Ischemic Heart Dz/MI Flashcards
If a patient is dx with Acute Coronary Syndrome, what 3 categories could their disease fall into yet?
Unstable Angina (UA)
Non ST Elevation MI (NSTEMI)
ST Elevation MI (STEM)
***Note: Excludes Stable Angina
Approximately 6 million patients present to the ER each year with CP, how much percent of these are diagnosed with ACS?
~20-25%
Etiology of ACS
Fatty streak –> Foam Cells –> Fibrous Cap with liquid rich core –> Soft plaque
When this plaque ruptures, platelets will aggregate, thrombosis will form and cause a vasospasm.
Which plaques are more at risk for rupture?
Smaller than 50% about.
Which plaques will rupture?
Soft plaques that are frequently not 70%
A _________ obstruction will cause typical angina (chronic stable angina).
Fixed Coronary Obstruction
RYAN NEEDS TO MAKE QUESTIONS FROM
THE CHART
In ________ you will see a non-occlusive thrombus.
Unstable Angina
In ________ you will see a partially occlusive thrombus, and partial myocardial necrosis.
NSTEMI
In ________ you will see a total coronary thrombosis, and transmural myocardial necrosis.
STEMI
Risk Factors for ACS
Non-modifiable
- Age
- Gender
- Family Hx
- Personal Hx. of CAD or Stroke
- Ethnicity (AA have higher incidence)
Modifiable
- HTN
- Hyperlipidemia
- Diabetes Mellitus
- Smoking
- Metabolic Syndrom
- Others (lots)
***Same as Stable Angina
A patient comes into clinic with chest discomfort, recent gradual dyspnea with and without exertion. Does complain of some nausea and diaphoresis. What should you do?
At the very least do a EKG!!!
Silent Ischemia needs to be in your differential
Pain patterns with the chest and be similar to patients in which two conditions?
- Angina Pectoris
2. Myocardial Infarction
New onset of Cardiac Symptoms that happen with or without exertion would be indicative of what disease?
ACS!
It could be US, NSTEMI, or STEMI
DDx for Angina
- Stable Angina
- Unstable Angina
- Vasospastic (Variant)
- MI (STEMI or NSTEMI)
- Pericardial Dz (Pericarditis or Tamponade)
- Aortic Dissection
- PE
- Pleuritic Pain (Pneumonia and Pleurisy)
- Pneumothorax
- GI Dz (GERD, Esphogeal Dz, PUD, Gall bladder)
- Cosotchondritis
- Anxiety/Panic
First line of action when patient comes in presenting with potential ACS?
EKG
A 55 year old female patient comes in to clinic with chest discomfort and dyspnea at rest. We do a EKG as soon as it possible and we find that it looks normal with Non-Specific ST-T wave changes.
Based on the combination, what can we think this is?
Unstable Angina
A 60 year old male patient comes in to clinic with chest discomfort and dyspnea at rest. We do a EKG as soon as it possible and we find that it looks normal with ST segment depression and T wave inversion.
Based on the combination, what can we think this is?
NSTEMI
A 35 year old male patient comes in to clinic with chest discomfort and dyspnea at rest. We do a EKG as soon as it possible and we find ST segment elevation in a regional pattern. About 1 mm or greater in precordial leads or 2 mm or greater in limb leaves. You also notice a new Left Bundle Branch Block.
Based on the combination, what can we think this is?
STEMI
When take a history of a patient presenting with potential ACS, what are the most important things you need to ask about?
- Presence/Absence of Risk Factors
- Determine temporal sequence
- What activities exacerbate or relieve symptoms
- Associative Symptoms
In a patient with potential ACS based on symptoms, during a Physical Exam, what would you want to do?
- General Survey
- Vital Signs
- Pulmonary exam
- Cardiac Exam
- Abdominal Exam
- Peripheral Vascular Exam
- 12-lead EKG (looking for ST-T wave changes, Rhythm Disturbances, Evolution of ST-T changes)
- Cardiac Biomarkers (CK-MB, Troponin, Myoglobin)
What is the most specific cardiac biomarker for checking for cardiac injury?
Troponin
Which cardiac biomarker would useful for reinfarction? (This is also checking levels in Cardiac and Skeletal muscle.)
CKMB
The CKMB > CK because it is more specific to cardiac muscle.
When evaluating biomarkers orders, you will want to do ________ blood draws in order to watch a _____.
Multiple
Trend
Positive Troponin with a borderline EKG and a symptomatic patient, you will diagnose as
NSTEMI
Normal Cardiac Biomarkers with normal or ST-T wave changes that are non-specific ECG would indicate
Unstable Angina
If the patient has Unstable Angina, what do you need to do?
MONITOR THEM, they can move into STEMI or NSTEMI unknowingly
Positive Cardiac Biomarkers with Abnormal EKG (ST elevation or new LBBB) and symptomatic patient.
STEMI!
What risk stratification test is commonly used for a patient with UA or NSTEMI?
TIMI Risk Score Calculation
In a TIMI Risk Score Calculation, you assign 1 point for the risk factors they have listed. What are these risk factors?
- Age 65+
- 3+ CAD risk factors
- Prior CAD
- ASA used in the last 7 days
- 2+ anginal events in 24+hours
- ST deviation on EKG
- Elevated cardiac biomarkers
The higher the number, the greater the risk
Management of Acute Unstable Angina
- Antiplatelet Therapy
- Nitroglycerin
- Morphine
- Beta Blockers
- Anticoagulation Therapy (LMWH or UFH)
- Oxygen (controversial, changing with research)
- Statins
Same as NSTEMI
What are common antiplatelet therapeutic drugs?
- ASA
- Thienopyridine Agents (Clopidogrel (Plavix), Prasugrel)
- Glycoprotein IIb/IIIa Inhibitors (Abciximab, Eptifbatide)
Management of NSTEMI
- Antiplatelet Therapy
- Nitroglycerin
- Morphine
- Beta Blockers
- Anticoagulation Therapy (LMWH or UFH)
- Oxygen (controversial, changing with research)
- Statins
Same as Unstable Angina
When do you do a Cardiac Cath and Revascularization on a patient with UA or NSTEMI?
- Recurrent symptoms despite optimal medical therapy
- Persistent elevations in troponin
- Persistent ST segment depression
- CHF
- Hymodynamic instability
- Dysrhythmia
- Recent coronary intervention (6 months)
- TIMI risk score
Management of Acute STEMI
- Revascularization ASAP
- Thrombolytic/Fibrinolysis Therapy ***
***ONLY if no intervention is available within 90 minutes, i.e. not having a hospital with a Cath Lab
- THEN Medical Managment (Same as UA and NSTEMI)
Medical Management of Acute STEMI
Same as UA and NSTEMI
- Antiplatelet Therapy
- Nitroglycerin
- Morphine
- Beta Blockers
- Anticoagulation Therapy (LMWH or UFH)
- Oxygen (controversial, changing with research)
- Statins
Why don’t we use Thrombolytics or Fibronolytics as soon as we find a clot/thrombosis?
Too many contraindications
Contraindications of Fibronolytics:
- Hx of Cerebrovascular Hemorrhage (NEVER GIVE IT)
- Cerebrvascular event within the last year
- SHTN > 180 and/or DHTN >110
- Internal Bleeding
How is revascularization completed?
Percutaneous Revascularization (PTCA/Stent)
Long Term Management of UA
- ASA
- Beta Blocker
- ACE Inhibitor
- Statin
- PRN Nitro
- Secondary Prevention
What is Long Term Management dependent on?
What type of treatment strategy was used in the acute phase.
Long Term Management of NSTEMI and STEMI
- ASA and Clopidogrel (Plavix)
- Beta Blocker
- ACE Inhibitor
- Statin
- PRN Nitro
- Secondary Prevention
If a PCI Stenting occurred in an acute managment of STEMI, what medication do we need to put them on?
Clopidogrel
What medications do we give to everyone (UA, NSTEMI, STEMI)?
- ASA (YOU GET AN ASPIRIN AND YOU GET AN ASPIRIN #Oprah)
- Beta Blocker
- Statin
- Nitro PRN
When do we give a ACE inhibitor?
- STEMI
2. UA/STEMI pt with DM, HTN, or CHF
When is an aldosterone antagonist used?
STEMI patients with good renal function, optimal ACE dose, and low EF, symptomatic CHF or DM
What are the potential complications of an acute MI?
- Ventricular Wall Rupture
- Acute Mitral Regurg
- Pericarditis/Dressler’s Syndrome
