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Cardio Exam 2 > Myocardial Infarction > Flashcards

Myocardial Infarction Flashcards

1
Q

Epidemiology of Myocardial Infarction

A

More common in older patients
* Approximately 60%–65% of MIs occur in patients > 65 years of age.
* Approximately 33% of MIs occur in patients > 75 years of age.
* 80% of all MI-related deaths occur in patients > 65 years of age.
* Men > women

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2
Q

Risk Factors of Myocardial Infarction

A
  • Hypertension
  • Hyperlipidemia
  • Smoking
  • Age
  • Family history of premature coronary heart disease (CHD)
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3
Q

Family history of premature coronary heart disease (CHD), is defined as:

A
  • A 1st-degree male relative < 45 years of age
  • A 1st-degree female relative < 55 years of age
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4
Q

elderly individuals are more likely to have these features of CAD/MI:

A
  • Have STEMI than NSTEMI
  • Have a silent or unrecognized MI
  • Present with atypical symptoms (e.g., weakness, confusion, syncope)
  • Have higher in-hospital mortality
  • Have heart failure associated with an MI
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5
Q

Patient Presentation with an MI

A

Crushing, substernal chest pain (exertional/non-exertional)
Radiation to jaw, shoulders or one/both arms

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6
Q

Associated Symptoms of an MI:

A

Nausea
Emesis
Diaphoresis
SOB
Lightheadedness, sudden dizziness
Fatigue
Heartburn/indigestion

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7
Q

DDx of chest pain By Organ System

A

Skin: Herpes Zoster
Breast: Fibroadenomas, Mastitis, Gynecomastia
MSK: costochondritis, precordial catch syndrome, pectoral muscle strain,
rib fx, cervical or thoracic spondylosis (C4-T6), myositis
Esophageal: spasm, rupture, GERD, esophagitis, neoplasm
GI: PUD, gallbladder dz, liver abscess, subdiaphragmatic abscess,
pancreatitis

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8
Q

Pulmonary causes of chest pain

A
  • Pleural effusion
  • Pneumonia
  • Neoplasm
  • Viral infections
  • Pneumothorax
  • PE
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9
Q

Cardiac causes of chest pain

A
  • ACS
  • Aortic
    Dissection
  • Pericarditis
  • Myocarditis
  • Stable Angina
  • Severe AS
  • Severe HCM
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10
Q

Stable plaque features

A
  • Thick fibrous cap
  • Narrowing of an artery → inability to meet oxygen demand with ↑ exertion
  • May lead to stable angina (symptoms only with exertion)
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11
Q

Unstable plaque

A
  • Thin fibrous cap
  • Massive inflammatory cell infiltrate
  • ↑ Activity of metalloproteinase enzymes –> weakens the fibrous cap
  • ↑ Lipid content
  • Angiogenesis
  • Rupture of unstable plaque in a coronary artery → thrombosis
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12
Q

Partial occlusion of the coronary artery

A
  • → affects the inner myocardium (subendocardium) → may cause:
  • NSTEMI
  • Unstable angina
  • if the ischemia does not result in cell death it is injury
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13
Q

if the ischemia does not result in cell death it is ____

A

injury

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14
Q

Myocardial Ischemia

A

supply/demand mismatch
Can occur in the setting of:
* increased myocardial tissue mass
(hypertrophy)
* increased workload on the
myocardium(tachycardia, exercise)
* increased tissue “stress” (cardiac
dilatation)

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15
Q

Complete occlusion → transmural infarction →

A

STEMI

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16
Q

Myocardial Injury:

A

elevation of at least one troponin (>99th percentile), with or without, ischemic symptoms

17
Q

Myocardial Injury on EKG

A
18
Q

Myocardial Infarction on EKG

A

Cell death (aka necrosis)
caused by ischemia.

19
Q

Myocardial Ischemia on EKG

A
20
Q

Acute Coronary Syndrome

A

Group of clinical symptoms compatible with acute myocardial ischemia and includes unstable angina (UA), non-ST-segment
elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI)

21
Q

New left bundle branch block (LBBB) PLUS symptoms → ______

A

STEMI until proven otherwise

22
Q

Time course for Serum markers in acute MI: What is the onset, peak and duration of Troponin, CK, LDH and Myoglobin?

A
23
Q

ACS Management Strategies: Outpatient clinic

A
  • If clinical suspicion for ACS –> quickly obtain
    history, EKG*à transfer by EMS to ED
  • There is no validated decision tool to
    safely rule out ACS in outpatient setting
24
Q

ACS Management Strategies: With EMS

A
  • En route to hospital, pt should be placed on
    cardiac monitoring, receive 162 to 325 mg of
    ASA, supplemental O2 if SpO2 < 90%,
    sublingual NTG 0.4 mg q5 mins for chest pain
25
Q

ACS Management Strategies: Inpatient

A
  • STEMI should receive coronary angiography
    then PCI with drug-eluting stent withing 120
    mins of presenting to ED1
  • If unable to get PCI in this time à fibrinolytics
  • NSTEMI should receive coronary angiography.
    ~60% will then get PCI, 10% will undergo
    bypass surgery, 30% will be managed with
    medical therapy alone
26
Q

ACS Diagnostics: Inpatient

A

Obtain EKG within 10 mins of arrival, repeat serially as 5% of pts will have
normal EKG
Evidence of ischemia on EKG that predicts ACS:
* T-wave inversions
* Presence of Q waves
* ST depression
* ST elevation

27
Q

ACS Pharmacologic Management: Inpatient

A

Antithrombotic therapy should be initiated with
aspirin, a P2Y12 Inhibitor and a parenteral
anticoagulant
Antiplatelets for ACS
Daily rounds: monitor for bleeding

28
Q

The HEART SCORE – clinical prediction tool

A

High sensitivity/specificity for identifying CAD as cause of chest pain useful in determining which patients deserve further work up

29
Q

The “ischemic work up” is based on RISK stratification by HEART SCORE

A
  • HEART SCORE 0-3: Low Risk à no additional testing; evaluate outpatient
  • HEART SCORE 4-6: Intermediate Risk à non-invasive testing: CTA, stress
  • HEART SCORE 7-10: High Risk: invasive testing: coronary angiography +/- PCI
    ACS Diagnostics: Ischemic Work Up
30
Q

Prevention Shown to reduce post-MI mortality

A
  1. Smoking cessation
  2. Annual influenza vaccine
  3. Referral to cardiac rehab
31
Q

Post MI Complications: Mechanical

A
  • Ventricular free wall rupture 15-30% of
    deaths, most serious (0.8 to 6.2%
    incidence), within 1st week.
  • Ventricular septal rupture 0.2 to 0.34%
    incidence, first 24 hours and again in 3-5
    days.
  • Papillary muscle rupture with severe mitral
    regurgitation 1% incidence, occurs within 1-
    14 days with MR in 7-10 days.
  • Left ventricular aneurysm, 3-15% incidence,
    can be transient.
  • MI remains the MCC of Heart Failure
32
Q

Post MI Complications: Arrhythmias

A

90% of patients will develop arrhythmia
of some type. From SVT to
bradyarrhythmias, AV blocks to right or
left BBB, and lastly VT/VF (highest
incidence in 1st hour)

33
Q

Post MI Complications: Inflammatory

A

Inflammatory (early pericarditis)
- Incidence is 10% and occurs within 24-
96 hours.
- Post MI syndrome (Dressler), 1-5%
incidence (fever, chest pain and other
signs of pericarditis) 2-3 weeks after MI

34
Q

Post MI Complications: Left ventricular mural thrombus

A

20-40% incidence in anterior MI, occur
within 10 days

Cardio Exam 2 (12 decks)

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