strategy if TIMI risk score is 0-2

A
  • start aspirin,
  • BB,
  • nitrates,
  • heparin,
  • statin,
  • clopidogrel
  • predischarge stress test and angiography if significant myocardial ischemia
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20
Q

management strategy if TIMI risk score is 3-7

A
  • start aspirin,
  • BB,
  • nitrates,
  • heparin,
  • statin,
  • GP 2b/3a inhibitor
  • clopidogrel
  • EARLY angiography
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21
Q

when is immediate angiography also indicated in ACS?

A
  • hemodynamic instability
  • HF
  • recurrent REST angina despite therapy
  • new or worsening MR murmur
  • sustained VT
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22
Q

DON’T BE TRICKED

besides STEMI, what are other causes of STE’s??

A
  • acute pericarditis
  • LV aneurysm
  • takotsubo (stress) CM
  • coronary vasospasm (Prinzmetal angina)
  • normal variant
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23
Q

other causes of acute chest pain:

  • vignette: young woman w/ /o migraines, acute CP, and STE
  • possible dx
  • test/therapy
A
  • coronary vasospasm (Prinzmetal angina, variant angina)

- CCB

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24
Q

other causes of acute chest pain:

  • vignette: young person w/ CP following a party
  • possible dx
  • test/therapy
A
  • cocaine

- CCB (avoid BB)

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25
Q

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
A
  • Marfan syndrome w/ aortic dissection
  • MRI, contrast CT, or TEE
  • immediate surgery for type A dissection
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26
Q

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
A
  • PE
  • UFH or LMWH
  • CTA
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27
Q

other causes of acute chest pain:

  • vignette: tall, thin young man who smokes w/ sudden pleuritic chest pain and dyspnea
  • possible dx
  • test/therapy
A
  • spontaneous PTX

- CXR

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28
Q

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
A
  • stress-induced (takotsubo) CM
  • look for characteristic apical ballooning on ventriculogram
  • BB
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29
Q

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
A
  • HCM
  • echocardiography
  • BB
30
Q

STEMI goal time

A
  • first medical contact to PCI time 90 minutes or LESS

- 120 minutes or less IF transferred from non-PCI capable facility

31
Q

other indications for PCI

A
  • 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
32
Q

if PCI is NOT available, tx for STEMI

A

thrombolysis

33
Q

MC CI’s for thrombolysis tx in STEMI

A
  • active bleeding
  • high r/o bleeding (recent major surgery)
  • BP > 180/110 on presentation
34
Q

indications for acute CABG

A
  • failure of thrombolysis
  • failure of PCI
  • mechanical complications (papillary muscle rupture, VSD, free wall rupture)
35
Q

presentation of RV/posterior MI

A
  • hypotension or hypotension after nitroglycerin or morphine
36
Q

tx for hypotension in setting of RV/posterior MI

A

IVF

37
Q

signs of RV/posterior MI

A
  • elevated CVP w/ clear lungs
  • hypotension
  • tachycardia
38
Q

most predictive ECG finding for RV/posterior MI

A

STE in lead V4R on right-sided ECG

39
Q

when should place an IABP in STEMI pts?

A
  • cardiogenic shock
  • acute MR
  • acute VSD
  • intractable VT
  • refractory angina
40
Q

DON’T BE TRICKED

when should you ONLY transfer a STEMI pt for PCI instead of thrombolytic therapy?

A

ONLY if PCI can be done 120 minutes or less

41
Q

DON’T BE TRICKED

when should you NOT use thrombolytic therapy?

A
  • pts w/ NSTEMI

- asymptomatic pts w/ onset of pain > 24 hours

42
Q

DON’T BE TRICKED

what is the typical reperfusion arrhythmia that can occur after thrombolytic therapy?

A

transient accelerated idioventricular arrhythmia

43
Q

DON’T BE TRICKED

should you tx referfusion arrhythmias following thrombolytic therapy?

A

NO

44
Q

drug therapy for MI:

  • indication for aspirin
A
  • ASAP for all pts w/ ACS

- continue indefinitely as secondary prevention

45
Q

drug therapy for MI:

  • indication for P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel)
A
  • ASAP for all pts w/ ACS

- continue for 1 year following MI

46
Q

drug therapy for MI:

  • indication for AC (UFH, LMWH, bivalirudin)
A
  • ASAP for definite or likely ACS
47
Q

drug therapy for MI:

  • indication for GP 2b/3a antagonists (abciximab, eptifibatide, tirofiban)
A
  • ASAP for HIGH-risk NSTEMI

- give prior to PCI

48
Q

drug therapy for MI:

  • indication for BB (metoprolol, carvedilol)
A
  • give w/i 24 hours

- continue indefinitely as secondary prevention

49
Q

drug therapy for MI:

  • indication for CCB (NOT nifedipine)
A
  • use BB is CI
50
Q

drug therapy for MI:

  • indication for ACEI
A
  • give w/i 24 hours

- continue indefinitely in pts w/ reduced IVEF or clinical HF

51
Q

drug therapy for MI:

  • indication for ARB
A
  • give if can’t take ACEI
52
Q

drug therapy for MI:

  • indication for nitroglycerin
A
  • give if ongoing chest pain or HF
53
Q

drug therapy for MI:

  • indication for statin
A
  • given high-intensity statin early

- continue indefinitely as secondary prevention

54
Q

drug therapy for MI:

  • indication for eplerenone
A
  • give 3 to 14 days after MI if LVEF 40% or less and clinical HF or DM
55
Q

when does stent thrombosis occur?

A

24 hours to 1 year after placement

56
Q

how does stent thrombosis present?

A
  • recurrent angina
  • sudden death
  • MI, usually w/ STE
57
Q

how to prevent stent thrombosis?

A

DAPT

58
Q

indication and duration of DAPT

  • stable angina pectoris
  • if NO stent
  • if bare-metal stent (BMS)
  • if drug-eluting stent (DES)
A
  • 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
59
Q

indication and duration of DAPT

  • unstable angina/NSTEMI
  • if NO stent
  • if bare-metal stent (BMS)
  • if drug-eluting stent (DES)
A
  • 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
60
Q

indication and duration of DAPT

  • STEMI
  • if NO stent
  • if bare-metal stent (BMS)
  • if drug-eluting stent (DES)
A
  • 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
61
Q

DON’T BE TRICKED

which med’s effectiveness is unknown in pts w/ AMI?

A

spironolactone

62
Q

when should you temporarily pace a pt w/ AMI?

A
  • asystole
  • symptomatic bradycardia (including complete heart block)
  • alternating LBBB and RBBB
  • new or indeterminate-age bifasicular block w/ 1st-degree AVB
63
Q

what are the mechanical complications of MI?

A
  • VSD
  • papillary muscle rupture
  • LV free wall rupture
64
Q

when do mechanical complications of MI occur?

A

2-7 days after MI

65
Q

what are the physical exam findings of VSD and papillary muscle rupture?

A
  • abrupt pulmonary edema
  • hypotension
  • loud holosystolic murmur and thrill
66
Q

what are the physical exam findings of LV free wall rupture?

A
  • sudden hypotension

- sudden cardiac death w/ PEA

67
Q

how to stabilize pts w/ VSD and papillary muscle rupture?

A
  • IABP
  • afterload reduction w/ sodium nitroprusside
  • diuretics
  • emergent surgical intervention
68
Q

how to stabilize pts w/ LV free wall rupture?

A
  • emergent pericariocentesis

- emergent surgery

69
Q

when is cardiac catheterization indicated in pts w/ postinfarction angina or following post-MI stress test results?

A
  • 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)
70
Q

when are ICDs indicated?

A
  • > 40 days since MI
  • > 3 months since PCI or CABG
  • EF < 35%
  • h/o demodynamically significant ventricular arrhythmia or cardiac arrest (secondary prevention)
71
Q

what should all post-MI pts be screened for?

A

depression

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