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Cardiology Exam III > Emergency Medicine 2: Acute Coronary Syndrome > Flashcards

Emergency Medicine 2: Acute Coronary Syndrome Flashcards

1
Q

Myocardial ischemia is due to ..

A

Reduced myocardial blood flow.

This is caused by arterial spasm, disruption of atherosclerotic plaques, and platelet aggregation/thrombus formation

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2
Q

stable angina

A

Ischemia occurs only when activity increases oxygen demand beyond the supply restrictions of a partially occluded coronary vessel

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3
Q

Unstable angina

A

The patient now has chest pain at rest or with minimal activity

The pain pattern is increasing in frequency, severity, and duration

Reversible myocardial ischemia without injury develops as a result of plaque rupture and thrombus development

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4
Q

Acute Myocardial Infarction

A

There is irreversible damage to the myocardium secondary to the ischemia

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5
Q

Myocardium supplied by the LAD

A

Anterior wall of left ventricle
Most of interventricular septum
Some of lateral wall of left ventricle

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6
Q

Conductions system supplied by LAD

A

Most of right bundle branch
Anterior fascicle of left bundle branch
Part of posterior fascicle of left bundle branch

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7
Q

Myocardium supplied by Left Circumflex

A

Left atrium
Most of lateral wall of left ventricle
Posterior wall of left ventricle (in about 15% of population)
Inferior wall of left ventricle (in about 10% of population)
Inferior third of the interventricular septum (in about 10% of population)

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8
Q

Conduction system supplied by the Left Circumflex

A 
SA node (in about 40% of population)
AV node (in 10 to 15% of population)
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9
Q

Myocardium supplied by Right Coronary

A

Right atrium
Right ventricle
Inferior wall of left ventricle (in about 90% of population)
Inferior third of the interventricular septum (in about 90% of population)
Posterior wall of left ventricle (in about 85% of population)

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10
Q

Conduction system supplied by Right Coronary

A

AV node (in 85 to 90% of population)
SA node (in about 60% of population)
Proximal portion of bundle of His
Part of posterior fascicle of left bundle branch

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11
Q

Risk factors for CAD

A

> 40 yo

Male or postmenopausal female
    Estrogen may be cardio-protective 
Hypertension
Cigarette smoking
Hypercholesterolemia
Diabetes
Truncal obesity
Family history
Sedentary lifestyle
*Cocaine
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12
Q

How does cocaine affect the heart

A

Causes coronary artery vasoconstriction, tachycardia, systemic arterial hypertension, increased myocardial oxygen demand, platelet aggregation, and thrombus formation
Symptoms are often atypical
Can occur after only small amounts of cocaine
Approximately 6% sustain AMI
20 to 60% suffer transient myocardial ischemia

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13
Q

What does routing history determine in regards to chest pain ?

A

quality, location, radiation, intensity, frequency, associated symptoms, and precipitating factors

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14
Q

Classic angina presentation

A

is retrosternal left anterior chest/epigastric discomfort consisting of crushing, tightening, squeezing, or pressure

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15
Q

Is prognosis better or worse in atypical patients ? What demographics typically present atypically ?

A

Worse, due to difficulty in diagnosis.

Women and elderly

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16
Q

Angina (duration)

A

15-20 mins

Chest pain that lasts for only a few seconds is more likely due to another cause; as is constant, unremitting pain that lasts 12 to 24 hours without EKG changes

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17
Q

What is the response of angina to nitroglycerin ?

A

Usually improves within 2 to 5 minutes after rest or nitroglycerin

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18
Q

DDx fo Chest pain includes…

A 
Pulmonary embolism (PE)
Aortic dissection
Pneumothorax
Pericarditis
Pneumonia
Esophagitis/gastritis/cholecystitis
Musculoskeletal
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19
Q

What must be done when a patient presents to the ED with chest pain ?

A

placed on a cardiac monitor, have IV access, oxygen by nasal cannula, vital signs measured immediately, and portable chest x-ray ordered]]

A 12-lead EKG should be performed within 10 minutes of arrival and handed directly to the treating physician for immediate review

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20
Q

what should ED EKG’s be compared with when available ?

A

Old EKG’s !

Only about 50% of patients with AMI present with diagnostic changes on the initial EKG

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21
Q

What does ST segment elevation suggest ?

A

suggests acute transmural injury

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22
Q

What does ST depression indicate ?

A

ST-segment depression suggests subendocardial ischemia (non Q-wave MI)

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23
Q

Reciprocol ST segment changes indicate ?

A

Reciprocal ST-segment changes predict a larger infarct distribution, increased severity of underlying CAD, more severe pump failure, a higher likelihood of complications, and

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24
Q

Inferior leads

A

II,III, aVF

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25
Q

Lateral Leads

A

I, aVL, V5, V6

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26
Q

Septal leads

A

V1, V2

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27
Q

Anterior Leads

A

V3, V4

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28
Q

RIght Ventricle Leads

A

V4 placed on right side of chess

29
Q

Tachycardia in relation to ACS is may be due to

A

increased sympathetic tone or decreased left ventricular stroke volume

30
Q

Bradycardia in relation to ACS may be due to

A

to inferior wall ischemia

31
Q

WHat are rales, crackles indicative of on lung ausculation in relation to ACS ?

A

Congestive Heart Failure.

32
Q

The presence of jugular venous distention (JVD) or peripheral edema may suggest

A

RIght Sided heart failure

33
Q

Reproducible chest pain MAY be indicative of ?

A

MSK cause

Do not rule out MI because of this though

34
Q

MONA B (Initiated in all patients with possible ACS

A 
Morphine
Oxygen
Nitrates
Aspirin
Beta-Blockers
35
Q

What may be a benefit of administering O2 ? (this can be seen on EKG*)

A

Reduces the amount of ST elevation by limiting the amount of ischemic myocardial injury

36
Q

Dosing rate for 02 ?

A

4L /min

37
Q

What does Aspirin inhibit ?

A

Thromboxane A2 production and Platelet cycle-oxygenase –> inhibition of coronary artery re-occlusion

38
Q

Normally, nitrates are given sublingually 0.4 mg, which can be repeated X 2 at 5 minute . What can you do if patient is not pain free after admin in traditional manner ?

A

Infusion of nitrates at 10 mcg/minute

39
Q

At what BP would you not administer Nitro ?

A

systolic blood pressure is < 90 mm Hg

Also do not give in severe bradycardia or RV infarction

40
Q

With what other meds should nitro be avoided ?

A

Viagara (within 24 hrs) or other PDEF inhibitors (anything that would increase vasodilation)

41
Q

Would you give Morphine in a right sided heart disease (infarction) ?

A

No, it is a venodilator and will decrease right sided preload. (will also decrease after load)

42
Q

What co-morbidities would you avoid use of morphine with ?

A

hypersensitivity, hypotension, or respiratory depression

43
Q

In which patients should you exercise caution with when administering Beta Blockers ?

A

Patients with LV failure or severe COPD/asthma

LV failure requires high inotropic effect to move blood

COPD and asthma may be worsened due to unspecific B2 blockade.

44
Q

What is the EKG criteria needed to be a candidate for reperfusion therapy ?

A

ST-segment elevation > 1 mm in two or more contiguous EKG leads or a new LBBB

Unstable angina, especially in patients with recurrent ischemia, depressed LV function, widespread EKG changes, or prior MI

45
Q

Indications for fibrinolytic therapy

A

Chest pain suggesting AMI

ST-segment elevation > 1 mm in two or more contiguous EKG leads or a new LBBB

Time to therapy < 12 hours

Age < 75 years

46
Q

Absolute Contraindications to fibrinolytic therapy

A 
Previous hemorrhagic stroke
Other stroke within one year
Active internal bleeding (excluding menses)
Suspected aortic dissection
Arteriovenous malformation
Cerebral malignancy
47
Q

Cautionary co-morbidities when using fibrinolytic therapy include :

A

Severe uncontrolled hypertension (BP >180/110)
Current use of anticoagulants (INR > 2.5)
Known bleeding disorder
Recent trauma or major surgery within 2 - 4 weeks
Recent internal bleeding within 2 - 4 weeks
Pregnancy

48
Q

What is the goal time for getting a patient catheterized for PCI ?

A

Door to balloon intervention time < 90mins

49
Q

What patients will receive the most benefit from Percutaneous Coronary Intervention ?

A

Patients in cardiogenic shock

For patients with contraindications to fibrinolytic therapy

50
Q

Unfractionated Heparin directly inhibits which molecule ?

A

thrombin

51
Q

Why is UFH used as an adjunct therapy to fibrinolytic and PCI therapies ?

A

To inhibit re-occlusion

52
Q

In unstable angina with ST depression, UFH can be given with what other drug as treatment ?

A

Aspirin

53
Q

What must be monitored with UFH ?

A

aPTT

54
Q

Is LMWH useful in Non Q-wave MI ?

A

Yes !

Also, useful in angina

55
Q

Like UFH, LWMH inhibits thrombin. What does not need to be done in with LWMH that is needed with use of UFH ?

A

Monitoring via aPPT.

56
Q

How is LWMH administered ?

A

Sub Q (1mg/kg BID)

57
Q

Like LWMH, Glycoprotein IIB/IIIA inhibitors are useful in

A

Non-Q wave MI and unstable Angina

58
Q

Can you use GP IIB/IIIA inhibitors in conjunction with ASA and heparin ?

A

YES ! This is actually a very good regimen.

59
Q

Contraindications for GP IIA/IIIB inhibitors

A

Active internal bleeding or bleeding disorder in the past 30 days
History of intracranial hemorrhage, neoplasm, arteriovenous malformation, aneurysm, or stroke within 30 days
Major surgical procedure or trauma within one month
Aortic dissection, pericarditis, or severe hypertension
Platelet count < 150,000

60
Q

When does Myoglobin double in the blood ? Peaks ? Is it a good marker

A

2x in 2 hours, peaks in 4 hours

Not really

61
Q

When does CK-MB peak in the blood ?

A

within 24 hrs

62
Q

What conditions other than MI can present with elevated CK-MB ?

A

elevated levels are also seen in patients with skeletal muscle disease, acute muscle exertion, chronic renal failure, and cocaine use

63
Q

Is Troponin I found in skeletal muscle ?

A

No, it is not. Unlike with CK-MB

64
Q

Describe the chronology of Troponin I elevation, peak and prolongation

A

Elevation 6 hours post MI, peak at 12 hrs post MI and remain elevated 7-10 days

65
Q

What makes Troponin I the main marker tested for ?

A

It is the most specific and can be tested at bedside !

The only disadvantage for this marker is that due to it prolonged elevation it is difficult to test for re-infarction

66
Q

Who gets put into a Cardiac Care Unit ?

A 
Positive myocardial infarction
S/P fibrinolytic therapy or PCI
Ongoing ischemia
Unstable angina
Unstable vital signs
*High-dose antianginal medication
67
Q

Which patients will often be put into a step-down unit ?

A

Prior history of CAD
CHF
Recurrent chest pain in the ED
New EKG changes

68
Q

Telemetry floors are appropriate for which patients ?

A

patients with very low risk of adverse events and no EKG changes

Cardiology Exam III (12 decks)

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