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ALS > chapter 4 > Flashcards

chapter 4 Flashcards

1
Q

what are the specific group of people that present with angina uncharacteristically ?

A

no chest pain just breathlessness - diabetics , females , elderly

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2
Q

angina usually gets misdiagnosed as what?

A

in digestion

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3
Q

what is crescendo angina ?

A

a form of unstable angina -
angina on exertion , occuring with increasing frequency , provoked by progressively less exertion

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4
Q

unstable angina characteristic ?

A

angina like pain occurring recurrently and unpredictably without exercise provocation

may settle spontaneously and relieved for short term by GTN sublingual

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5
Q

the categories of ACS?

A

STEMI - ST elevation or new LBBB

Non ST segment elevation ACS :
NSTEMI (High troponin)
unstable angina (no ECG CHANGES OR NO HIGH TROPONIN)

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6
Q

unstable angina ECG ?

A

normal
show evidence of acute myocardial ischemia -ST depression
non specific abnormalities - T wave inversion

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7
Q

in unstable angina - when there are no ecg changes and troponin levels are normal = GRACE SCORE LOW what can be done ?

A

further risk assessment test = exercise testing
non invasive imaging

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8
Q

NSTEMI angina characteristic ?

A

pain >20 mins
nausea and vomiting
sweating
belching

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9
Q

NSTEMI in vascular sense ?

A

partial or intermittent occlusion

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10
Q

treatmnet for NSTEMI and unstable angina is the same ?

A

yes
unlike STEMI - needing immediate reperfusion

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11
Q

what does the development of q waves mean in STEMI ?

A

damage to the myocardium in the area where the artery is occluded - causing iMPAIRED VENTRICULAR FUNCTION

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12
Q

during acute phase of STEMI there is substantial risk of what ?

A

tach and vfib

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13
Q

DD for angina in STEMI ?

A

PE and aortic dissection

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14
Q

suspect aortic dissection when ?

A

acute chest pain - radiating to the back
marked hypotension
loss of peripheral pulse
asymmetry f pulse in the upper limbs

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15
Q

does a single normal ECG exclude ACS?

A

no - should be repeated in intervals

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16
Q

what needs to be established if PPCI is not given within 20 mins?

A

fibrinolytic

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17
Q

symptoms of PE

A

sudden hypoxia

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18
Q

how to detect anterior or anteroseptal infraction on ECG

A

change in leads V1-V4
by LAD artery - left anterior descending

if V5-V6 involved , lead 1 and AVL = anterolateral

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19
Q

which infraction has the worst prognosis ?

A

anterior infract causes most damage on left ventricle function - worst prognosis

20
Q

how to detect inferior infraction ?

A

lead 2,3 and avF

right coronary artery

21
Q

how to detect lateral infraction ?

A

lead V5 V6
or
lead 1 and aVL

22
Q

how to detect posterior infraction ?

A

ST segment depression V3-V4 (anterior leads)

dominant r wave in v1-v2- reflects posterior q wave development

= right coronary artery occlusion

confirmed with repeating ecg with posterior leads v7-v10

23
Q

one third of patients with inferior and posterior STEMI May also have ?

A

right ventricular infraction

st elevation in v1
and inferior posteriori STEMI

24
Q

are ST segment depression and t wave inversion in the ecg lead related to where the damage occurred in the heart ?

A

no

25
Q

other causes pf st elevation ?

A

SAH
TBI
brigade syndrome - ST elevation in V1 -V2
takotsubo cardiomyopathy

26
Q

pe ecg changes ?

A

t wave inversion v1-v4

27
Q

other causes for high troponin ?

A

PE
aortic dissection
myocarditis
heart failure
chronic renal failure
sepsis

28
Q

what is the GRACE SCORE BASED ON ?

A

age
troponin levels
ecg changes
signs of heart failure
HR
serum creation
BP
cardiac arrest

29
Q

treatmnet for ACS

A

ACS protocol
cardiac monitor
loading 300mg aspirin
GTN
oxygen
pain relief - opiate analgesia - morphine
anti metic

clopidrogel - 300mg /600
prasugrel - 60mg
ticagrelor - 180mg

30
Q

when does PCI not become useful ?

A

after 12 hour of symptom onset
however should be considered if in ecg shows ongoing ischemia

31
Q

some setting PCI is used with what adjuncts ?

A

glycoprotein 2b/3a inhibitors

32
Q

benefits of PCI to fibrinolytic ?

A

lower risk of bleeding into the brain and bleeding in general

33
Q

contra for PCI?

A

previous hemorrhagic stroke
schema stroke last 6 months
recent major injury or trauma
active bleeding
non or suspected aortic dissection
known bleeding disorder

34
Q

if patient getting fibrinolytic do they need additional antithmbotic therapy ?

if so what

A

yes

= aspirin 300mg and clop 300= if high bleeding risk
/ or ticagrelor =180mg
+
antithrombin therapy
LMWH/ UFH / fondaparinoux

35
Q

indication for fibrinolytic ?

A

more tha 12 hr since symptom onsert and PCI not possible within 120 min

AND

ST segment elevation in 2 adjacent chest leads of 0.2mv or more
or
2 or more peripheral limb leads of 0.1mv or more
or
dominant r waves and st depression in v1-v3
or
new onset LBBB

36
Q

after successful thrmbolysiswith fibrinolytic what should be considered ?

A

angiography with or without PCI

37
Q

how do you know fibrinolytic therapy has failed ?

A

cardiac monitoring continuously
12 lead ecg recored 60-90 mins after fibrinlitics
failure of st elevation to depress in more than 50 percent compared to pre treatmnet ECG

or no reperfusion arrythmia - accelerated idioventriuclar rythm - NOT in all cases and might not be witnessed

symptoms unreliable guide for reperfusion

38
Q

treatmnet for NSTEMI ?

A

immediate treatmnet object - prevent new thrombus formation , reduce myocardial oxygen demand

= further thrombus prevention
fondaparinoux

aspirin loading and daily maintenance

prasugrel 60mg (contra >75 and hx of bleeding) then 10 mg
or
clop 300mg then 75mg
or ticagrelor 180mg then 90 mg

reduce myocardial oxygen demand = beta blockers
bb contra = diltiazem
avoid DCCB such as nifedipine
consider Nitrate infusion if angina persist pr reoccurs after sublingual nitrate
consider early ACE

39
Q

long term therapy for ACS?

A

cardiac rehab - reduce hospital admission begins from he cardiac unit tot he community

long term anticoagulant
if PCI minimum of one year

if atrial fib as complication - DOAC or warfarin

ACEI - reduce the remodelling that contributes to left ventricular dilation
reduce risk of HF and future MI
for first few days
if low LVEF (<40) - aldosterone antagonist

ECHO examination of LVF

BB - shown to reduce mortality
cardioprotective effect
prevent future arrythmia

statins - reduce risk of future coronary event

stop smoking

anti hypertensives

40
Q

NSTEMI CONSIDERED cause of cardiac arrest ?

A

immediate coronary angiography and PCI if needed

41
Q

if an arrythmia occurs within 24-48 hr after an ACS has happened what is the management ?

A

ICD is not indicated unless persistently severe LV function at least 4 weeks post ACS

also check for other factors that might have predisposed the arrythmia - hypokalaemia

42
Q

if there is sustained ventricular arrythmia after 48 hr of ACS ?

A

ICD unless arrythmia associated with ischemia which can be reversed with revascularisation

43
Q

who are at most risk for cardiac arrest as late complication

A

those who develop Vf and tach - should be seen by a cardiologist for an ICD

44
Q

what indicates poor prognosis in relation to myocardial infraction and arrythmia ?

A

AV block - extensive myocardial injury

usually slow and hesitant to atropine

temporary cardiac pacing is usually needed

45
Q

if cardiac arrest occurs in the contact of MI what should happen

A

if esp in cardiac lab -
mECHANICAL DECOMPRESSION - AND START PCI

or extracorporeal CPR

ALS (19 decks)

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