EMED Block 3 Flashcards
What is the leading cause of death among US adults?
What disease process causes this?
Ischemic heart dz
Atherosclerotic dz of epicardial coronary arteries (CADz)
What is the predominant Sx of CAD
PTs w/ NSTEMIs usually present w/ ?
Chest pain
Angina at rest
What are the 3 different presentations of unstable angina?
Rest- angina lasts >20min
New- limited activity
Increased- previous dx, more frequent/longer
High likelihoods for short term risk of death or non-fatal MI risk stratification
Inc Sx tempo past 48hrs
Lasting >20min
Pulmonary edema New/worsening MR S3/new/worsening rales HOTN, Brady/Tachy >75y/o
Angina at rest w/ ST >0.5mm
BBB
Sustained V-tach
Inc TnT
Intermediate likelihood of death from MI
Hx of MI/CVDz/CA bypass
ASA use
Angina >20min of rest self resolved/resolved w/ Nitro
Nocturnal angina
New onset angina <2wks
> 70y/o
Twave cahnges
Pathologic Q waves
Resting ST depressions <2mm
Slightly elevated TnT
Low likelihood of death from MI
Inc angina frequency/severity/duration
Angina provoked at lower thresholds
New onset in past 2wks-2mon
Chest discomfort reproduced by palpitations
Normal EKG/markers
Left coronary artery divides into ? and ? to supply ?
What does the RCA supply?
Circumflex- ant/lat wall
LAD- anterior/septal regions
RV, inferior LV vis right posterior descending artery
AV conduction system receives blood from ?
What supplies the RBB and posterior division of LBB?
What supplies the posteromedial papillary muscles?
Antrioventriuclar (RCA) Septal perforating (LAD)
LAD and RCA
RCA
What influences O2 supply to the heart?
What influences O2 carrying capacity?
O2 carrying capacity /CAD flow
Hbg, O2 saturation
What determines coronary blood flow?
Exercise induced MI occurs as result of ?
Duration of diastolic relaxation in heart
Peripheral resistance
Fixed atherosclerotic lesions
Atherosclerotic plaque from due to ?
ACS can be caused by reduced flow due to secondary causes including ?
Repetitive injury to vessel wall
Coronary spasm
Microvascular dysfunction
Disrupted/erosion of plaques
Platelet aggregation or thrombus formation at lesion
What are the three factors that can cause a plaque to rupture?
After this rupture happens, what response occurs?
Composition/shape
Local factors
Artery movement
Platelet activation
How is ischemia produced during stable angina?
Activity induces O2 demands higher than supply
Ischemia occurs at fixed point, slowly over time
Atherosclerotic plaque has not ruptures, no thrombus
What causes ischemia to occur during ACS?
What is the main Sx of ischemic heart Dz
Plaque rupture/platelet rich thrombus develop
Coronary flow reduced
Chest pain
What 5 characteristics of ischemic heart dz Sxs may be helpful?
Sxs of acute MI can be described as ?
Less common descriptions include?
Severity Location Radiation
Duration Quality
Pressure Heavy Tight Fullness Squeeze
Knife Sharp Stab
What is the classic location of acute MI pain?
What are the three classic triggers that precipitate angina and how long does it last?
Sub-sternal/Left chest w/ radiation to arm, neck or jaw
Stress Exercise Cold
<10min
Acute myocardial ischemia pain usually lasts longer than angina and has ? 3 more prominent Sxs?
What is the difference in angina and AMI response to initial therapy?
Diaphoresis Nausea SOB
Angina: improves <5min w/ rest/nitro
AMI: little response to nitro
What are the 3 non-classic ACS presentations?
What gender is more likely to present w/ a silent MI w/out pain?
Advanced age
Female
DM
Female
PTs have poor prognosis if they present w/ ? non-classic MI Sxs
What are the traditional cardiac risk factorsfor CAD that are not helpful to predict ACS in PTs >40y/o?
Fatigue Weakness Not well
Vague discomfort
HTN DM Tobacco FamHx Hypercholesterolemia
What type of HR is usually noted w/ inferior wall MIs
What are two poor prognosis factors for anterior wall MIs?
Brady
Brady/new heart block
What PE finding usually indicates a failing myocardium due to MI?
Presence of a new systolic murmur is ominous sign and may signify ? three issues?
S3 (can be normal: young pregnant athlete)
Papillary muscle dysfucntion
Flail leaflet of MV w/ MR
VSD
The presence of ? w/ or w/out S3 indicates S3 LV dysfunction and L-sided HF
Presence of what 3 findings suggest R-sided HF?
Rales
JVD
Hepato-jugular reflex
Peripheral edema
Dx of STEMI requires ?
Dx of NSTEMI requires ?
How is unstable angina Dx
EKG
Abnormaly elevated cardiac biomarkers
Hx
What is the TIMI score for unstable angina
What is the max score?
\+65y/o 3 or more RFs for CADz Hx coronary stenosis >50% ST deviation on EKG 2 + anginal events <24hrs ASA w/in 7d prior Elevated cardiac markers
7pts, one each
How fast do EKGs need to be obtained and interpreted for MIs?
What is the “general” definition of a STEMI?
10min of presentation
ST elevations of 1mm or more in 2 contiguous leads w/ reciprocal changes
ST elevations on EKG suggest ?
ST depressions suggest ?
Transmural injury/infarction
Ischemia
Inferior wall MIs need to have ? obtained
Why does this step need to be taken?
R sided V4
ST elevation in V4R= highly suggestive of RV infarction
PTs w/ RV infarctions are ? dependent
What two meds need to be used w/ caution in these PTs?
Preload
Nitro and BBs
PT w/ non-diagnostic EKG and persistent MI like Sxs needs to have ? done next
PT w/ new LBBB is equivalent to ? Dx
Repeat EKG
STEMI
What causes the reciprocal changes on EKGs?
How does the size of EKG changes correlate to the severity?
Subendocardial ischemia
Larger= more extensive injury
What leads are involved in each of the locations of MIs
Anteroseptal: V1-3 Anterior: V1-4 Anterolateral: V1-5, 1, aVL Lat: 1, aVL Inferior: 2, 3, aVF Inferolateral: 2, 3, aVF, V5-6 True posterior: R waves in V1-2 >0.04s, R/S ratio +1 RV: 2, 3, aVF and ST elevation on R sided V4
? test is the risk stratifier for PTs w/ ACS
When are leads V7-9 used?
12 lead EKG
Posterior MI from circumflex lesion
Criteria for pre-existing LBBB
What is the MC pacemaker lead location and what EKG issue does this cause?
Elevation >1mm and concordant
Depression >1mm V1-3
Elevation +5mm and discordant
RV pacing- secondary repol of opposing polarity
Where is Wellens seen on an EKG?
What is this finding associated with?
What abnormality occurs during this condition?
V2-3
Critical stenosis of LAD, pending future anterior MI
T-waves when pain free
Normal EKS w/ pain
PTs w/ diagnostic ST elevations on initial EKG don’t need ?
When is this missing step preferably done?
Serum labs drawn
Non-Dx EKG of NSTEMI
Risk stratification for NSTEMI, unstable angina
What type of serum marker is used for Dx of ACS
What types of results indicate a very low risk for ACS
D-troponin over 1-3hrs
Undetectable high sensitivity troponin + no EKG evidence
Results showing elevated and __ are a worse prognosis
How long does it take troponin to rise, peak and return to normal?
BNP
Rise: 3-12hrs
Peak: 12-24hrs
Norm: 5-14d
How are STEMIs Tx
What is the time frame this Tx must be done within?
What alternative Tx is done if the primary STEMI Tx is unavailable?
PCI
<90min w/ PCI capability
<120min w/out PCI capability
Fibrinolysis <30min
PTs w/ ACS get ? 3 drugs in the ED
What is added if they’re refractory to these therapies or about to undergo PCI?
Antiplatelets
Antithrombins
Nitrates
Glycoprotein 2b/3a antagonist
When is the aggressive STEMI Tx method applied to the NSTEMI PT
Guide lines recommend if unstable angina/NSTEMI Pts are hemodynamically unstable, then invasive Tx strategies are implemented within ?
One or more of:
Refractory angina
Hemo/electric instability
PTs at increased risk
2hrs
___ is the preferred reperfusion Tx method if contact to Tx time is between ?
PCI
90-120min
What is the MC PCI?
What medications are added if stents are used?
Coronary angioplasty w/ or w/out stent placement
Antiplatelet therayp- Thienopyridines, Glycoprotein 2b3a inhibitors
What is the MOA of fibrinolytics
What part of the heart does this Tx improve?
Plasminogen activators acting on thrombosis
LV function
When can fibrinolytics be used for STEMI PTs
Fibrinolytic therapy is more beneficial for ? types of MIs
Time to Tx is 6-12hrs from Sx onset and,
EKG has 1mm ST elevation in two leads
Larger, anterior
If fibrinolytics fail, rescue PCI is recommended for ? PTs?
<75y/o in cardiogenic shock
Severe HF/Pulm Edema
Hemodynamic compromising ventricular arrhythmia
Large are of myocardium at risk
What is the most catastrophic complication of fibrinolytic Tx
Differen benefits of using ASA or Glycoprotien 2b/3a inhibitors
Intracranial bleeding
ASA: inhibits platelet aggregation stimulated by thromboxane A2 mediated by arachidonic acid pathway
G2b/3a: stronger, interrupt platelet activation regardless of agonist present
Absolute c/is for Fibrinolytics
Relative c/is for Fibrinolytics
Slide 85
PTs receiving fibrinolytics should get ? for how long?
When is Clopidogrel used instead of ASA?
Full dose anticoagulant (UFH, Enox, Fonda) x 48hrs
True ASA allergy
Active PUD
What ADP antagonists are used and when is it c/i?
Prasurgel- irreversible platelet receptor antagonist
Prior CVA/TIA or bleeding
Ticagrelor- reversible P2y12 antagonist, gone w/in 3d of d/c
Clopidogrel- addition to ASA and antithrombin therapy improves STEMI PTs receiving fibrinolysis
? reduces risk of AMI and death during the acute phase of unstable angina
Combining this w/ __ dec risk by over 50%
UFH
ASA
D/c use of UFH w/in ?hrs of therapy to prevent development of ?
Why would LMWH heparin be preferred?
<48hrs
HIT
Greater BioAvail
Lower protein binding
Longer t1/2
LMWH (Enoxaparin) is not considered a first line antithrombin for ? PTs unless they’re already on it?
What class of drugs are used to reduce the infarct size?
Primary PCI for STEMI
Nitrates- relax smooth muscles , inhibit platelet aggregation
What are the 3 benefits of using Nitro in AMI PTs not Tx w/ thrombolytics?
When using nitrates in AMI, titrate flow to ?
Dec infarct size
Improves regional function
Dec rate of CV complications
BP reduction, not pain
Avoid Nitrates in PTs who took phosphodiesterase inhibitors in the past ?hrs
BBs hold what 3 beneficial properties
24hrs- Sildenafil
48hrs- Tadalafil
Anti dysrhythmic, ischemic and HTN properties
Usually ? meds are given post-MI w/in 24hrs
BBs can only be given if PT has none of ?
PO Metoprolol
ACEIs
Signs of HF
Low output
Cardiogenic shock risks
Use of BBs are still c/i in ? PTs
What class of drug may be used for limiting infarct size but doesn’t improve mortality
2/3rd degree blocks
PR interval >0.24sec
Asthma
Reactive airway dz
CCBs
What PTs may find benefit from CCBs?
Ischemia A-fib w/out CHF LV dysfunction AV blocks C/i BB use
Anterior AMIs tend to cause TPs to develop ? sequelae dysrhthmia that indicates poor prognosis?
PTs w/ SVT, Afib/flutter w/ hemodynamic compromise are best Tx w/ ?
Sinus tach
Cardioversion
? is used for Tx sinus bradycardia causing HOTN, ischemia or ventricular escape rhythms?
Anterior and inferior wall MIs can cause PTs to develop ?
Atropine
Complete heart blocks from occlusion of RCA/LAD
What type of rhythms occur from anterior/inferior MIs
How does a mechanical complication present?
Transient junctional <48hrs of infarct
Previously stable PT suddenly decompensates- usually due to tearing/rupture of infarcted tissue
When do ventricular free wall ruptures tend to occur?
What doe these usually lead to?
If this occurs, what is the dx test of choice?
1-5 days after infarct
Pericardial tamponade
Death
Echo
How does a rupture of the interventricular septal wall present?
What is the Dx procedure of choice?
Chest pain
Dyspnea
Sudden/new holosystolic murmur
Doppler echo
What PTs are more likely to have a septal rupture?
Papillary muscle rupture is more common after ? MI and presents w/ ?
Anterior wall MI
Three vessel CADz
Inferior MI
Dyspnea Inc HF/Dyspnea
Pulm edema
New holosystolic murmur w/ MR
When are AMI PTs more likely to develop pericarditis
How are these PTs Tx
Transmural AMI and delayed presentation
ASA
Colchicine
Do not use Ibuprofen
How does Dressler’s Syndrome present?
How is it Tx
Chest pain
Fever
Pleuropericarditis
ASA
Colchicine
What Tx/PE finding suggests PT may be having RV infarction
Although not always available, what images can be Dx?
JVD/HOTN in response to Nitro
Echo/nuclear imaging
What is the most serious complication that can occur from RV infarcts?
How are these types of infarcts Tx
Shock
Maintain pre-load (NS)
Reduce RV afterload
Inotropic support of RV
Early reperfusion
Post-PCI PT presenting w/ chest pain has ? until proven other wise?
What biomarker is the most sensitive for detecting cocaine associated biomarker?
Abrupt vessel closure
Cardiac troponin
How is cocaine induced ACS Tx
What meds are c/i in the first 24hrs
Benzos ASA Nitrates
BBs
Define HF
What are the cardinal manifestations?
Structural/functional impairment of ventricular filling/ejection
Fatigue
Fluid retention
Edema
Dyspnea
What is the most endogenous counter regulatory response to HF?
What are the three types of this response?
Natriuretic peptides
A: atria
B: ventricles
C: endotelium
What two effects are stimulated by natriuretic peptide release?
Dilation
RAAS inhibition
What are the 6 classifications of acute HF?
HTN: SBP >140
High Output: tachy, warm extremities, pulmonary congestion
Cardiogenic shock: Hypoperfusion w/ SBP <90
RHF: low output w/ JCD, hepatomegaly
Acute on Chronic: peripheral edema but doesn’t fit other categories
PEdema: rales, dec O2 sat
How do PTs w/ acute on chronic HF present
How is higt output HF distinguished?
Gradual Sxs
Weight gain over days/wks
Normal ejection fraction
Caused by anemia/thyrotoxicosis
Normal ejection fraction is ?
Reduced ejection fraction is ?
60%
<50%
Define Systolic Dysfunction
Define Diastolic Dysfunction
HF w/ reduced EF <50%
HF w/ preserved ejection fraction, impaired ventricular relaxation
How is HF Dx
What are the RFs for HF
Clinical Dx w/ Hx and PE
HTN DM Valvular dz Age Male Obese
What Sx has the highest sensitivity for Dx of HF
What 3 Dxs have the highest specificity?
Dyspnea on exertion
Paroxysmal nocturnal dyspnea, Orthopnea and Edema
What result has equivocal accuracy as clinical gestalt for Dx HF?
? test/image results are most specific for a final Dx of acute HF?
BNP value
CXR w/ congestion, cardiomegaly and edema
What EKG finding has the highest likelihood ratio for HF?
Afib
