CHD/ACS Flashcards by Megan Jacobson

What is classic ACS initial therapy

MONA---
Morphine
Oxygen
Nitro (vasodilation)
Aspirin

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What are atypical symptoms of ACS that women can present with

Fatigue, GI, pulmonary

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What is angina (general)

clinical syndrome w/ chest, jaw, shoulder, or arm discomfort attributable to coronary ischemia (supply too little for demand)

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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

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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

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What is NSTEMI/STEMI

angina w/ elevated cardiac biomarkers indicating MI

-Actual muscle is dying

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What is NSTE-ACS

imbalance of myocardial oxygen consumption and demand causing ischemia/infarct

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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

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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

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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

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What are some causes of NSTE-ACS

Atherosclerosis
Vasospasm 
Coronary embolism
Dissection
Non-obstructive (HTN, anemia, hyperthyroid)

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What are some possible findings in CHD PE

Levine's sign
New S4
Paradoxical splitting of S2
New murmur
Pericardial friction rub
CHF/shock

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What are the 3 P’s that tell you its LESS likely to be a STEMI/NSTEMI

Palpable
Positional
Pleuritic

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What are some CAD risk factors

DM
HTN
HLD
Tobacco
sex age FHx 
ESRD

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What categorizes ST depression and T wave changes

new ST depression 5mm (0.5mV) in 2+ leads

T wave inversion 1mm in 2+ leads

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What is the ACS early branch system

Patient comes in with ACS
EKG
Biomarkers
Risk stratify to determine approach

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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&amp;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