Initial Treatment of ACS Flashcards
What is the basic pathophysiology of ACS, and what do medical treatments focus on?
ACS is related to an imbalance in oxygen supply and demand in the heart. Medical treatments focus on restoring the balance by increasing blood flow to the cardiac vasculature.
What is required to diagnose a myocardial infarction, and what is the most important lab test?
To diagnose a myocardial infarction, you need a detailed history and physical, an electrocardiogram (ECG), and a basic set of labs, with the most important lab being troponin.
What data is collected during a history and physical for ACS diagnosis, and what are some modifiable risk factors for infarction?
- Data collected during history and physical include non-modifiable factors like age, sex, and family history.
- Modifiable risk factors include hyperlipidemia, hypertension, smoking, obesity, and diabetes.
Why is chest pain a significant complaint in the emergency department, and what are the statistics regarding chest pain presentations?
Chest pain is significant because patients with acute ACS are at an increased risk of dying if not treated promptly. About 5% of chest pain presentations are true STEMIs, 25% are NSTEMIs, and the rest have other causes.
Does the intensity of chest pain correlate with the severity of an acute myocardial infarction (AMI), and how does this relate to women’s symptoms?
No, the severity of chest pain does not predict the severity of an AMI. Women often do not present with classic symptoms like chest pain and may have atypical symptoms, such as feeling “out of it” or pain in other body parts like the shoulder or back.
What are common chest pain symptoms in patients having an acute MI, and how do they relate to likelihood ratios?
Common chest pain symptoms include pain radiating to the arm or shoulder. The likelihood ratios help assess the correlation between symptoms and the likelihood of AMI.
What should the emergency department (ED) doctor determine when a patient presents with chest pain, and what are some other conditions that can present as chest pain?
The ED doctor should determine the cause of chest pain, as there are various conditions that can cause chest pain, such as a large clot in the lungs, aortic dissection, pneumothorax, or pericarditis.
What is the main lab that is typically checked when a patient presents with chest pain, and what does its presence in the blood indicate?
The main lab checked is troponin, which is specific to cardiac tissue. Its presence in the blood indicates that the heart tissue is damaged and leaking troponin. Troponin levels start rising after 3-4 hours
How does troponin levels change after a myocardial infarction, and why is a single troponin level not sufficient for ruling out an MI?
Troponin levels start rising and take a few days to peak. The higher the troponin, the more heart tissue has died. A single troponin level is not sufficient to rule out an MI, so troponin levels are trended every 2-3 hours to see if they are rising or falling.
What are the steps taken after taking a detailed history of chest pain, obtaining an EKG, and sending a troponin level to the lab?
It is time to make treatment decisions for the patient.
What is the initial focus when it comes to treatment for chest pain, and how are patients with STEMI and NSTEMI differentiated?
The initial focus is on identifying patients with STEMI who require immediate treatment. Patients without ST segment elevation are evaluated for NSTEMI and risk stratified and treated medically.
What medications are started in patients who are suspected of having a heart attack, and what is the classic acronym to help remember these medications?
Medications started include MONA (Morphine, Oxygen, Nitroglycerin, Aspirin) and other anticoagulants like clopidogrel and heparin, as well as a statin. MONAS adds “S” for Statin.
Who should receive oxygen when they present with chest pain, and what is the role of oxygen in this context?
Almost everyone should receive oxygen if they are short of breath or have low pulse oximetry. It helps oxygenate the tissue that may be dying but should not be given to patients who do not need it.
Who should receive aspirin in the acute setting, and are there any exceptions?
Almost everyone should receive aspirin in the acute setting. Exceptions are patients with a true allergy to aspirin, where it causes throat swelling or shortness of breath, or if the patient is actively vomiting blood.
What important trial showed the life-saving benefits of aspirin in heart attack treatment?
The ISIS-2 trial in 1988 demonstrated that aspirin prevented close to 400 patients from dying from a heart attack, highlighting its importance in heart attack treatment.
What is the recommended dose of aspirin, and how should it be taken in the acute setting?
The recommended dose is 324 mg, which is equivalent to 4 baby 81-mg aspirins. Patients should chew aspirin to increase absorption. If enteric-coated tablets are available, they should be chewed to bypass the coating, or a 300 mg rectal suppository can be used for altered patients.
Which antiplatelet agent should be given to patients undergoing PCI or with moderate to high-risk NSTEMI, and what is the role of clopidogrel?
Patients going for PCI or with NSTEMI should receive another antiplatelet agent, most commonly clopidogrel. It can be used by itself as the primary antiplatelet agent if there is a true aspirin allergy.
