CIHD and ACS Clinical Correlates

Question 1

What is Levine’s Sign?

Answer 1

Holding chest with right hand to indicate angina

Question 2

What is the clinical presentation of angina?
Location
Quality
Duration
Aggravating or Alleviating factors
Associated Symptoms or Signs

Answer 2

Location: Retrosternal region, radiates to or occasionally isolated to neck, jaw, shoulders
Quality: Pressure, squeezing, tightness, heaviness, burning, indigestion
Duration: <2-10 Min
Aggravating or Alleviating Factors: Precipitated by exertion, cold weather, emotional stress
Relieved by rest or nitroglycerin
Variant (Prinzmetal): Angina may be unrelated to exertion often early in the morning
Associated symptoms or signs: Dyspnea, S3, S4, Murmur of papillary dysfunction during pain

Question 3

STEMI Progression on ECG

Answer 3

Immediate before MI: T-wave inversion
Within hours of MI: ST elevation + Upright T-wave
Hours later: Significant Q + ST elevation + Upright T-wave
1-2 Days Later: Significant Q + Less ST elevation + Marked T inversion
Days to weeks later: Significant Q + T-wave inversion
Permanent: Significant Q

Question 4

Elevation in which ECG leads indicates STEMI in the:

Inferior Wall?
Lateral Wall?
Anterior Wall?

Which arteries are associated with each?

Answer 4

Inferior - II, III, aVF: Right Coronary Artery
Lateral - V5/6, I, aVL: Left Circumflex Artery
Anterior: V2-V4: LAD

Question 5

What is the gold standard of coronary imaging?

What lesion size is considered significant?

Answer 5

Angiography is the gold standard

Lesions > 70% blockage are significant

Question 6

What do beta-blockers do for MI?

Answer 6

BIG ONE:
Decreased O2 demand due to HR reduction, BP drop, and contractility drop
Relief of ischemic chest pain

Others:
Decreased risk of ventricular fibrillation
Decreased automaticity, increased electrophysiologic threshold for activation, and slowing of conduction
Prolongs diastole, improving coronary perfusion
Remodeling and improvement in left ventricular hemodynamic function, depending upon infarct size and timing of treatment
Improved left ventricular diastolic function with less restrictive filling pattern
Reduces mortality MI risk by 23%
Slows progression of coronary atherosclerosis
Improved LV diastolic function with a less restrictive filling pattern

Question 7

Which is the important receptor for beta-blockers in MI?

What are the most commonly used beta-blockers in MI?

Answer 7

Beta-1

Metoprolol, Carvedilol

Question 8

What is the important effects of calcium channel blockers?

Which ones are typically used?

Answer 8

BP & Symptom Control

Diltiazem and Amlodipine

Question 9

Is estrogen replacement a useful MI treatment?

Answer 9

No real evidence of it despite estrogen being protective for MI.

Question 10

What are the two types of revascularization techniques?

Answer 10

Percutaneous coronary intervention (Balloon/Stent)

Surgical bypass

Question 11

When is CABG preferable to PCI?

Answer 11

Left Main
Triple vessel
Double vessel w/ proximal LAD and LVEF < 50%
Diabetics

Question 12

When should an implantable cardiac defibrillator be used?

Answer 12

If LVEF < 35% more than 40 days post-MI (or 3 months post-revascularization)