Khalid Chest Pain, NSTEMI/STEMI/ACS, shock

Question 1

what is the clinical presentation of ACS (NSTEMI)?

Answer 1

CP: sub-sternal chest pain radiating to the jaw and left arm. moderate to sever severity. crushing sensation. dyspnea and nausea. relieved by two nitro tablets.

Question 2

What is the diagnostic findings of ACS-NSTEMI?

Answer 2

Vitals: normal HR/R and elevated BP
ECG: sinus rhythm, no ST elevation or depression
labs: CK-MB/Troponin I/T (elevated with NSTEMI, no elevation with UA). variable CMP and renal function

Question 3

How to treat ACS-NSTEMI?

Answer 3

First: oxygen, nitro/opiates, aspirin

second: anti platelet P2Y12 inhibitor (clopidorgrel), GP2B/3A Inhibitor (Abciximide), anticoagulant therapy (IV heparin). (NO FIBRINOLYTIC MEDS)
third: coronary angiography w/ percutaneous coronary intervention. (for high risk pts) Stress testing for low risk (UA)
fourth: stop smoking, repeat CA

Question 4

what is the clinical presentation of ACS (STEMI)?

Answer 4

CP: severe sub-sternal pain, nausea and diaphoresis

Question 5

What is the diagnostic findings of ACS-STEMI?

Answer 5

Vitals: elevated HR and elevated BP
ECG: ST elevation (STEMI)
labs: CK-MB/Troponin I/T elevated. variable CMP and renal function

Question 6

How to treat ACS-STEMI?

Answer 6

First: aspirin, P2Y12 inhibitor (clopidogrel), reperfusion therapy (PCI or less or thrombolytics)
PCI in 90 mins, no PCI go to hospital with PCI under 2hrs away (if not possible then thrombolytics)
contraindications of thrombolytics: hemorrhagic stroke, trauma, internal bleeding, AD
second: oxygen, nitro, BB, nitrates, ACEI

Question 7

What are complications of STEMI?

Answer 7

1. post infarction ischemia
2. arrhythmia
3. RV infarction
4. mechanical complications
5. myocardial disfunction

Question 8

How to treat post MI ischemia?

Answer 8

seen after thrombolytic therapy. TX with vigorous medical therapy, CA and revascularization

Question 9

How to treat post MI Arrythmias?

Answer 9

sinus bradycardia: temporary pacing
SV tacky: metoprolol or CCB
AV blocks 1: no tx needed
AV block 2: no tx needed
Av block 3: permanent pacing 
VT/VF: prompt defibrillation

Question 10

How to treat post MI RV infarction

Answer 10

ST elevation in V1/V2, Tx: IV fluids

Question 11

How to treat post MI mechanical defects?

Answer 11

papillary muscle rupture: new systolic murmur, needs surgery
VSD: new systolic murmur, surgery needed
myocardial rupture: anterior wall rupture, death
Pericarditis: aspirin
mural thrombus: anticoagulant therapy

Question 12

How to treat post MI. myocardial dysfunctions?

Answer 12

hypotension and not responsive to fluids. Tx: urgent echo and oxygen, IV morphine, Diueretics, vasodilators

Question 13

What is cardiogenic shock?

Answer 13

• systolic BP less than 90
• diminished perfusion
• patients need urgent CA, revascularization
• echo
• LV is usually limited function

Question 14

Treatment for cardiogenic shock?

Answer 14

IV diuretics, inotropic support (domain/dobutamine/norepinephrine),

Question 15

Other shocks?

Answer 15

hypovolemic (blood loss, tx fluids), obstructive shock (pneumothorax tension, PE, tamponade), distributive shock (sepsis)