CHD/ACS Flashcards
What is classic ACS initial therapy
MONA--- Morphine Oxygen Nitro (vasodilation) Aspirin
What are atypical symptoms of ACS that women can present with
Fatigue, GI, pulmonary
What is angina (general)
clinical syndrome w/ chest, jaw, shoulder, or arm discomfort attributable to coronary ischemia (supply too little for demand)
What are the subtypes of angina
- Typical: substernal, provoked by EXERTION/stress, relieved by REST
- Atypical: may be PLEURITIC, reproduced by palpation/MOVEMENT, lasts days or seconds
What is stable vs unstable angina
- Stable: develops w/ EXERTION, resolves with REST. short duration
- Unstable: develops AT REST/minimal exertion. lasts longer. D/t insufficient blood flow w/o myocardial necrosis
What is NSTEMI/STEMI
angina w/ elevated cardiac biomarkers indicating MI
-Actual muscle is dying
What is NSTE-ACS
imbalance of myocardial oxygen consumption and demand causing ischemia/infarct
How do you characterize an MI
High or low Troponin w/ at least 1 of following:
- Sx of ischemia
- New ST-T wave changes/LBBB
- Pathologic Q waves
- Loss of myocardium/new RWMA
- Intracoronary thrombus
What patients would you use an ischemia guided strategy in, and what is the strategy
Low risk score (TIMI 0-2)
Extensive comorbidities
-Start on meds and plan for stress test
What patients would you use an early invasive strategy in, and what is it
New ST depression, elevated trop, recurrent angina, CHF
-Send to cath lab
What are some causes of NSTE-ACS
Atherosclerosis Vasospasm Coronary embolism Dissection Non-obstructive (HTN, anemia, hyperthyroid)
What are some possible findings in CHD PE
Levine's sign New S4 Paradoxical splitting of S2 New murmur Pericardial friction rub CHF/shock
What are the 3 P’s that tell you its LESS likely to be a STEMI/NSTEMI
Palpable
Positional
Pleuritic
What are some CAD risk factors
DM HTN HLD Tobacco sex age FHx ESRD
What categorizes ST depression and T wave changes
new ST depression 5mm (0.5mV) in 2+ leads
T wave inversion 1mm in 2+ leads
What is the ACS early branch system
Patient comes in with ACS
EKG
Biomarkers
Risk stratify to determine approach
How long does it take for Troponin to elevate
2-4 hours, persists 14 days
What are causes of elevated troponin
Tacky/brady arrhythmia Shock HTN HF Severe PE Sepsis Renal failure
When is CKD helpful
when diagnosing reinfarction and assessing perfusion
What are the TIMI risks
- Age 65+
- 3+ CAD RF (HTN, DM, HLD, FHx, smoking)
- CAD
- Elevated cardiac biomarker
- ASA w/in 7 days
- ST elevation
- Severe angina
What are admission criteria for ACS
Recurrent symptoms
Ischemic changes on ECG
Elevated troponin
TIMI 3+
What are standard medical therapies for NSTE-ACS
Oxygen Anti-Platelet (ASA&P2Y12 inhibitor/) Statins (high intensity) Nitro Analgesics (NO NSAIDS)
What is a P2Y12 inhibitor
an anti platelet given WITH ASA
Clopidogrel (Plavix)
*If possible hold clopidogrel 5 days prior to surgery
What are GP IIa/IIb inhibitors
Anti-platelet used WITH ASA and heparin during AMI
What anti-HTN med takes precedence when treating NSTE-ACS
BB- given within first 24 hours (but NOT in CHF, HB, or asthma)
If BB contraindicated, use CCB
Add CCB to BB if with persistent angina
What are other NSTE-ACS therapies to initiate
ACE (if LVEF <40%
ARB
Ald. Antagonist (on ACE and BB with EF <40%)
What are stress test options
Exercise ECG
Echo (exercise or Dobutamine)
Myocardial perfusion imaging (exercise or adenosine)
–For those with abnormal baseline ECG
What are the most specific and sensitive stress tests for detecting CAD
Sensitive: Vasodilator nuclear MPI
Specific: Dobutamine Echo
What post-hospital care should be given to patients
\+/- cardiac rehab (if rule in and have MI) TLC Aspirin ACE/ARB BB
What are likely causes of ACS with ST elevation
AMI
STEMI
Cocaine (young w/o RF)
Vasospasm
Who might you see a painless MI in
women
elderly
DM
alcoholic
What categorizes ST elevation
> 1mm in 2+ leads
2mm in V2V3 for men
1.5mm in V2V3 for women
What are key goal times for a STEMI
12 lead ECG w/in 10 min Reperfusion w/in 24 hours FMC to device w/in 90 min Transfer to PCI w/in 120 min Fibrinolytic therapy w/in 120 min
What is the best vessel to graft the LAD
Internal thoracic artery
What is class I criteria for needing a CABG
Significant left main stenosis
>70% stenosis of LAD and LCA
three vessel CAD
What is PCI therapy
Unfractionated Heparin w/wo GP IIb/IIIa inhibitor
*Initiate ASAP
What are major contraindications for Fibrinolytics in STEMI
Prior ICH
malignant neoplasm
Ischemic stroke
aortic dissection
What is fibrinolytic therapy
Streptokinase
Urokinase
tPA
What are complications of infarctions
arrhythmias/conduction abnormality
HF shock
mechanical defect
Inflammatory (pericarditis)
What will you see with a papillary muscle rupture
Systolic Apical murmur and pulmonary edema
What will you see with an IVS rupture
holosystolic murmur at LSB
