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Week 5 - Cardiology > MI & Management of Acute Coronary Syndrome > Flashcards

MI & Management of Acute Coronary Syndrome Flashcards

1
Q

What are the symptoms of myocardial infarction? [8]

A
  1. chest pain
  2. back pain
  3. jaw pain
  4. indigestion
  5. sweatiness, clamminess
  6. shortness of breath
  7. none (silent MI) - diabetes/dementia
  8. death
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2
Q

What are the signs of myocardial infarction? [8]

A
  1. Tachycardia (increased heart rate)
  2. Distressed patient/agitated
  3. Heart failure (crackles/raised JVP)
  4. Cardiogenic Shock - due severe ventricular damage
    • Hypotensive
    • Delirium
  5. Ventricular Arrhythmia - caused by acute MI
  6. None
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3
Q

What are the investigations used in acute myocardial infarction? [5]

A
  1. Electrocardiograph (ECG)
  2. Bloods - cardiac troponin
  3. CXR
  4. Echocardiogram
  5. Coronary angiogram
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4
Q

What are you looking for on ECG when investigating acute myocardial infarction? [1]

A

evidence of ST segment deviation

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5
Q

What are you looking for on CXR and echocardiogram when investigating acute myocardial infarction? [2]

A

evidence of acute heart failure and left ventricular systolic dysfunction

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6
Q

What is the role of a coronary angiogram when investigating acute MI? [1]

A

to look at the coronary artery anatomy for any narrowings that need intervention

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7
Q

What is troponin and what are the 3 types? [4]

A

protein that is an integral part of the cardiac myocyte

3 types:

  • TnI
  • TnT
  • TnC
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8
Q

What is the significance of troponin in the bloodstream?

A

Presence in the bloodstream = a marker of cardiac necrosis

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9
Q

What is the universal definition of MI? [2]

A

Any elevation in troponin in clinical setting consistent with myocardial ischaemia

NOTE: isolated troponin elevation does not equal MI

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10
Q

Describe the 6 types of MI [6]

A

Type 1: Spontaneous MI due to a primary coronary event

  • Coronary artery plaque rupture and formation of intraluminal thrombus
  • Occludes the coronary artery leading to necrosis of that part of the heart that the artery supplies

Type 2: MI due increased oxygen demand and/or decreased oxygen supply to the heart muscle

  • leading to the heart isn’t getting enough oxygen

Type 3: Sudden cardiac death

Type 4a: MI associated with percutaneous coronary intervention

Type 4b: MI stent thrombosis documented by angiography (stent reoccludes causing MI)

Type 5: MI associated with CABG (coronary artery bypass graft)

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11
Q

What conditions can cause Type 2 MI? [6]

A
  1. heart failure
  2. sepsis
  3. anaemia
  4. arrhythmias
  5. hypertension
  6. hypotension
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12
Q

What are the risk factors for atherosclerotic disease? [6]

A
  1. Hypercholesteremia
  2. Hypertension
  3. Diabetes mellitus
  4. Cigarette smoking
  5. Positive family history
  6. Obesity (BMI > 30)
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13
Q

What are the non-coronary causes of elevated troponin (type 2 MIs)?

A
  1. Congestive heart failure - acute
  2. Tachy-arrhythmias (i.e. tachycardia)
  3. Pulmonary embolism
  4. Sepsis
  5. Apical ballooning syndrome (Takotsubo cardiomyopathy)
  6. Anything that stresses the heart (e.g. critically unwell patient)
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14
Q

Define tachy-arrythmias (tachycardia) [1]

A

Abnormally high heart rate - puts the heart into an increased oxygen demand

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15
Q

Define pulmonary embolism [1]

A

Blockage of one of the pulmonary arteries in the lungs

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16
Q

What is sepsis and why can it cause elevated troponin? [2]

A

Life-threatening reaction to an infection

Heart is under a lot of pressure to fight infection

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17
Q

Define apical ballooning syndrome (Takotsubo cardiomyopathy) [1]

A

Temporary heart condition that is brought on by stress

Has the same symptoms as a heart attack but is not caused by any underlying cardiovascular disease

18
Q

What are the causes of chronic elevation of troponin (that isn’t an MI)? [3]

A

Renal failure (troponin is cleared from the blood by the kidneys)

Chronic heart failure

Infiltrative cardiomyopathies (e.g. amyloidosis, hemochromatosis, sarcoidosis)

19
Q

Define unstable angina [3]

A

An acute coronary event withOUT a rise in troponin (due to no myocardial necrosis)

i.e. Clinical presentation of an MI + ECG changes

or

Tight narrowing on coronary angiography

20
Q

Define atherosclerosis [1]

A

a disease of the arteries in which fatty plaques develop on their inner walls, leading to eventual obstruction of blood flow

21
Q

Describe the pathophysiology of atherosclerosis [6]

A
  1. Dysfunction of the endothelial lining of the vessel leads to inflammation of the vascular wall
  2. This causes the build up of lipids, cholesterol and inflammatory cells (i.e. cellular debris) within the intima and subintimal layers of the vessel wall
  3. This results in plaque formation and remodelling of the arterial wall
  4. At first the body tries to maintain adequate blood flow to the heart muscle by expanding the coronary artery eccentrically → i.e. compensatory expansion maintaining constant lumen
  5. But over time, the artery cannot expand anymore and the degree of the atherosclerotic plaque begins to impinge on the lumen
    • this is when patients present with stable angina
  6. So under periods of increased demand of oxygen (e.g. exercise), the blood supply is not sufficient to maintain oxygen supply to the heart muscle and the patient presents with symptoms of ischaemia/angina
22
Q

Define atheroma [1]

A

degeneration of the walls of the arteries caused by accumulated fatty deposits and scar tissue, and leading to restriction of the circulation and a risk of thrombosis

23
Q

What are the risk factors to developing atheroma? [7]

A
  1. common in adults in Western countries
  2. high cholesterol
  3. smoking
  4. obesity
  5. lack of exercise
  6. diabetes
  7. hypertension
  8. family history of early atheroma
24
Q

Name 1 clinical manifestation that can result from atheroma in…

  1. kidneys? [1]
  2. eyes? [1]
  3. brain? [1]
  4. heart? [1]
  5. legs? [1]
A
  1. chronic kidney disease (kidney failure)
  2. visual field defects
  3. stroke
  4. angina
  5. claudication
25
Q

What are the 2 types of acute coronary syndromes and how do you get to a final diagnosis for each type? [6]

A
  1. ST elevation (STEMI)
    • STEMI is always a myocardial infarction by definition
    • Can either be:
      • Qw MI → where there is full thickness infarction (or)
      • NQMI → where there is partial thickness infarction
  2. No ST elevation (NSTEMI)
    • Troponin release? NO → unstable angina
    • Troponin release? YES → myocardial infarction
    • Also can be either Qw MI or NQMI
26
Q

What is the blood supply of the inferior part of the heart? [2]

A

right coronary artery (mostly)

left circumflex artery

27
Q

What is the blood supply of the posterior part of the heart? [2]

A

circumflex artery (mostly)

right coronary artery

28
Q

What is the blood supply of the lateral part of the heart? [1]

A

left circumflex artery

29
Q

What is the blood supply of the anteroseptal part of the heart? [1]

A

left anterior descending artery

30
Q

Label the coronary vessels in the image: [8]

A
  • A: Aorta
  • B: Left main coronary artery
  • C: Left pulmonary artery
  • D: Left circumflex
  • E: Marginal artery
  • F: Left anterior descending
  • G: Right coronary artery
  • H: Superior vena cava
31
Q

Describe the evolution of acute ST elevation MI using the diagram [10]

A
  1. Graph A
    • normal
  2. Graph B
    • subtle elevation of J point
    • subtle elevation of ST segment
    • hyperacute tenting of T wave
  3. Graph C
    • marked elevation of J point
    • marked elevation of ST segment
  4. Graph D
    • abnormal repolarisation of the ventricles → T wave inversion
    • development of Q waves (due to full thickness infarction)
  5. Graph F
    • months after MI, the ECG doesn’t ever go back to normal as you always get the Q waves
32
Q

Describe the immediate management of STEMI [9]

A
  1. ABCD
  2. Put in an ambulance attached to defibrillator
  3. Aspirin 300mg PO
  4. Unfractionated heparin 5000U iv
  5. Morphine 5-10mg iv
  6. Anti-emetics
  7. Clopidogrel (in ambulance)
    • 600mg if for PPCI (Primary Percutaneous Coronary Intervention)
    • 300mg if for Thrombolysis (75mg if aged > 75)
  8. Ticagrelor 180mg (in hospital)
  9. Activate PPCI team (PPCI = primary percutaneous coronary intervention)
33
Q

What is the subsequent management of STEMI? [5]

A
  1. Monitor in Coronary Care Unit for complications of MI*
  2. Give drugs for secondary prevention
  3. Echocardiogram for LV function and cardiac structure - given to all patients
  4. Cardiac rehabilitation
  5. If LVSD at >9 months consider primary prevention ICD
34
Q

What drugs are given for secondary prevention of STEMI? [4]

A

ACE inhibitors (for all — if LVSD reduce mortality)

Beta Blockers (for all — if LVSD reduce mortality)

Statins —for all

Eplerenone (mineralocorticoid receptor antagonist) — only for diabetes and LVSD or clinical HF

35
Q

What are the complications of STEMI? [5]

A
  1. Arrhythmias
    • VT/VF —DC cardioversion
    • AF — why (?heart failure/LVSD or other structural complication)
  2. Heart Failure
    • Diuretics, inotropes, vasodilators
  3. Cardiogenic shock
    • IABP (intra-aortic balloon pump, ventricular assist device)
  4. Myocardial rupture
    • Septum —VSD - surgery
    • Papillary muscle — mitral regurgitation - surgery
    • Free wall — tamponade — usually fatal
  5. Psychological
    • Anxiety/depression
    • Cardiac rehabilitation essential for this
36
Q

What drugs are given in the coronary care unit after a NSTEMI? [5]

A

Aspirin

Clopidogrel or ticagrelor

Low molecular weight heparin or fondaparinux

37
Q

45 year old male smoker gives 1 hour history of central chest discomfort and vomiting. His ECG is as follows (see photo):

Is this…?

  1. Normal
  2. Anterior STEMI
  3. NSTEMI
  4. Lateral STEMI
  5. Inferior STEMI
A
  1. lateral STEMI
38
Q

78 year old diabetic gives a several hour history of shoulder and left arm discomfort and sweating. Her ECG is as follows:

Is this…?

  1. NSTEMI
  2. Anterior STEMI
  3. Posterior STEMI
  4. Inferior STEMI
A
  1. posterior STEMI
39
Q

22 year old student presents with a 3 day history of fatigue and flu-like symptoms and a several hour history of sharp left sided chest pain which is worse on inspiration. His ECG is as follows:

Is this…?

  1. Anterior STEMI
  2. Lateral STEMI
  3. Pericarditis
  4. Inferior STEMI
A
  1. pericarditis
40
Q

A 56 year old woman complains of palpitations and dizziness. Her ECG is as follows:

Is this…?

  1. Anterior STEMI
  2. Posterior infarct
  3. No infarct
  4. Inferior STEMI
A
  1. no infarct
41
Q

A 77 year old man with known LV systolic dysfunction who is visiting a friend in Glasgow and has forgotten to bring his “water tablets” wakes with acute breathlessness in the middle of the night. O2 sats are 83% and his ECG looks like this:

Is this…?

  1. Anterior STEMI
  2. Inferior STEMI
  3. LBBB
  4. Pericarditis
A
  1. LBBB

Week 5 - Cardiology (12 decks)

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