Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Cardiology Handbook > Chapter 1- AMI > Flashcards

Chapter 1- AMI Flashcards

0
Q

Name physical findings associated acute myocardial infarction.

A

Possible rales , pulmonary edema, increased JVD , or new S3 heart sound. See Killip classification. Systolic murmur could indicate MR or VSD.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
1
Q

What is the definition of acute myocardial infarction?

A

Detection of rise and or fall in cardiac troponin with at least one value about the 99th percentile upper limit of normal together with evidence of ischemia.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Name the 5 Types of MI.

A
  1. Plaque rupture/dissection in coronary vessel.
  2. O2 increased demand/decreased supply
  3. Sudden cardiac death with ischemic symptoms. 4a. MI with PCI
    4b. MI with in stent thrombosis.
  4. MI associated with CABG.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Name six causes of chest pain without cardiac ischemia.

A

Aortic dissection, myopericarditis , pulmonary embolism, costochondritis, gastrointestinal disorders

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Give five examples of ST elevation but no ischemia.

A

Early repolarization, left ventricular hypertrophy, left bundle branch block, hyperkalemia, Brugada syndrome.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Name six causes of comorbid ischemia in STEMI.

A

Aortic dissection, Systemic arterial embolism , hypertensive crisis, aortic stenosis, cocaine use, arteritis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How can you measure infarct size independant of reperfusion? (hint; lab test)

A

Measure of Troponin T 72 hours after acute MI.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

When Does CK peak?

A

24 hours.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

When does troponin peak?

A

About 36 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

When does myoglobin peak?

A

1-4 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Name STEMI EKG requirements.

A

ST elevation of 2 consecutive leads 1mm or greater. In leads V2-V3,2mm in men or 1.5mm in women required.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Name the Sgarbossa Criteria. How specific and what is the positive predicitve value?

A

LBBB in MI.
ST segment elevation >1mm concordant with QRS= 5 points.
ST-segment depression >1mm in leads V1,V2,or V3= 3 points
ST segment elevation >5mm discordant with QRS = 2 points.

Total score of 3 >90% specific and 88% positive predictive value.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Other than ECG, how might you rapidly determine if acute MI present in a patient with LBBB and ongoing symptoms?

A

Echocardiography: abnormal septal motion due to LBBB will likely be present but you would be able to see other wall motion abnormalities if pain is ongoing.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What does the TIMI score for STEMI measure?

A

Predicts 30 DAY MORTALITY in patients treated with THROMBOLYTIC therapy.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What does the GRACE score predict?

A

IN-HOSPITAL mortality in patients with ACS.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Give the approximate 30 day mortality rate based on Killip Class I, II, III, IV. On which trial was this based?

A 
I: 5%
II: 14%
III: 32%
IV: 58%
GUSTO-1
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is the class, mechanism of action, absorbtion, half life, and loading and maintinance dose of clopidogrel? What is the wait time for surgery after loading? Cautions?

A

Clopidogrel:
Thienopyridine, P2Y12 inhibitor.
Requries in-vivo tranformation to acitve thiol metabolite.
Irreversibly blocks the P2Y12 component of ADP receptors on the platelet surface, which prevents activation of the GPIIb/IIIa receptor complex.
Half life 6 hours
Time to peak effect: 0.75 hours.
Load with 600mg, maintinance 75mg.
Wait time for surgery after loading: 5 days
The optimal dose for CYP2C19 poor metabolizers has yet to be determined

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is the class, mechanism of action, absorbtion, half life, and loading and maintinance dose of prasugrel? What is the wait time for surgery after loading? Cautions?

A

Prasugrel:
Thienopyridine, P2Y12 inhibitor.
Prodrug: metabolized to both active and inactive metabolites.
Irreversibly blocks the P2Y12 component of ADP receptors on the platelet surface, which prevents activation of the GPIIb/IIIa receptor complex.
Half life 7 hours
Time to peak effect: 30 minutes
Load with 60mg, maintinance 10mg.
Wait time for surgery after loading: 7 days.
Contraindications: prior stroke, 75.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Name the advantages and disadvantages to prasugrel copared to clopidogrel seen in the TRITON TIMI-38.

A 
Advantages:
Faster onset of action.
Overall more effective.
Not influenced by cytochrome P450 genetic polymorphisms.
Greater benefits with diabetics.

Disadvanteges:
Higher bleeding risk. Longer wait time if surgery needed.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the class, mechanism of action, absorbtion, half life, and loading and maintinance dose of ticagrelor? What is the wait time for surgery after loading? Cautions?

A

Ticagrelor:
non-Thienopyridine, P2Y12 inhibitor.
Prodrug: metabolized to both active and inactive metabolites.
Reversably, and non-competitively blocks P2Y12 component of ADP receptors on the platelet surface, which prevents activation of the GPIIb/IIIa receptor complex.
Half life ~7 hours, metabolite ~9 hours.
Time to peak effect: 30 minutes
Load with 60mg, maintinance 10mg.
Wait time for surgery after loading: 5 days
Box warning of history of intracranial hemorrhage. Only use aspirin 81mg as higher doses suppress effect. Do not use in severe hepatic impairement.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Name the trial that won ticagrelor FDA approval? Advantages over clopidogrel?

A

PLATO, improved outcomes of death from vascular causes, MI, stroke without increase in major bleeding compared to clopidogrel.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Dose of unfractionated heparin in ACS? Goal of PTT? Goal of ACT in Cath lab?

A

60mg/kg bolus (max 4000 units) followed by 12U/kg/h infusion (max 1000U/h). Goal PTT 45-65 seconds. Goal ACT 300-350 seconds, unless on GPIIb,IIIa then goal is 200-250 seconds.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Name the trials that vallidated use of UFH with reteplase and tenecteplace?

A

Gusto III, and Assent 2 respectively.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What should be done with heparin if thrombolytics are given?

A

Alteplace, Reteplace, Tenecteplace: give heparin

Streptokinase: hold heparin unless there is recurrant ischemia, or for another reason.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Which trial proved benefit of LMWH over UFH in thrombolytics (tenecteplace)?

A

Assent 3

25
Q

If LMWH is used in STEMI, what considerations should be made in the cath lab reguarding re-dosing?

A

If last dose….
< 8 hours, do not re-dose
8-12 hours, give 0.3mg/kg IV
>12 hours, give 1mg/kg re-dose

26
Q

LMWH should be avoided in patients who…?

A

….are >75 years of age, and patient’s with renal insufficiency.

27
Q

Bivalirudin during PCI is a class ____ recommnedation. This recommendation came about based on the results of the _______ trial.

A

Class I, HORIZONS-AMI trial.

28
Q

What is the dose of LMWH in STEMI?

A

Patients < 75 years of age: 30mg IV with 1mg/kg SQ (max 100mg for first 2 doses), then 1mg/kg q12 hours afterward.
Patients > 75 years of age: no IV bolus, 0.75mg/kg q12 hours (max 75mg first two doses), then 0.75mg/kg q12 hours.
No optimal duration defined, 8 days or until discharge.

29
Q

What is the dose of LMWH in unstable angina/NSTEMI?

A

1mg/kg SQ q12 hours, at least for two days.

30
Q

Fondaparinux use in ACS:

use with ______, but not with _______. This is because of concerns related to ________.

A

Fibrinolytics, primary PCI, catheter related thrombosis.

31
Q

A patient with ACS is given fondaparinux, and the decision is made to go to the cath lab. What should be done with anticoagulation?

A

Additional anticoagulation should be given with a direct thrombin (factor IIa) inhibitor. (Oasis-6)

32
Q

After ___hours, there’s little benefit to fibrinolytics in ST elevation myocardial infarction.

A

12

33
Q

Current guidelines recommend against intervening for STEMI in which situation?

A

If it has been greater than 24 hours, and the patient is hemodynamically stable without signs of severe ischemia.

34
Q

The OAT (Occluded Artery Trial) trial suggested that intervening on a lesion ____ hours after initial event was of little benefit, and could be harmful. The major criticism of this trial was _______.

A

> 72, Exclusion of high-risk patients (NYHA class III-IV HF, rest angina, clinical instability, multi vessel disease, severe inducible ischemia on stress testing.

35
Q

Relative lack of efficacy of fibrinolytic’s is seen in which two situations?

A
  1. Those in cardiogenic shock.

2. Those with prior CABG surgery.

36
Q

Door to balloon time should be within how many minutes? (This includes transfer time)

A

90 minutes

There is some evidence that extended transfer time up to 120 minutes is still beneficial for primary PCI compared to fibrinolytic’s. See DYNAMI-2.

37
Q

Door to needle time should be ____?

A

30 minutes

38
Q

What is the BRAVE -3 trial?

A

Looked at 800 STEMI patients received aspirin +600 mg of PLAVIX and either abciximab or placebo during PCI. The primary in point was infarct size based on SPECT. It also compared 30 day major adverse cardiovascular events. There were no significant differences between the two groups.

39
Q

What is the HORIZONS trial?

A

HORIZONS-AMI compared bivalirudin to heparin + GP IIb/IIIa inhibition in patients with STEMI undergoing primary PCI. Patients treated with bivalirudin alone had lower rates of net adverse clinical events at 30 days (9.2% vs. 12.1% for UFH + GP IIb/IIIa, P<0.01). They also had a lower incidence of death from cardiovascular causes (1.8% vs. 2.9%, p=0.030) and death from all causes (2.1% vs. 3.1%, p=0.047) at 30 days.

40
Q

GP 2b/3a inhibitor administration is a class ___ recommendation during PCI. While upstream GP 2b/3a inhibitor prior to PCI is a class ____ recommendation.

A

IIb, III

41
Q

Is there benefit to thrombus aspiration on STEMI? What is in the current guidelines regarding thrombus aspiration in STEMI?

A

Improved ST segment resolution and myocardial blush score. Limited data suggests improved one year mortality (TAPAS trial). Current guidelines suggest thrombus aspiration is reasonable during PCI who have high clot burden and short ischemic times.

42
Q

When should you use distal embolic protection devices (EDP) in ACS?

A

When the culprit vessel is a saphenous vein bypass graft, an EDP reduces composite endpoint of death, MI, emergency CABG, and target lesion revascularization. In native coronary arteries, EDP’s have no benefit and may increase infarct size.

43
Q

What is the role of calcium channel blockers in acute MI?

A

CCB’s in acute MI should be avoided, as there has been no benefit to increased mortality seen. They can be used for SVT, cocaine induced MI or refractory angina not responsive to beta blockers. Amlodipine safe in CHF while verapamil and diltiazem not.

44
Q

Gissi 3 and ISAR 4 showed which class of medications reduced mortality in acute MI?

A

Ace inhibitors.

45
Q

Current AHA statements recommend against PCI in STEMI for symptoms > ____, IF the patient is _____ and there are no signs of _____.

A

> 24 hours, hemodynamically stable, severe ischemia.

46
Q

Name the absolute contraindications for the use of thrombolytic agents to manage myocardial infarction. (There are four of them).

A
  1. Previous hemorrhagic stroke at any time; ischemic stroke within three months.
  2. Known intracranial neoplasm, structural cerebral vascular lesion, or closed head injury within three months.
  3. Active bleeding or bleeding diathesis (Excluding menses)
  4. Suspected aortic dissection.
47
Q

Name the relative contraindications of thrombolytic therapy.

A
  1. Severe, uncontrolled hypertension (blood pressure greater than 180/110).
  2. History of ischemic stroke >3 months, dementia, or known intracerebral pathologic condition not covered in contraindications.
  3. Current use of anticoagulants, the risk increases with increasing INR.
  4. Traumatic or prolonged (>10 minutes) CPR or major surgery less than three weeks.
  5. Noncompressible vascular punctures
  6. Recent (Within 2 to 4 weeks) internal bleeding.
  7. Pregnancy
  8. Active peptic ulcer
  9. For streptokinase , prior exposure
48
Q

Lytic therapy has a relative lack of efficacy in patients with prior ____, or who are in_____.

A

Bypass operations, cardiogenic shock

49
Q

Which trial showed that stenting in ACS reduced the incidence of target vessel revascularization at 6 months compared to thrombolytics and PTCA?
Which trial for showed decreased incidence of restenosis at 6 months with PCI?

A

The STENT-PAMI and CADILLAC trials respectively.

50
Q

Which of the following are reduced with placement of drug eluding stents compared to bare metal stents.

  1. Mortality
  2. MI
  3. Stent Thrombosis
  4. Target vessel re-vascularization
A

Only Target vessel revascularization. There is no difference in mortality, MI, or stent thrombosis.

51
Q

Which patients benefit most from DES compared to BMS?

A

Patients with the highest risk of in-stent restenosis. Diabetics with small diameter vessels and long lesions.

52
Q

Review the administration instructions and dose of Alteplace (tPA)

A

IV dose of 15mg followed by 0.75mg/kg (50mg max) over 30 minutes and then 0.5mg/kg over 60 minutes. Alteplace is considered fibrin specific.

53
Q

Review the administration instructions and dose of Reteplace.

A

Double bolus dose of 10mg IV each, 30min apart.

54
Q

Tenecteplace administration and dose.

A

30-40mg weight adjusted one time dose. No mortality difference compared to tPA at 30 days, but less non cerebral bleeding.

55
Q

Name the major risk factors for intracranial hemorrhage in fibrinolytic therapy.

A

Age >75, hypertension, low body weight, female gender, coagulopathy.

56
Q

When is it reasonable to use combined half dose fibrinolytic therapy with GP IIb/IIIa inhibitors? How does this combination help?

A

In patients <75 years of age, no increase in intracranial hemorrhage. Reduced reinfarctions and complications after MI but did not reduce 30 day or 1 year morality (GUSTO V and ASSENT 3)

57
Q

What is the definition of rescue PCI? Is it helpful?

A

Defined as use of PCI when fibrinolytic therapy has proved unsuccessful after 90 minutes. It is helpful, reduces death, reinfarction, stroke, and severe heart failure by 50%.

58
Q

How is determination of re-perfusion defined?

A

> 70% resolution of ST elevation complete resolution of chest pain. Chest pain resolution alone is unreliable. Run of AIVR is specific but not sensitive for successful reperfusion.

59
Q

Define facilitated PCI. Is it beneficial?

A

Initial use of anticoagulants and fibrinolytics prior to planned PCI. Primary PCI is superior to facilitated PCI, and has less bleeding risk.

60
Q

What is the pharmacoinvasive strategy? Is it helpful?

A

Use of fibrinolytics where indicated and then immediate transfer to PCI capable facility for reassessment and rescue PCI if indicated. There is a benefit in hight-risk STEMI patients.

61
Q

What is considered a “high risk” STEMI?

A

CARESS in AMI definition: (1) any of the following
STEMI with extensive ST segment elevation, prior MI, new LBBB, Killip class >II or EF 2mm ST elevation in two or more leads.

TRANSFER-AMI definition:
(1) >2mm ST elevation in two anterior leads, or >1mm inferior leads with at least SBP 100, Killip class >II, ST depression in anterior leads, 1mm ST elevation in rV4

Cardiology Handbook (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions