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Cardiology > Ischaemic Heart Disease > Flashcards

Ischaemic Heart Disease Flashcards

1
Q

ANTERIOR MI:
- Leads
- Vessels
- Heart part
- Complications

A

Anterior (V3- 4)
Anteroseptal (V1-4)
Anterolateral (V3-V6)
De Winter pattern
Wellens = impending

________
LAD
Anterior LV wall
IV septum

___________
CX:
- Death. ‘Widow maker’, most fatal
- LV failure/ cardiogenic shock
- Arrhythmia

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2
Q

INFERIOR MI:
- Leads
- Vessels
- Heart part
- Complications

A

II, III, aVF

Always look for RV extension!! (Apply right sided leads if suspected)
________

RCA\Circumflex
SA node, papillary mm
Inferior LV wall
_________
Bradycardia
AV block
Mitral incompetence
RV INFARCT risk
Posterior extension

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3
Q

LATERAL MI:
- Leads
- Vessels
- Heart part
- Complications

A

V5, V6
I, avL ‘high lateral’

__________

Circumflex
Lateral LV wall
L atrium

Uncommon in isolation

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4
Q

POSTERIOR MI:
- Leads
- Vessels
- Heart part
- Complications

A

Can occur in isolation, or as extension of inferior or lateral MI (extensive +, bad)
____________

Won’t see directly
Will see reciprocal STD in V1-V3
If this is seen, add on V7-9 for direct view
—> (only requires 0.5mm STE here!)

___________

Posterior Descending
Posterior LV wall

_________

If see anterior STD, always apply posterior leads

If see inferior or lateral STEMI, always check for evidence of posterior extension.

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5
Q

Wellen’s Syndrome:

A

Now resolved chest pain
+
Deeply inverted or biphasic, anterior T waves

…critical LAD occlusion.

__________

ECG may pseudonormalise when pain is present

Thought to be transient STEMI –> reperfusion, with risk of reocclusion at any moment.

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6
Q

De Winter pattern:

A

Tall, symmetrical T waves in praecordials
+
Upsloping ST depression
+
Reciprocal STE in aVR

…Active anterior MI (STEMI equivalent, without STE)

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7
Q

What are the STEMI equivalents?

A

ie. immediately activate cath lab:

1- De Winter’s

2- Posterior MI

3- Sgarbossa +

4- STE aVR
If:
- >1mm
- Diffuse ST depression
–> TVD, L main or proximal LAD

(Wellen’s is impending, not active MI)
(New LBBB no longer)

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8
Q

What ECG findings raise suspicion of an RV infarct?

A

Inferior STEMI- always look for RV signs:

STE III > II
STE V1 (or isoelectric) +\ ST depression V2

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9
Q

ECG features of ischaemia:

A

Q waves (old)
- >1mm wide, 2mm deep
- V1-3

Hyperacute T waves
- Broad, symmetrical
- >5mm (chest), >10mm (limb)

T wave flattening/ inversion or change

Poor R wave progression

Dynamicity

New LBBB

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10
Q

Modified Sgarbossa criteria

A

Use: LBBB, ventric pacing

  • Concordant STE >1mm in >1 lead
  • Concordant STD V1-3 >1mm in >1 lead
  • Excessively discordant STE (>25% preceding S wave) in >1 lead

…90% sens/spec.

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11
Q

Late complications of MI:

A

LATE
- Dilated cardiomyopathy/ CCF
- Arrhythmia/ AV block
- Dressler’s
–> 1w to 3m
–> Usual Mx.
- LV aneurysm
–> 2 weeks +
- Mural thrombus
- VSD
- Rupture
–> Death
–> Pericardial effusion

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12
Q

STEMI definition/ when to call Code STEMI:

A

Typical symptoms >20mins

+

STE 1-2mm, >2 cont. leads, >20mins:
>2.5mm Ant. men <40
>2mm Ant. men >40
>1.5mm Ant. women
>1mm elsewhere

OR
Sgarbossa, STEMI equivalent (De Winter, STE aVR, anterior STD)

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13
Q

LV aneurysm:

A

2 weeks + after MI

On ECG, looks like anterior STEMI but:
- Nil reciprocal
- Q waves
- Not dynamic

+ clinical picture.

–> Rupture
–> Mural thrombus
–> Arrhythmia

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14
Q

Onset/duration of troponin and CK-MB:

A

Troponin
–> Onset 3-6 hours
–> Peaks 24 hours
–> Persists 2 WEEKS

CK-MB
Same
…… but gone after 2 DAYS
–> Better for assessing re-infarct

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15
Q

What is a ‘significant’ trop level:

A

> 99th centile (red)

Within range, but rise >20%

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16
Q

Recommended ‘timeframes’ for care in ACS (as per NHF):

A

ECG interpreted within 10 mins

_________

STEMI:
- Reperfuse if within 12 hours of onset
- Primary PCI if within 90mins of medical contact (otherwise lysis)
- Primary lysis best within 30mins ‘door to needle’
- After lysis, PCI within 24 hours

_________

NSTEAC: (eg. HEART)
- Very high risk: cath lab by 2 hours
- High risk: cath lab by 24 hours
- Intermediate risk: cath lab by72 hours
- Low risk: Non-invasive provocative strateg (to guide timing of cath)

_________
‘POSSIBLE’ ACS:
-

17
Q

INITIAL management in NSTEACS:

A
  • ECG seen within 10 mins
  • O2 if sats <93%
  • Aspirin 300mg
  • Second antiplatelet:
    For PCI: Ticagrelor 180mg
    For lysis: Clopidogrel 300mg
  • Heparin
    –> UFH 80units/kg
    –> Clexane 1mg/kg SC daily
  • GTN
    –> Spray 400 x3, PO 400 x3, patch 25mg, infusion
  • Atorvastatin 80mg
  • Morphine PRN
  • Manage via validated pathway incl. risk strat
    (HEART or ADAPT)
18
Q

Management of cardiogenic shock (LV dysfunction) during STEMI:

A
  • Optimise: oxygenation, pH, electrolytes, volume
  • Inotrope:- no best one
    –> Dobutamine
    –> Adrenaline (coronary perfusion)
    —> Inodilator later
  • NIV as required for APO
  • Urgent REPERFUSION!
  • Overdrive pacing
  • IABP
  • ECMO
  • Bypass
19
Q

Management of RV infarct:

A

PRESERVE PRELOAD
Fluid bolus 10-20ml/kg
–> Unless overloaded
AVOID NITRATES
Avoid PPV if possible (intrathoracic pressures)

REDUCE RV AFTERLOAD- lungs
- Optimise oxygenation and acidosis
- Nitric

….Urgent REPERFUSION

20
Q

Indications for thrombolysis in STEMI:

A

Within 12 hours of symptom onset

PCI not available within 90mins, or contraindicated

21
Q

Contraindications for thrombolysis:

A

ABSOLUTE:
ICH ever
AVM or tumour
Stroke (within 3 months)
Dissection
Active bleeding (excluding menses)
GI or GU bleeding (4 weeks)
Trauma or surgery (3 weeks)
Non-compressible puncture (24hours)

RELATIVE:
BP >180/ 110
Anticoagulated
Isch stroke/ trauma/ surgery outside above windows
Pregnancy

22
Q

Dose of thrombolytic in STEMI:

A

Alteplase 15mg then weight-based at 30 and 60mins

Reteplase 10mg IV. Repeat in 30mins

23
Q

What defines ‘successful’ thrombolysis in STEMI:

A

50% STE resolution at 90mins

Resolved pain

(not stability- can be from infarcted tissue)

24
Q

Disposition in NSTEACS by risk category:

A

Extremely high: 65% MACE
- Admit
- Telem
- PCI within 2 hours

High: 50% MACE
- Admit
- Telem
- PCI within 24 hours

Intermediate: 12-15% MACE
- Admit (no telem)
- PCI within 72 hours
OR
- DC
- PCI or non-invasive testing within 7 (max 14) days

Low: 1-2% MACE
- DC home
- Follow up with nil, GP, or chest pain clinic. Non-invasive +-

25
Q

Features of unstable angina:

A

At lower levels of exertion
At rest
Persistent/ harder to relieve
Less responsive to GTN or rest

26
Q

When should troponin be checked?

A

Different risk-strat pathways suggest different things. Local guidelines.

Initial:
- High/ very high-sens will detect from 3-6 hours
- Low-sens (POC) won’t detect for up to 12 hours

Delta:
2-3 hours

Single trop okay if:
- >12 hours resolved
- > 6 hours onset and high-sens normal
- >3 hours onset, high-sens AND undetectable “<3”

0 and 2 hour trop okay if:
- low risk ADAPT

0 and 3 hours okay if:
- Low risk HEART

27
Q

ACCELERATED DIAGNOSTIC PROTOCOLS in possible ACS:

A

DC after single trop if:
- >12 hours (low sens)
- >6 hours (high sens)
- > 3 hours (high sens) AND undetectable (<3)

DC after 0 and TWO hour trops, if:
- ADAPT pathway low risk

DC after 0 and THREE hour trops, if:
- HEART score (pathway) low risk

__________

Any low sens trop needs at LEAST 12 hours
Any intermed/high HEART score should be admitted
Any intermed/high ADAPT score should continue ACS work up

28
Q

ADAPT chest pain pathway:

A

Use on: ANY chest pain

Application: Decide who can have ACS ruled out after 2 hours.

Looks at: TIMI (patient factors) then adds on clinical factors (ECG + trop at 0 and 2 hrs)

Gives: 30 day MACE risk

ie. low risk ADAPT –> stop
Intermed/ high ADAPT –> standard ACS pathway

________

29
Q

HEART score/ pathway

A

SUPERIOR to TIMI, GRACE.
6 week MACE risk.

Decide who can be discharged at 3 hours vs who needs consult/admission

________

0-3 = LOW 1-2% can be DC if 0 and 3hr trop okay
3-6= MOD 12- 16% -admit
6 or more = HIGH 50-60%- admit

30
Q

TIMI (NSTEACS) score:

A

Inferior to HEART. THUMBS DOWN.
14 day MACE risk.

  • Doesn’t consider symptoms of current pain episode
  • Doesn’t weight any of the factors
  • NOT used to assess safety of discharge
31
Q

CHEST PAIN UNITS: Composition/ function

A
  • Physically next to ED
  • Monitoring beds
  • Treatment/ diagnostics room
  • ECG, biomarkers, CXR available within 30mins
  • ACLS/defib available
  • PCI available
    –> At hospital
    –> Predefined transfer plan
  • Admission criteria predefined by ED + Cardiology
  • Risk stratification using validated tool (eg. HEART, ADAPT)
  • Overseen by Cardiologist (direct, or in conjunction FACEM)
  • Staffed with:
    –> At least 1 doctor (can be registrar)
    –> 1 nurse per 4 beds
  • Quality assurance program
32
Q

Significance of STE in aVR:

A

If in the presence of widespread ST depression:
= Critical L main occlusion.
—> STEMI equivalent’

DDx:
- Prox LAD, TVD
- RBBB
- Any demand mismatch

33
Q

Recognising MI in RBBB

A

NORMAL to have anterior (V1-V3) STD and/or TWI.

Unlike LBBB, can still see and interpret STE in RBBB- why Sgarbossa not used.

Additionally, even ISOELECTRIC ST segments anteriorly can be STE equivalent in RBBB (because STD is expected)

Cardiology (14 decks)

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