Myocardial Infarction Flashcards
What is seen on ECG with a Non-STEMI or Unstable Angina?
Inverted T wave and ST depression
What is seen on ECG in a STEMI?
ST elevation
What is a Type 1 MI?
Spontaneous MI caused by a primary coronary event (plaque erosion or rupture)
What is a Type 2 MI?
MI secondary to Increased O2 demand or decreased supply
What is a Type 3 MI?
Sudden unexpected cardiac death. Cardiac arrest, ishcemia, ST segment elevation, or obstruction of a coronary
What is a Type 4a MI?
MI associated with PCI
What is a Type 4b MI?
MI associated with stent thrombosis
What is a Type 5 MI?
MI associated with CABG
What are the characteristics of an Unstable Plaque?
Thin fibrous plaque Inflammatory cells Few SMC Eroded endothelium Activated macrophages
What are the characteristics of a Stable Plaque?
Thick fibrous plaque No Inflammatory cells More SMC Intact endothelium Foam Cells
What is compensatory luminal expansion?
Lumen stays the same until severe CAD
What are the history features of an acute MI?
Chest Pain
Unstable angina
- New onset
- less activity
- increasing frequency or severity
What are PE findings in an Acute MI?
GE: anxious, distressed, diaphoretic,
HR, BP, and Pulse ox can all be variable or normal!
Ocular Retinopathies of DM, HTN, gen Atherosclerosis
What are the Heart sounds associated with an acute MI?
Paradox. Split S2 if LV dsfunction S4 at the apex from stiff LV S3 with LV dysfunction/HF New systolic murmur Pericardial Friction rub Dec. PErfusion in extremities
Who presents atypically most often?
Elderly, women, diabetics
What are unusual causes of chest pain/MI in women?
Spontaneous Coronary Artery dissection Coronary Vasospasm(prinzmetal's angina) Microvessel Disease(Cardiac syndrome X)
What are the causes of chest pain that can kill you?
MI PE Pneumothorax Acute Aortic Syndromes -Dissection -perforated ulcer -intramural hematoma
What are the lab tests to do following an acute MI?
Serum Biomarkers:
Cardiac Specific Troponin
Creatine Kinase MB
Serum Myoglobin
Also evaluate for anemia, DM, dyslipidemia
What are the traits of Troponin in Acute MI?
Rise within 3 hrs of AMI
Released continuously
Peaks 24-48 hrs
What are the traits of Creatine Kinase MB in Acute MI?
Exceeds normal in 4-8 hrs, back to normal in 2-3 days
peaks in 24 hrs
Also present in Skeletal muscle
What are the different imaging modalities of Imaging in ACS?
Chest XR Echocardiography Nuclear SPECT CT Coronary Angiogrphy Cardiac MRI
What can tell you how extensive a STEMI/NSTEMI is?
The degree of ST elevation/depression and the number of leads involved
When are delta waves seen?
WPW syndrome
What are the immediate therapies for AMI?
ECG within 10 min, ABCs, Vitals IV Access LABS Stabilize the Patient MONA If consistent with STEMI Prep for Immediate Reperfusion
What does MONA stand for?
Morphine, Oxygen, Nitro, Aspirin
What are the 3 main Classes of medical therapy?
Antiplatelet Agents
Anticoagulant Agents
Anti-ischemic Agents
What Antiplatelet agents are use in MI?
P2Y12 inhibitor
GP 2b3a inhibitor
What Anticoagulant agents are use in MI?
.
What Anti-ischemic agents are use in MI?
Beta Blockers(tachy and HTN or vent arrythmia)
IV Nitroglycerin(Acute pulm edema/CHF)
Useful if Pt is Hypertensive
Ca Channel Blockers
What should all ischemic Chest pain patients recieve?
Oxygen low flow (keep above 90% O2 sat)
Aspirin
Sublingual NTG
Anticoagulant
What are charicteristics of a STEMI?
Complete occlusion of Cor BF Myocardium is continually lost
ST elevation localizes the area of injury
Fibrin rich, red clot
Plaque is typically soft nd previously non-obstructive
-no collateral devt
-no ischemic preconditoning
What are charicteristics of and Anterior Wall MI?
Bad prognosis because there is a lare amount of myocardium involved(LAD occlusion)
Widow Maker
AV block uncommon
What are charicteristics of and Inferior Wall MI?
High vagal tone state
Low normal or Bradicardia from SA ischemia and Inc Vagal tone
AV block uncommon and usually transient
What are the characteristics of Inferior wall MI with associated RV infarction?
JVD, Hypotension, Clear lung fields
Preload Sensitive, avoid NTG, caution with BB may need trial of IV fluids
Diagnose with V4R lead ECG
How can a RV MI be better diagnosed?
Right sided EKG
What are the gross changes following an Infarction?
6hr- Myocardium pale, bluish, edematous
18-36 hr- Muscle tan to purple with epicrdial exudate
8-10 days- Wall thins as necrotic tissue organized by fibroblasts
2-3 months- firm scar forms
What is the management of a STEMI?
ASA
P2Y12 blocker
Beta Blocker(less ARR more cardiogenic shock)
Unfractionated heparin or bivalrudin if bleeding risk higher
What are the benefits of using Fibrinolytic therapy?
Reduces mortality short and long term
Increased risk of stroke or major bleeding
What are the contraindications for throobolytic therapy?
Past Intracranial Hemmhorrage
Cerebral vascular lesion…
Who are the best candidates of PCI in STEMI
Delayed presentation High bleeding risk Lytic contraindication or failed lytic complex coronary disease Shock Compilication diagnosis less certain
What is a danger of PCI?
Can shower microthrombi downstream when Stent opened
What is unique about a NSTEMI?
Platelet rich White clot
ECG changes do not localize the area of ischemia or culprit vessel
ECG may be normal (ST depression or T inversion)
What are the guidelines for Tx for different patients?
VHRP?
HRP
IRP
LRP
What are considerations for Post-MI care?
Assess Ejection fraction
Assess cardiovascular Risk factors
Education(event, meds, CV disease, heart healthy lifestyle)
Cardiac Rehab
What drugs should be given in post MI care?
Aspirin 81-162 mg for life
P2Y12 inhibitor: Clopidogrel, ticagrelor for 1 year
Why is readmission so high post MI?
Polypharmacy
Early discharge
Side effects
Feel overwhelmed and depressed
