EMED Block 3 Flashcards by brandon lovin

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)

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What is the predominant Sx of CAD

PTs w/ NSTEMIs usually present w/ ?

Chest pain

Angina at rest

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What are the 3 different presentations of unstable angina?

Rest- angina lasts >20min

New- limited activity

Increased- previous dx, more frequent/longer

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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

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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

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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

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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

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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

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What influences O2 supply to the heart?

What influences O2 carrying capacity?

O2 carrying capacity /CAD flow

Hbg, O2 saturation

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What determines coronary blood flow?

Exercise induced MI occurs as result of ?

Duration of diastolic relaxation in heart
Peripheral resistance

Fixed atherosclerotic lesions

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Dx of STEMI requires ?

Dx of NSTEMI requires ?

How is unstable angina Dx

EKG

Abnormaly elevated cardiac biomarkers

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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

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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