HEART BLOOD SUPPLY, AREA SUPPLIED AND EKG LEADS Flashcards
INFERIOR WALL
RCA
LEADS II, III, AVF
IWMI
POSTERIOR WALL
RCA
V1, V2-R WAVES
RVWMI
RIGHT VENTRICLE
RCA
V3R, V4R IN RIGHT SIDE EKG
SA NODE
RCA
ARRHYTHMIAS
AV NODE
RCA
HEART BLOCKS
ANTERIO-SEPTAL
LAD
V1-V4
ANTERIOR
LAD
V3-V4
APICAL/LATERAL
LAD
V5-V6
SAL
LAD
S V1 V2 SEPTAL
A V3 V4A ANTERIOR
L V5 V6 LATERAL
APICAL/LATERAL
LAD-V5 V6
LEFT CIRCUMFLEX BRANCH ARTERY-V5 V6
APICAL
POSTERIOR DESCENDING ARTERY
V5-V6
HIGH LATERAL WALL
CIRCUMFLEX BRANCH/DIAGNOL BRANCH OF LCA
I, AVL
MI
ST ELEVATION
ISCHEMIA
ST DEPRESSION
LEAST COMMON AREAS FOR MI AND ISCHEMIA DUE TO COLLATERAL/DUAL BLOOD SUPPLY
V5-V6
APICAL LATERAL
AND APICAL HEART
IWMI II,III, AVF -RCA POST TPA
PATIENT BECOMES HYPOTENSIVE
MUST DO RIDE SIDE ECG TO R/O EXTENSION OF MI TO RVWMI V3R-V4R
LAD
WIDOW MAKER
CP
ON EXERTION
RELIEVED WITH REST
ALL 3+
CLASSICAL ANGINA
CP
ON EXERTION
RELIEVED WITH REST
2+/3
ATYPICAL ANGINA
CP
ON EXERTION
RELIEVED WITH REST
ONLYCP+
NONCARDIAC ORIGIN OF CHEST PAIN
CP+ ALONE AND
MALE 40 OR OLDER
FEMALE 60 AND OLDER
INTERMEDIATE PROBABLITY NEED TO
DO STRESS TEST
CP+ 2/3(ATYPICAL ANGINA
MALE 39 AND ABOVE
FEMALE 50 AND ABOVE
NEED TO DO STRESS ON HEART TO REPRODUCE ISCHEMIA
60 F WALKS DAILY ON TREADMILL WHEN INCREASES SPEED AND INCLINE GETS SOB ON EXERTION WITH CHEST HEAVINESS WITH NORMAL BASELINE ECG NEXT STEP?
DO EXERCISE EKG STRESS TEST
50M WALKS DOG DAILY, RECENTLY NOTED CP LASTING 15 MIN CANT RECALL RELIEVING OR AGGRAVATING FACTORS
HTN+ ON CHLORTHALIDONE
BASELINE EKG +LVH
NEXT STEP?
EXERCISE STRESS ECHO
60 M WITH EXERTIONAL CP, CANNOT WALK MORE THAN 1 BLOCK W/O DYSPNEA
NO EXACERBATING OR RELIEVING FACTORS
+PMHX COPD- +WHEEZE
BASELINE EKG NORMAL
NEXT STEP?
DOBUTAMINE STRESS TEST
65 F WITH EXERTIONAL DYSPNEA AND OCCASIONAL CP+
NO RELIEVING FACTORS
BASELINE EKG+LBBB NEXT STEP?
VASODILATOR PET
REGADENOSINE, DUPYRIDAMOLE
WHO CAN UNDERGO EKG EXERCISE STRESS TEST?
RBBB
48M WITH CP+ AND EKG +LBBB
RAGADENOSON MPI REVEALS ANTEROSEPTAL ISCHEMIA ARTERY?
HIGH GRADE LAD STENOSIS
V1-V4
62 F +EXERTIONAL CP, EKG STRESS TESTS -STOPPED AT 5 MIN D/T CP+ AND ST DEPPRESION IN I, AVL, V4-V6 ARTERY?
LEFT CIRCUMFLEX ARTERY STENOSIS
APICAL/LATERAL WALLMI
62 F WITH +HTN AND CP+ EKG WITH +LVH, EXERCISE ECHO STRESS TEST STOPPED IN 5 MIN DUE TO CP+ AND ST DEPRESSION IN II, III, AVF ARTERY?
RCA
IWMI
WHO GETS GATED POOL STUDIES OR MUGA SCAN?
IN PTS TO DETERMINE LV EF AND WALL MOTION ABNORMALITIES DECREASED LV EF IS POOR PROGNOSTIC FACTOR ON MUGA
WHEN NOT TO DO STRESS TEST
UNSTABLE ANGINA
OR
AS WITH SYMPTOMS
OBESE FEMALE WITH ATYPICAL CP+
DOES EXERCISE STRESS TEST , STOPS TEST AFTER 5 MIN D/T FATGIUE BUT NO CP.
HR INCREASED BY 50%
EKG- NORMAL NEXT STEP?
PHARM STRESS TEST DUE TO SUBMAXIMAL CARIAC STRESS STUDY
UNSTABLE ANGINA
-NEW ONSET SEVERE ANGINA <2 MONTHS
-ANGINA AT REST
-RECENT INCREASED FREQUENCY
-POST-INFARCT ANGINA
PT WITH +ANGINA CONTROLLED ON BB, ASA AND NITRATES PRESENT WITH RECENT INCREASED FREQUENCY AND CP NOW LASTS FOR>30 MIN
EKG-ST DEPRESSION IN II, III, AVF
MOST LIKELY MECH OF PATIENTS Cp?
ATHEROSCLEROTIC PLAQUE WITH INTERMITTENT RUPTUREMAND THROMBOLYSIS
UNSTABLE ANGINA
PT WITH +HX CHRONIC ANGINA CONTROLLED ON ASA AND NITRATES
WITH THE INCREASING FREQUENCY OF ANGINA NEXT STEP?
ADD BB
PT WITH +HX CHRONIC ANGINA CONTROLLED ON ASA AND NITRATES (12HR NITRATE FREE INTERVAL +) RECENTLY ADDED BB-METOPROLOL 12.5MG QD 6 MONTHS LATER COMES IN WITH ANGINA AFTER WALKING 2 BLOCKS PAIN RESOLVES AFTER FEW MINS OF REST. PE HR IS 80/M BP 140/90
NEXT STEP?
INCREASE METOPROLOL DOSE TIL HR<60
PT WITH +HX CHRONIC ANGINA CONTROLLED ON ASA AND NITRATES (12HR NITRATE FREE INTERVAL +) METOPROLOL 50MG BID 6 MONTHS LATER COMES IN WITH ANGINA AFTER WALKING 2 BLOCKS HR 55/M NEXT STEP?
ANGIOGRAM —>PCI
PT WITH CP+ ON EXERTION AND RELIEVED WITH REST. PAST 4HRS
EKG+ ST DEPRESSION WITH NORMAL TROP
PT GETS ASA, NTG, BB, HEPARIN AND SX RESOLVES THE NEXT STEP?
PCI
HAS TO BE DONE WITHIN 24 HOURS
IT HAS SHOWN TO DECREASE RATE OF RECURRENT MI AND DECREASE ALL CAUSE MORTALITY
PT ON ASA, NITRATES, BB, STATINS FOR HIGH CHOL.
HB NORMAL AND NO SIGNS OF INFECTIONOR STRESS WITH INCREASING EPISODES OF ANGINA ON EXERTION. ANGIOGRAM REVEALS MULTIVESSEL DISEASE NOT AMEANABLE TO TEVASCULARIZAATION
BEST MNGMT?
RANOLAZINE-DECREASES FREQUENCY OF ANGINA EPISODES AND IMPROVED EXERCISE TOLERANCE BUT NO DECREASE IN ALL CAUSE MORTALITY
PT SOPPED ASA D/T PUD 2 MONTHS AGO. WAS SRATED ON PPI
NO PRESENTS WITH CP
NEXT STEP?
start ASA
45 M OTHERWISE HEALTHY, NONSMOKER, NO DM, PRESENTS WITH NEW ONSET CP OF > 30 MIN DURATION WHILE SHOVELING SNOW. IN ER-EKG NORMAL NEXT STEP?
ADMIT TO CHEST PAIN UNIT
45 M OTHERWISE HEALTHY, NONSMOKER, NO DM, PRESENTS WITH NEW ONSET CP OF > 30 MIN DURATION WHILE SHOVELING SNOW. IN ER-EKG NORMALADMITTED TO CHEST PAIN UNIT
NEXT DAY
ENX-, TROP -, EKG NO CHANGES THE NEXT STEP?
STRESS EKG TEST
65 M WOKE UP EARLY AM WITH SEVERE RESTROSTERNAL CP LASTING 40 MIN WITH SWEATING AND DIAPHORESIS
ER EKG+ST DEPRESSION AND T WAVE INVERSION
PT STARTED ON ASA, IV NITRATES, BB, LMWH AND GPIIB/IIIA INHIBITORS.
ANGINA PAIN RESOLVES BUT
24 HOURS LATER ST DEPRESSION PERSISTS WHAT DOES THIS REPRESENT?
SILENT ISCHEMIA
65 M WOKE UP EARLY AM WITH SEVERE RESTROSTERNAL CP LASTING 40 MIN WITH SWEATING AND DIAPHORESIS
ER EKG+ST DEPRESSION AND T WAVE INVERSION
PT STARTED ON ASA, IV NITRATES, BB, LMWH AND GPIIB/IIIA INHIBITORS.
ANGINA PAIN RESOLVES BUT
24 HOURS LATER ST DEPRESSION PERSISTS MOST APPROPRIATE DIAGNOSTIC STEP?
CORONARY ANGIOGRAM
WHAT CAN REPRESENT AS AN ANGINAL EQUIVLANT?
IN ABSENCE OF PULMONARY DISEASE WITH SX+ EXERTIONAL DYSPNEA WITHOUT CP IN A PATIENT
42 F PRESENTS WITH RETROSTERNAL CP FOR PAST 2 HOURS
PMHX-
RUNS 2 MILES 3X/WEEK
EKG+NONSPECIFIC
T-WAVE CHANGES
TROP IS 22 NEXT STEP?
CORONARY ANGIOGRAM
IN ABSENCE OF PULMONARY DISEASE WITH SX+ EXERTIONAL DYSPNEA WITHOUT CP IN A PATIENT REPRESENTING ANGINA EQUIVELANT MC SEEN IN PATIENTS WITH?
DM
FEMALES
ELDERLY
POSTCABG
65 F HAS EXERTIONAL SOB DURING EXERCISE AND RELIEVED POST EXERCISE. MR MURMUR DURING EXERCISE WHICH DISAPEARS POST EXERCISE
S4+
ECHO+ MILD HYPOKINESIS AND EF 60% MOST LIKELY ETIOLOGY?
ISCHEMIC
46 M WITH CP+ LASTING 15 MIN
ER- CP RESOLVED
HR 72/M BP 118/76
EKG- ST ELEVATION, +ONLY DEEP TWAVE INVERSION IN V1,V2,V3,V4
WHAT DOSE THIS REPRESENT?
MYOCARDIAL ISCHEMIA
WELLENS SYNDROME/LAD T WAVE INVERSION SYNDROME
ANTEROSEPTAL ISCHEMIA V1-V4
46 M WITH CP+ LASTING 15 MIN
ER- CP RESOLVED
HR 72/M BP 118/76
EKG- ST ELEVATION, +ONLY DEEP TWAVE INVERSION IN V1,V2,V3,V4
WHAT TO DO FOR THIS PATIENT NEXT?
STRAIGHT TO ANGIOGRAM
NOT ECHO
NOT STRESS TEST
PT PRESENTS WITH CP+, EKG-
THALLIUM STRESS TEST WITH REVERSIBLE ISCHEMIA
CORONARY ATERIOGRAPHY IS NEGATIVE
WHAT IS DIAGNOSIS AND HOW DO YOU TREAT IT?
DX: MICROVASCULAR ANGINA/SYNDROME X
RX:
-CCBS
-BBS AND NITRATES
PT WITH CP AT NIGHT 5-15 MIN AT REST
NEXT STEP?
EKG–>ST-T WAVE CHANGES–> ANGIOGRAM —> NEGATIVE–>NEXT DO AMBULATORY EKG–> POSITIVE–> VASOSPASTIC ANGINA
PT WITH CP AT NIGHT 5-15 MIN AT REST
NEXT STEP?
EKG–>NO CHANGES–> STRESS TEST –> NEGATIVE–> AMBULATORY EKG–> POSITIVE ST ELEVATIONS–> ANGIOGRAM –> NEGATIVE–> VASOSPASTIC ANGINA
TOC FOR VASOSPASTIC ANGINA
CCBS-AMLODIPINE, NIFEDIPINE,DILTIAZEM, VERAPIMIL
ELDERLY M WITH +SYNCOPE.
EKG ON PRESENTATION -NORMAL
FEELS DIZZY AFTER DINNER
EKG SHOWS ST DEPRESSION IN II, III, AVF
REPEAT EKG AFTER 15 MIN -NORMAL
DX?
NEXT BEST STEP IN MGNMT?
DX: POSTPRANDIAL ISCHEMIA
NEXT STEP: CARDIAC CATH(ANGIOGRAM)
ELDERLY M COMPLAINS OF LIGHTHEADEDNESS AFTER MEALS ESPECIALLY LUNCH AND DINNER FOR PAST COUPLE MONTHS
PASSED OUT 2X/6 MONTHS
BP 122/82
NEXT STEP?
SMALL FREQUENT MEALS
LEAST LIKELY TO CASE ST ELEVATION?
UNSTABLE ANGINA
OTHER CAUSES OF ST ELEVATION
-TRANSMURAL MI
-LV ANEURYSM POST MI-CONFIRM DX WITH ECHO
-ACUTE PERICARDITIS
-PRINZMETALS ANGINA
-TAKOTSUBO CARDIOMYOPATHY
21 PT CP+ COCAINE+ BP160/100
STEPS IN ORDER FOR MNMGT?
AND PREVENTION OF CP IN FUTURE?
1-BZD
2-NITRATES
3-ASA
4-PCI
PREVENTION WITH CCB
MYGLOBIN LEVELS
INCREASE IMMEDIATELY
-PEAKS IN 1-4 HOURS
-BACK TO NORMAL IN 24 HOURS
NORMAL RANGE 0-85NG/ML
PT CP+, ST ELEVATIONS AND TROPS ELEVATTED
S/P TPA , ST RESOLVE, CP RESOLVED
NEXT BLOOD DRAW-TROPININ LEVELS EVEN HIGHER NEXT STEP?
NOTHING
GOOD SIGN MEANS GOOD REPERFUSION REOPS PEAK FASTER AND PEAK IS HIGHER THAN THOSE NOT SUCCESSFULLY REPERFUSED
PT WITH ACUTE CP+, ST ELEVATION
PCI DONE
NEXT DAY CP+, BEST MARKER TO DIAGNOSE MI?
MYGLOBIN
INCREASES IN 1 HR–> PEAKS IN 1-4–>BACK TO NORMAL IN <24 HOURS
65 M ADMITTED WITH PNA TO MICU ON IV ABX. EKG NORMAL
TROP 1.3 NEXT STEP?
ECHO
INDICATIONS FOR THROMBOLYSIS WITH TPA?
**CP+ TYPICAL FOR INFARCTION>30 MIN WIHT LBBB
**ST ELEVATION 1MM IN 2 CONTIGUOUS LEADS
**<12HOURS POST MI
** PT >2HOURS AWAY FROM PCI CENTER AND NOT IN SHOCK
ELEVATED TROPS ARE POOR PROGNOSTIC FACTORS AND CAN BE SEEN IN?
-CHF
-CRITICAL ILLNESS
-LVH
-HOCM
-PAD
-CORONARY VASOSPASM
-PE
-CKD
-PNA
CONTRAINDICATIONS FOR THROMBOLYTIC RX
ABSOLUTE
**PREVIOUS HEMORRHAGIC STROKE
**ISCHEMIC STROKE <3 MO AGO
**INTRACRANIAL NEOPLASM
** ACTIVE INTERNAL BLLED
CONTRAINDICATIONS FOR THROMBOLYTIC RX
RELATIVE
** ISCHEMIC STROKE>30 MO AGO
** RECENT INTERNAL BLEED OR MAJOR TRAUMA <2-4 WEEKS AGO
**BP>180/110
**PREGNANCY
**ACTIVE PUD
INDICATIONS FOR PCI(PCI OR ANGIOPLASTY)
**ACUTE STEMI
**ST ELEVATION WITH CP>12HOURS
**MI WITH SHOCK AND PT <2 HOURS AWAY FROM PCI CENTER & <75 Y/O
**STEMI POST CABG PTS
**IF TPA IS CONTRAINDICATED
** UNSTABLE ANGINA
FACTS ABOUT TICAGRELOR, PRASUGREL, CLOPIDOGREL
-P2Y12 ADP PLT INHIBITORS
-PT WITH MI ALLERGIC TO ASA THEN USE TICAGRELOR OR PRASUGREL
-PT GOING FOR PCI AFTER MI-USE TICA OR PRASU–NOT CLOPID
-PT GOING FOR CABG DO NOT USE TICAGRELOR OR PRASUGREL
WHEN IS CABG BETTER THAN PCI
-LEFT MAIN DISEASE
-3 VESSEL DZ WITH DECREASED LV EF
-2 VESSEL DZ WITH PROXIMAL LAD AND DECREASED LV EF
-DM WITH CAD
TICAGRELOR AND PASUGREL ARE SUPERIOR TO CLOPIDOGREL IN PCI
PT WITH CAD S/P PCI WITH STENT PLACEMENT WHICH MEDS TO D/C PATIENT HOME ON?
-ASA+
-TICAGRELOR+ (DAPT)
FOR AT LEAST 12 MONTHS
PT WITH CAD S/P PCI WITH STENT PLACEMENT ON ASA+
TICAGRELOR+ (DAPT) STARTED 3 MONTHS AGO COMES IN WITH -LOW HB, +BRBPR AND EKG WITH ST DEPRESSION
PRBC TRANSFUSED
NEXT STEP?
CSC
PT WITH STENT PLACED 3 MONTHS AGO ON ASA AND TICAGRELOR PRESENTS WITH GI BLEED
NEXT STEP?
-HOLD TICAGRELOR
-CONTINUE ASA
-RESTART TICAGRELOR ASAP
PT WITH STENT PLACED 12 MONTHS AGO ON ASA AND TICAGRELOR PRESENTS WITH GI BLEED
NEXT STEP?
-D/C TICAGRELOR
-CONTINUE ASA 81MG QD
PT WITH STENT PLACED 9 MONTHS AGO ON ASA AND TICAGRELOR GOING FOR KNEE REPLACEMENT SURGERY NEXT STEP?
DELAY SURGERY BY 3 MONTHS
PT WITH AFIB HAS MI WITH PCI TREATMENT?
-DOAC PLUS CLOPIDOGREL X1 YEAR
-THEN DOAC ALONE AFTER 1 YEAR
PT NOW WITH AFIB HAD MI 1 YEAR AGO WITH PCI ON ASA TREATMENT?
-D/C ASA
-START DOAC
60 PT UNDERGOAS CABG
COUPLE OF MONTHS LATER HE IS DOING FINE BUT HAS PRB KEEP ACCOUNTS OCCASIONALLY
THIS REPRESENTS?
NEUROCOGNITITVE DEFECT
PT WITH +RETROSTERNAL CP>1HOUR, DIAPHORETIC
EKG+ LBB, ST ELEVATED IN ANTERIOR LOADS
NO OLD EKG TO COMPARE
CK AND TROPS PENDING NEXT BEST STEP?
CATH/ANGIOGRAM
PT WITH CP+ ST ELEVATIO IN ANTERIOR LEADS
S/P TPA WITH BP90/60
2 HOURS LATER-ST ELEVATION IN LATERAL LEADS AND SBP 80
PT IS + SOB
NO NEW MURMURS AT LSB OR APEX
CXR+PULMO EDEMA
NEXT BEST STEP?
PCI
IF CANT DO PCI NOW, THEN IABP INFLATE IN DIASTOL AND DEFLATE IN SYSTOLE
PT WITH CP+ ST ELEVATIO IN ANTERIOR LEADS
S/P TPA WITH BP90/60
2 HOURS LATER-ST ELEVATION IN LATERAL LEADS AND SBP 80
PT IS + SOB
NO NEW MURMURS AT LSB OR APEX
CXR+PULMO EDEMA IS GOING FOR PCI AND ALLERGIC TO ASA
BEST RX?
TICAGRELOR OR PASUGREL
PT IS POST IWMI AND 2HR LATER BP 90/60 SUSPESTING RV INFARCT NEXT DIAGNOSTIC STEP?
AND NEXT STP IN MNGMT?
DXIC: RIGHT SIDE EKG WITH V3R AND V4R
MGMT: BOLUS NORMAL SALINE FIRST
** IF BP CONTINUES TO DECREASE THEN NEXT STEP START DOPAMINE**
PT WITH CP+ X3 HOURS
ER WKG+ ST ELEVATION IN II,III,AVF
TROPS NEG
NEXT STEP?
PCI
PT WITH CP+ X3 HOURS
ER WKG+ ST ELEVATION IN II,III,AVF
TROPS NEG
PCI NOT AVAILABLE
NEXT BEST STEP IN MNGMT?
TPA
PT WITH CP+ X3 HOURS
ER WKG+ ST ELEVATION IN II,III,AVF
TROPS NEG
PCI NOT AVAILABLE
TPA GIVEN WITH IN 30 MIN ARRIVAL
NEXT STEP IN MNGMT?
PCI AFTER 2 HOURS
PT WITH CP+ X3 HOURS
ER EKG+ ST ELEVATION IN V2, V3, V4
TROPS +
TPA GIVEN WITH IN 30 MIN ARRIVAL
PT HAS DEVELOPED CRACKLES IN THE LUNGS AND SOB+
NEXT STEP IN MNGMT?
PCI ASAP
PT PRESENT WITH 13 HRS OF CP+, TOOK ANTACIDS WITH NO RELIEF
EKG+ ST ELEVATION IN ANTERIOR LEADS
BP140/80
GIVEN ASA TO CHEW AND IV NITRATE AND IV BB AND IV MORPHINE
CLOSES PCI CENTER IS AT LEAST 1 HOURS AWAY NEXT BEST STEP?
TRANSFER AND DO PCI
60 M PRESENTS TO SMALL COMMUNITY HOSP WITH CP AND FOUND TO HAVE AN ANTERIOR WALL mi.
NEAREST TERIERY CENTER IS 2HRS AWAY BEST STP IN MNGMT?
TPA AND THEN TRANSFER TO DO PCI
65 M PRESENTS WITH AWMI WITH BP 80/60
PT WAS PUT ON IABP
NEAREST PCI CENTER IS 2.5 HOURS AWAY NEXT BEST STEP?
TPA AND THEN TRANSFER TO DO PC
PT ADMITTED WITH MI
3 DAYS LATER PRESENT WITH CP RELIEVED WITH NTG NEXT STEP?
CARDIAC CATH(ANGIOGRAM)
PT HAD CARDIAC CATH 6 HOURS AGO APPEARS DIAPHORETIC AND CLAMMY SKIN
BP80/60 HR 116/M PE-NO ERYTHEMA OR SWELLING AT PUNCTURE SITE
IVF BOLUS GIVEN
HB THIS AM WAS 14 NEXT STEP?
CT ABDOMEN TO CHECK FOR RETROPERITONEAL BLEED
PT HAS CARDIAC CATH
2 DAYS LATER PRESENTS WITH PAIN IN RIGHT GROIN
PE+ERYTHEMATOUS AREA AND MILD SWELLING
NEXT STEP?
US-BECAUSE PSEDOANEURYSMS CAN GROW
PT WITH MI 5 DAYS LATER(2-5 DAYS)LATER PRESENT WITH PERSISTENT CP+ WORSE ON DEEP BREATH
PERICARDIAL FRICTION RUB+
PT IS ON BB, ASA 81MG, STATIN, ACEI
CXR+EFFUSION
EKG+ DIFFUSE ST ELEVATIONS CONCAVITY UPWARDS AND PR DEPRESSION
DX?
RX?
DX: POST-MI INFARCTION SYNDROME (DRESSLER SYNDROME)
PERINFARCTION PERICARDITIS
RX: ASA HIGH DOSE 6-8G/DAY FOR 3-4 WEEKS PLUS COLCHICINE
FACTORS SHOWN TO IMPROVE SURVIVAL IN MI-MEANING THEY ARE SHOWN TO DECREASE ALL CAUSE MORTALITY
-PCI
-THROMBOLYTIC RX AFTER QWAVE MI
-BB
-ASA
-AFTERLOAD REDUCTION (ACEI OR ARNI)
-STOP SMOKING
-STATINS
-ICD (40 DAYS LATER)
-CARDIAC REHAB
PT WITH CP+
DIAGNOSED WITH AWMI AND TREATED IN CCU W/O COMPLICATIONS
EF 30%
D/C MEDS?
-DAPT X 12 MONTHS
-BB
-ACEI
-HMG COA REDUCTASE INHIBITOR(STATINS)
-ICD (40 DAYS LATER IN MEANTIME IF HIGH RISK FOR VT MAKE THEM WEAR CARDIAC DEFIB VEST)
PT WITH MI 3 MONTHS AGO AND CURRENTLY ON ASA AND BB
WHAT WILL INCREASE HIS LONGTERM SURVIVAL?
START STATIN
SEQUENCE OF MNGMT OF ACUTE CORONARY SYNDROME?
1-ASA
2-SL NTG
3-BB
4-ATORVASTATIN
5-UFH
6-TICAGRELOR** BEFORE PCI***
7-PCI
PT WITH UNSTABLE ANGINA ASA, BB, STATIN STARTED
CREAT IS 1.8 NEXT STEP?
UFH
POST MI COMPLICATIONS ARRHYTHMIAS
<48 HOURS
-NSVT-PVC 3-5 IN A ROW
ONLY OBSERVRE NO RX
-SUSTAINED VT-PVC FOR AT LEAST 30 SECS IN A ROW-MCC RECURRENT ISCHEMIA- NEEDS TO TAKE BACK FOR PCI AFTER STABALIZE
-HEART BLOCK
POST MI COMPLICATIONS ARRHYTHMIAS
<48 HOURS
SUSTAINED VT-PVC FOR AT LEAST 30 SECS IN A ROW MNGMT
STABLE SUSTAINED VT
TOC: AMIODARONE OR LIDOCAINE
UNSTABLE SUSTAINED VT(CP+ OR +HOTN)
*QRS IS DISTINCT
—-SYNCHRONIZED CARDIOVERSION
OR
**QRS IS NOT DISTINCT
—DEFIBRILLATION
THEN LIDO OR AMIO
THEN PCI AND FIX
POST MI COMPLICATIONS ARRHYTHMIAS
>48 HOURS
-NSVT-PVC 3-5 IN A ROW
ONLY OBSERVRE NO RX
-SUSTAINED VT-PVC FOR AT LEAST 30 SECS IN A ROW-MCC SCAR TISSUE- NEEDS ICD BEFORE D/C HOME
POST MI COMPLICATIONS ARRHYTHMIAS
>48 HOURS
WITH SUSTAINED VTACH
STABLE SUSTAINED VT
TOC: AMIODARONE OR LIDOCAINE
UNSTABLE SUSTAINED VT(CP+ OR +HOTN)
*QRS IS DISTINCT
—-SYNCHRONIZED CARDIOVERSION
OR
**QRS IS NOT DISTINCT
—DEFIBRILLATION
THEN LIDO OR AMIO
THEN ICD PLACEMENT BEFORE D/C
POST MI COMPLICATIONS
MECHANICAL RUPTURES
** POSTERIOR PAPILLARY MUSCLE RUPTURE–ACUTE MR
**D2-D14–SEPTAL RUPTURE –ACUTE VSD
**FREE WALL RUPTURE–CARDIAC TAMPONADE
POST MI COMPLICATIONS
MECHANICAL RUPTURES
POSTERIOR PAPILLARY MUSCLE RUPTURE–ACUTE MR
RCA-IWMI
+PULMONARY EDEMA
+ TALL V WAVES(~45MM TALL)(NORMAL IS ~10MM)
IMMEDIATELY TEMP PLACE IABP - (DEFLATE IN SYSTOLE AND INFLATE IN DIASTOLE)
THEN TAKE FOR MV REPAIR NOT REPLACEMENT
POST MI COMPLICATIONS
MECHANICAL RUPTURES
D2-D14–SEPTAL RUPTURE –ACUTE VSD
-ACUTE VSD MURMUR RADIATING THROUGH OUT THE PERICARDIUM
-INCREASE AUTOGRADIENT IN THE RV
THEN PLACE IABP ASAP
THEN TOC-VSD REPAIR
POST MI COMPLICATIONS
MECHANICAL RUPTURES*hy
FREE WALL RUPTURE–CARDIAC TAMPONADE
FIRST- PT PASSED OUT
SEE - PULSUS PARADOXUS-+JVP BULGE, INCREASE HR, BP DROP
WILL SEE THE AMPLITUDE OF PULSE DECREASE WITH EACH BEAT.
THEN DO ECHO- SEE RA COLLASPE IN DIASTOLE AND EVENTUALLY ECHO WILL SHOW EQUALIZATION OF DIASTOLIC PRESSURES IN ALL CHAMBERS PCWP=RAP
THEN OR ASAP
TOC- SURGERY AND REPAIR NOT PERICARDIOCENTESIS
VENTRICULAR ARRHYTHMIAS DURING ACUTE MI
VENTRICULAR ECTOPY OR NSVT
DO NO NOT TREAT JUST OBSERVE
- DO NOT NEED LONG TERM ANTIARRHYTHMIC RX
VENTRICULAR ARRHYTHMIAS DURING ACUTE MI
SUSTAINED VENTRICULAR TACHY CARDIA OR V.FIB OCCURING WITH IN 48 HOURS POST MI
- ARE INDEPENDENT RISK FACTORS FOR IN HOUSE MORTALITY
BUT NOT RISK FOR SUBSEQUENT MORTALITY FROM ARRHYTHMIA AFTER D/C - DO NOT NEED LONG TERM ANTIARRHYTHMIC RX
75 PRESENT WITH CP EKG+ MI AND TREATED WITH TPA, UFH, MITRATES, BB, ACEI
WITHIN 24 HRS PT DVPS NSVT OF <30SEC NEXT STEP?
OBSERVE ONLY
MECH OF REPERFUSION ARRHTHMIAS?
TRIGGERED ACTIVITY; CHANGE IN CARDIAC FREQUENCY DUE TO ACCUMULATED CALCIUM
75 PRESENT WITH CP EKG+ MI AND TREATED WITH TPA, UFH, MITRATES, BB, ACEI
WITHIN 24 HRS PT DVPS SUSTAINED VT OF >30SEC AND UNSTABLE( CP+ OR LOW BP)NEXT STEP?
QRS IS DISTINCT -SYNCHRONIZED CARDIOVERSION THEN LIDO OR AMIO
QRS AND T WAVES NOT SEEN-NOT DISTINCT- DEFIBRILLITATION THEN LIDO OR AMIO
IF STABLE–THEN DO LIDO OR AMIO
AFTER ALL OF THE ABOVE BACK TO CATH(ANGIOGRAM)
75 PRESENT WITH CP EKG+ MI AND TREATED WITH TPA, UFH, MITRATES, BB, ACEI
WITHIN 24 HRS PT DVPS SUSTAINED VT OF >30SEC AND UNSTABLE( CP+ OR LOW BP) SHOCKED STABALIZED AND REVERTS TO NSR AFTER CATH AND IS UNEVENTFUL
5 DAYS LATER PT READY TO DC DOES PT REQUIRE LONG TERM ANTI ARRHYTHMIC RX?
NO
PT WITH VT OR VF 48 HOURS AFTER MI AND NO EVIDENCE OF REINFARCTION
NEXT STEP IN MNGMT
TREAT
AFTER ACUTE TREATMENT OF VT OR VF THIS REPRESENTS AND INDEPENDENT RF FOR MORTALITY POST D/C THEREFORE BEFORE D/C
MUST HAVE ICD PLACED
AFTER ICD PLACED IN VT/VF PT PRESENTING >48 HOURS POSTMI. SHOWS 2 DISCHARRGES FROM ICD IN THE PAST 2 MONTHS NEXT STEP?
START AMIODARONE AND CHECK TSH Q3 MONTHS
AFTER ICD PLACED IN VT/VF PT PRESENTING >48 HOURS POSTMI. SHOWS 2 DISCHARRGES FROM ICD IN THE PAST 2 MONTHS WAS STARTED ON AMIO AND 4 MONTHS AFTER STARTING AMIO ICD SHOWS 4 SHOCKS NEXT BEST STEP IN MNGMT?
RADIOFREQUENCY CATHETER ABLATION
50 M PRESENTS WITH SEVERE CP FOR PAST HOUR
IN ER EKG + PR DEPRESSION IN ALL LEADS
PR DEPRESSION IS SPECIFIC FOR+DIAGNOSIS OF PERICARDITIS
OTHER FINDINGS ON EKG+ ST ELEVATION IN ALL LEADS-SENSITIVE FOR PERICARDITIS BUT NOT SPECIFIC
50 M PRESENTS WITH SEVERE CP FOR PAST HOUR
IN ER EKG + PR DEPRESSION IN ALL LEADS AND ST ELEVATION IN MOST LEADS
DX?
BEST RX?
DX: PERICARDITIS
RX: NSAIDS AND COLCHICINE
DO NOT USE STEROIDS-IT WILL CAUSE RECURRENT EPISODES
AFTER GIVE NSAIDS AND COLCHICINE TO TREAT PERICARDITIS AND PREVENT REOCURRENCE WHAT IS NEXT STEP
ECHO-NEED TO R/OPERICARDIAL EFFUSION(40-60% WILL HAVE PERICARDIAL EFFUSION)
WHAT IS EXPECTED TO BE SEEN IN PT WITH ACUTE PERICARDITIS ON EKG
IN FIRST 1-3 WEEKS?
AND
2-3 WEEKS LATER AFTER RXED?
FIRST 1-3 WEEKS: ST SEGMENT ELEVATIONS
3 WEEKS OR LATER - WILL SEE DEEP T WAVE INVERSIONS
PT WITH RECURRENT PERICARDITIS TREATED WITH NSAIDS AND COLCHICINE.
PAIN HAS RESOLVED
BEST MED FOR PROPHYLAXIS IS?
COLCHICINE FOR 4 WEEKS
PT POST CABG OR AVR 4 YEARS AGO NOW WITH INCREASING SOB FOR THE PAST 3-4 MONTHS.
PE+JVD 9CMS, +HPGMGLY AND+PEDAL EDEMA
ECG AND CXR- BOTH NORMAL
MOST LIKELY DX?
PERICARDITIS
POST PERICARDIOTOMY SYNDROME (CONSTRICTIVE PERICARDITIS)
