Khalid CIS Flashcards
Cry
In what form of ACS is the patient quickly responsive to NG/Vasodilators? What form do you not typically see have that immediate relief?
Non ST elevated ACS (NSTE-ACS) ST elevated ACS (STE-ACS)
What are the initial tests/imaging modalities do you use for NSTE-ACS?
1- ECG 2- Cardiac enzymes (CK-MB, Troponin) 3- CMP to get renal function
What are the initial steps of treatment for NSTE-ACS?
1- ASA
2- O2 via nasal cannula
3- Pain relief- NG, opiate analgesia
What is JVP measuring?
Right atrial pressure
What medications will you give NSTE-ACS?
1- ASA
2- P2Y12 inhibitors
3- Glycoprotein IIB/IIIA inhibitors (These are very strong anti-platlet agents)
4- Anticoag therapy
5- Beta blockers
6- Statins
7- ACEI for BP
8- NG (only for pain)
What are the two most important P2Y12 inhibitors?
1- Clopidogrel 2- Ticagrelor Less importantly: Prasugrel Cangrelor
What type of presentation would indicate usage of glycoprotein IIB/IIIA Inhibitors having the most impact?
For HIGH risk NSTE-ACS
What are the (3) glycoprotein IIB/IIIA inhibitors most commonly used?
1) Tirofiban
2) Eptifibatide
3) Abciximab
(one, TWO, THREE, let’s get some TEA)
What anticoagulation therapy drugs do you give to NSTE-ACS?
1) IV heparin
2) Enoxparin
What class of drugs are ABSOLUTELY contraindicated in NSTE-ACS?
Thrombolytic/fibrinolytics
What are the indications for coronary angiography and Percutaneous Coronary Intervention (PCI)?
1- recurrent angina/ischemia at rest/ low lvl of activity
2- Elevated Troponin or **ST depression**
3- Recurrent ischemia w/ HF
4- LVEF <40%
5- Hemodynamic instability
6- Sustained VTs
7- PCI within 6 months
8- Prior CABG (bypass surgery) These are all high risk features
What testing would you do in a LOW risk NSTE-ACS?
Do a stress test to see what’s cookin with their heart and to stratify how bad it is (non invasive)
After going through the whole shabang of meds with NSTE-ACS patients, what’s the most important alteration for getting a better prognosis?
Smoking cessation
What is a normal left ventricular ejection fraction percentage?
LVEF= 55%-60%
What is the most important treatment of coronary artery stenosis?
PCI with drug eluting stent (usual from femoral)
Why is it so important to distinguish between NSTE and STE?
To determine repurfusion therapy. REMEMBER: fibrinolytic therapy is harmful in ACS with a non elevated ST
What artery is associated with leads 2,3, AVF?
Right coronary artery (RCA) Less commonly: Left circumflex artery (LCA)
What artery is associated with V1-V4?
Left anterior descending A. (LAD)
How does an EKG change with a patient presenting with STE-ACS?
In order:
1) Hyperacute/peaked T waves
2) ST segment elevation
3) Q wave formation
4) T wave inversion
(happens over a few hours to several days)
What heart arrhythmia MUST you treat like a STEMI?
A (NEW) LBB with symptoms of an acute MI
What are the mainstay treatments of a STEMI?
1) ASA
2) P2Y12 inhibitors (Clopidogrel, Ticagrelor, Prasugrel)
3) Repurfusion therapy
What are the repurfusion therapies for STEMIs?
1) MUST DO PCI
2) Thrombolytics
When is it indicated to start thrombolytics and PCI?
1) Must do PCI in less than <90 minutes if available on site
2) If PCI is not available on site, transfer to a neigboring hospital <120 minutes (still better than thrombolytics)
3) ONLY when the PCI ETA is >120, then you administer them (IV Heparin, Enoxparin) and then you STILL transfer to a hospital for a PCI
What are the absolute contraindications for thrombolytic therapy?
1) If they had a previous hemorhagic stroke
2) Intracranial neoplasms
3) Recent head trauma
4) Internal bleeding
5) suspected aortic dissection
6) Cerebrovascular events this past year
What are the post MI complications?
1) Post MI ischemia
2) Arrhythmias
3) RV infarction
4) Mechanical complications
5) Myocardial dysfunction
When would you get post MI Ischemia?
1) After thrombolytic therapy for STEMI
2) After NSTEMI that is treated medically
How do you treat post MI ischemia?
Vigorous medical therapy and if it’s refractory, undergo early coronary angiography and revascularization
When is sinus bradycardia most common and do you need to treat it?
When you get an inferior MI or with meds
Nah, only temporary pacing and that’s rarely required
How do you treat post MI SVT/A fib?
Rate controlling agents like metoprolol or CCB if there is a contraindication to beta blockers
How do you treat if the patient is hypotensive with severe chest pain and HF?
Amiodarone
Shock them
Where are the most common conduction problems?
At the level of the AV node and less commonly distal/infra nodal to the AV node
What is the treatment for first degree AV block?
Sike, it does not require treatment
What is the treatment for second degree AV block?
Sike, it does not require treatment unless they’re very symptomatic
What is the treatment for complete AV block and when do they most commonly occur?
Occurs most with inferior MIs
Prognosis is worse with ant MI
Requires permanent pacing
When are V arrhythmias most common and how do you treat it?
Most commonly occurs in the first few hours of MI and most common COD
MUST treat with prompt defibrillation if unstable If stable treat with amiodarone
When do you most commonly get RV infarctions and how does it present?
Present in 1/3 of inf MIs
Presents with hypotension and normal LV function, elevated JVP, and clear lungs
How do you recognize and treat RV infarction?
ST elevation in right sided anterior chest leads (V1-3/4)
Treat with IV fluids
What treatments are contraindicated in RV infarction?
Vasodilators including NG
When do you see papillary muscle rupture?
3-7 days after MI
What does a papillary rupture present with clinically?
Systolic murmor due to mitral regurg (check apex)
Deterioration can also come with added pulm edema
How do you treat papillary muscle rupture?
Must do echocardiogram
Intra aortic balloon pump
Surgery is a definitive treatment
When do you see a VSD wall rupture?
3-7 days after MI
What does a VSD rupture present with clinically?
Systolic murmor due to mitral regurg (check apex)
Deterioration can also come with added pulm edema
How do you treat papillary muscle rupture?
Must do echocardiogram
Intra aortic balloon pump
Surgery is a definitive treatment
When do you see a myocardial rupture?
2-7 days post MI
What does a myocardial rupture present with clinically?
Usually associated with immediate death and is present on the anterior wall
Myocardial dysfunction/shock patients present with what and how do you diagnose it?
1) Hypotenion
2) Unresponsiveness to fluid resusitation
3) Refractory HF or cardiogenic shock
Need echocardiogram to rule out mechanical complications
What does acute LV failure present with?
Pulmonary edema
How do you treat acute LV?
O2, IV morphine, Diuretics, vasodilators to treat associated edema
What do all shock present with?
1) Hypotension
2) Signs of diminished perfusion that include clammy extremities, oliguria, confusion
3) Tachycardia
Could have altered mental status
How do you treat cardiogenic shock?
1) Get coronary angiography
2) Possible placement of intra aortic balloon pump
3) Echocardiogram (to asses LV function that is usually reduced)
4) Inotropic support with dopamine, dobutamine, NE If they are less sick, treat with IV diuretics
What is hypovolemic shock a result of?
Decreased intravascular volume secondary to loss of blood or fluids due to dehydration or hemorrhage
How do you treat hypovolemic shock?
Treat with intravascular volume (just give them fluids)
What are some potential causes of obstructive shock?
Cardiac tamponade, PE, pneumothorax
How do you treat obstructive shock?
Treat underlying condition
What is the most common form of distributive shock?
Septic shock
What is septic shock?
Sepsis with fluid unresponsive hypotension and serum lactate level > 2mmol/L and a need for vasopressors to keep mAP above 65 mm Hg (bc there is systemic vasodilation)
What is the most common cause of septic shock?
Infection with gram positive or gram negative bacteria
How do you generally approach shock?
1) Prompt diagnosis and initial resuscitation
2) Cardiac monitoring
3) Mechanical ventilation if required
4) IV fluids
What are the hemodynamic measurements associated with cardiogenic shock?
1) Reduced Cardiac Output (CO)
2) Reduced Cardiac Index (CI)
3) elevated Systemic Vascular Resistance( SVR)
4) Elevated Central Venous Pressure (CVP)
5) Elevated Pulmonary Capillary Wedge Pressure (PCWP)
*(Cardio shock is a central process with aggressive vasoconstriction)*
What are the hemodynamic measurements associated with septic shock?
1) CO, CI may be initially elevated or normal but in severe cases CO and CI can be decreased due to myocardial depression
2) Low SVR, CVP, PCWP
*Aggressive vasodilation*
What are the most important treatments to septic shock?
Since they’re in hypovolemic shock you must give fluids and vasopressors (NE, dopamine, vasopressin) Then IV antibiotics to treat infection
