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Cardio II Final > MI > Flashcards

MI Flashcards

1
Q

STEMI ECG

A
  • ST segment elevation of 2 mm or more at J point in V2-V3 in men; 1.5 mm or more in women in absence of LVH or 1 mm or more in 2 or more contiguous chest or limb leads
  • T wave ischemic pattern – inverted T waves or tall, peaked T waves
  • “transmural” – large Q wave
  • New LBBB (obscures ST elevation analysis)
  • May need serial tracings
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2
Q

STEMI causes

A

atherosclerosis, vasospasm, vasculitis, dissection, genetics

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3
Q

STEMI hx

A
  • Chest discomfort, more severe than angina
  • Heavy, pressure, crushing, etc
  • Retrosternal, left, across chest; neck, jaw, left arm, epigastrium
  • N/V, diaphoresis, dyspnea
  • Not reliably relieved by Nitro or rest
  • 20% painless – DM, elderly women
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4
Q

Physical exam findings for STEMI

A

• Normal
• S4 Gallop – atrial beating forcefully against less compliant, stiffened ventricle
• BP variable
• Sympathetic hyperactivity (increased HR, increased BP) seen in anterior MI
• Parasympathetic hyperactivity (bradycardia, decreased BP) in inferior MI
o GI manifestations
• Heart failure – S3, crackles, increased JVD, new murmur

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5
Q

Early Acute phase for MI

A
  • T wave increased amplitude
  • Hyper-acute pattern
  • Convex upward ST pattern
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6
Q

Chronic phase for MI

A
  • Resolution of ST elevation is variable (2 weeks for inferior wall, later for anterior wall)
  • Persistent ST elevation (after 2 weeks) think ventricular aneurysm
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7
Q

Zones of Infraction

A

o Infarction – dead tissue, lacks depolarization
• Q waves
o Injury – deficient blood supply, inability to fully polarize
• ST Segment shifts
o Ischemia – deficient blood supply, impaired repolarization
• T wave changes

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8
Q

Posterior wall infarctions

A

reciprocal changes in anterior leads
o V1 and V2
• Prominent R wave (reciprocal of posterior Q wave)
• Upright T waves (reciprocal of inverted T wave)
• ST depression (reciprocal of ST elevation)

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9
Q

Labs in MI

A

o Increased WBC 12,000-15,000 (hours to 2-4 days)
o Increased CRP
o BNP – increased in ventricular wall stress and fluid overload

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10
Q

Troponin I

A
  • 1-4 hrs detectable after onset AMI
  • 10-24 hour peak
  • Persists 5-14 days
  • Renal failure can cause false positive cTnT (clearance route)
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11
Q

non-MI cardiac causes for elevated troponin level

A
  • Myocardial injury, inflammation
  • Heart Failure
  • Cardiomyopathies
  • Aortic dissection
  • Severe aortic stenosis
  • Tachycardia
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12
Q

Pulmonary causes for elevated troponin

A

• PE, pulmonary HTN, respiratory failure

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13
Q

Neurologic causes for elevated troponin

A

stroke, intracranial hemorrhage

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14
Q

Other causes of elevated troponin

A
  • Shock: septic, hypovolemic, cardiogenic

* Renal failure

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15
Q

Standard of care STEMI

A

o 12 lead ECG with continuous cardiac monitoring
o IV lines inserted
o Cardiac enzymes (cTnI), CBC, CMP, PT, PTT

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16
Q

Primary percutaneous coronary intervention (PCI)

A

with angioplasty and stenting
• Within 12 hours
• Lower mortality rate and intracerebral hemorrhage

17
Q

Cath lab

A

within 90 minutes

• Transport to other hospital if needed within 120 min

18
Q

Fibrinolysis (clot busters)

A
  • Fibrinolytic or Thrombolytic
  • Begun in ED within 30 minutes
  • Useful for STEMI or new LBBB within 12 hours of onset of symptoms
  • Major risk is intracerebral hemorrhage
  • Contraindication with active bleeding at any site (ex. GI, GU (except menses))
19
Q

Reperfusion therapy

A
  • Accelerates changes over minutes to hours

* Failure of ST elevation to resolve by >50-70% within 1-2 hours, suggests failure of fibrinolysis

20
Q

Initial medical management of STEMI

A 
o	ASA (162-325 mg) PO – given on presentation – unless contraindicated
•	Helps prevent platelet aggregation

o IV Heparin or Enoxaparin
• Adenosine diphosphate receptor (p2Y12) inhibitor
• Antiplatelet agent
• Use for 1 year after PCI for STEMI with stenting to prevent stent stenosis

21
Q

Treatment of STEMI

A

o Nitroglycerin – relieve vasoconstriction, relieve pain, reduce pre and afterload
o Morphine – persistent pain
o Beta blocker – esp if increased BP or increased HR
• Don’t use in decompensated HF, decreased HR or BP, MCO2
o Oxygen
o Stool softener (avoid valsalva)
o ACEI – helpful if low EF, increased BP – prevent remodeling
o Coronary ICU – AHA diet

22
Q

Complications of MI - pericarditis

A
  • 2-4 days post MI
  • 2-10 weeks after MI could be Dressler syndrome (immune mediated)
  • Hurts to breathe, feels better leaning forward
  • Friction rub
  • Tx: ASA, NSAID
23
Q

Complications of MI - Arrhythmias

A 
o	Ventricular rhythm disturbance
•	Occur early
•	VF in 1st 4 hours – treat via elective cardioversion
•	VT
•	VT (polymorphic VT)
•	VF

o Accelerated Idioventricular Rhythm
• Slow VT (60-100/min)
• After fibrinolytic therapy
• Benign, still irritable

o Atrial fibrillation - First 24 hours (5-10%)

o Sinus Bradycardia
• Included parasympathetic tone
• Associated with inferior MI (up to 40%)

o Second degree AV Block (Wenckebach)
• Associated with inferior wall MI

24
Q

Complications of MI - HF

A

leading cause of death after AMI
• LV dysfunction – S3, S4 crackles
• RV infarction – 10-30% of inferior STEMI
• Decreased BP, clear lungs, increased JVP
• Kussmaul sign (distention of jugular vein on inspiration)
• Treat with IV fluids
• Cardiogenic shock – decreased BP, decreased CI (>1.8 L/min/m2)
• Increased Pulmonary capillary wedge pressure (PCWP) >18 mmHg
• Mortality 70-80%

25
Q

Mechanical complications of MI

A
  • Acute mitral valve regurgitation – infarction related rupture or dysfunction of papillary muscle
  • New holosystolic murmur associated with inferior wall MI
  • Treatment – surgery
26
Q

Complications of MI - VSD

A

o Septal Rupture with Ventricular Septal Defect (VSD) – associated with anterior wall MI
• LV free wall rupture – causes tamponade
• LV aneurysm- associated with anterior MI
• Treat with surgery

27
Q

Thromboembolic complications of MI

A
  • Arterial emboli from LV aneurysm

* Cause stroke, ischemic bowel

28
Q

RV infarction

A

o Proximal occlusion of RCA before acute marginal branch
• Cause acute inferior wall MI in 30% of cases
o Use right chest leads
o ST elevation of 1 mm or more in V4-V6 R
o Pericarditis, myocarditis, stress induced (takotsubo) syndrome, early repolarization

29
Q

DDX for STEMI

A

pericarditis, myocarditis, stress induced (takotsubo) syndrome, early repolarization

30
Q

Echocardiogram

A

o Global and RWM abnormalities
o Murmur, Papillary muscle dysfunction, VSD
o LV free wall rupture, LV aneurysm
o Mural thrombosis

Cardio II Final (15 decks)

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