Myocardial Infarction

Question 1

What is seen on ECG with a Non-STEMI or Unstable Angina?

Answer 1

Inverted T wave and ST depression

Question 2

What is seen on ECG in a STEMI?

Answer 2

ST elevation

Question 3

What is a Type 1 MI?

Answer 3

Spontaneous MI caused by a primary coronary event (plaque erosion or rupture)

Question 4

What is a Type 2 MI?

Answer 4

MI secondary to Increased O2 demand or decreased supply

Question 5

What is a Type 3 MI?

Answer 5

Sudden unexpected cardiac death. Cardiac arrest, ishcemia, ST segment elevation, or obstruction of a coronary

Question 6

What is a Type 4a MI?

Answer 6

MI associated with PCI

Question 7

What is a Type 4b MI?

Answer 7

MI associated with stent thrombosis

Question 8

What is a Type 5 MI?

Answer 8

MI associated with CABG

Question 9

What are the characteristics of an Unstable Plaque?

Answer 9

Thin fibrous plaque
Inflammatory cells
Few SMC
Eroded endothelium
Activated macrophages

Question 10

What are the characteristics of a Stable Plaque?

Answer 10

Thick fibrous plaque
No Inflammatory cells
More SMC
Intact endothelium
Foam Cells

Question 11

What is compensatory luminal expansion?

Answer 11

Lumen stays the same until severe CAD

Question 12

What are the history features of an acute MI?

Answer 12

Chest Pain

Unstable angina

• New onset
• less activity
• increasing frequency or severity

Question 13

What are PE findings in an Acute MI?

Answer 13

GE: anxious, distressed, diaphoretic,

HR, BP, and Pulse ox can all be variable or normal!
Ocular Retinopathies of DM, HTN, gen Atherosclerosis

Question 14

What are the Heart sounds associated with an acute MI?

Answer 14

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

Question 15

Who presents atypically most often?

Answer 15

Elderly, women, diabetics

Question 16

What are unusual causes of chest pain/MI in women?

Answer 16

Spontaneous Coronary Artery dissection
Coronary Vasospasm(prinzmetal's angina)
Microvessel Disease(Cardiac syndrome X)

Question 17

What are the causes of chest pain that can kill you?

Answer 17

MI
PE
Pneumothorax
Acute Aortic Syndromes
-Dissection
-perforated ulcer
-intramural hematoma

Question 18

What are the lab tests to do following an acute MI?

Answer 18

Serum Biomarkers:
Cardiac Specific Troponin
Creatine Kinase MB
Serum Myoglobin

Also evaluate for anemia, DM, dyslipidemia

Question 19

What are the traits of Troponin in Acute MI?

Answer 19

Rise within 3 hrs of AMI
Released continuously
Peaks 24-48 hrs

Question 20

What are the traits of Creatine Kinase MB in Acute MI?

Answer 20

Exceeds normal in 4-8 hrs, back to normal in 2-3 days
peaks in 24 hrs
Also present in Skeletal muscle

Question 21

What are the different imaging modalities of Imaging in ACS?

Answer 21

Chest XR
Echocardiography
Nuclear SPECT
CT Coronary Angiogrphy
Cardiac MRI

Question 22

What can tell you how extensive a STEMI/NSTEMI is?

Answer 22

The degree of ST elevation/depression and the number of leads involved

Question 23

When are delta waves seen?

Answer 23

WPW syndrome

Question 24

What are the immediate therapies for AMI?

Answer 24

ECG within 10 min, 
ABCs, Vitals
IV Access
LABS
Stabilize the Patient
MONA
If consistent with STEMI Prep for Immediate Reperfusion

Question 25

What does MONA stand for?

Answer 25

Morphine, Oxygen, Nitro, Aspirin

Question 26

What are the 3 main Classes of medical therapy?

Answer 26

Antiplatelet Agents Anticoagulant Agents Anti-ischemic Agents

Question 27

What Antiplatelet agents are use in MI?

Answer 27

P2Y12 inhibitor | GP 2b3a inhibitor

Question 28

What Anticoagulant agents are use in MI?

Answer 28

.

Question 29

What Anti-ischemic agents are use in MI?

Answer 29

Beta Blockers(tachy and HTN or vent arrythmia) IV Nitroglycerin(Acute pulm edema/CHF) Useful if Pt is Hypertensive Ca Channel Blockers

Question 30

What should all ischemic Chest pain patients recieve?

Answer 30

Oxygen low flow (keep above 90% O2 sat) Aspirin Sublingual NTG Anticoagulant

Question 31

What are charicteristics of a STEMI?

Answer 31

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

Question 32

What are charicteristics of and Anterior Wall MI?

Answer 32

Bad prognosis because there is a lare amount of myocardium involved(LAD occlusion) Widow Maker AV block uncommon

Question 33

What are charicteristics of and Inferior Wall MI?

Answer 33

High vagal tone state Low normal or Bradicardia from SA ischemia and Inc Vagal tone AV block uncommon and usually transient

Question 34

What are the characteristics of Inferior wall MI with associated RV infarction?

Answer 34

JVD, Hypotension, Clear lung fields Preload Sensitive, avoid NTG, caution with BB may need trial of IV fluids Diagnose with V4R lead ECG

Question 35

How can a RV MI be better diagnosed?

Answer 35

Right sided EKG

Question 36

What are the gross changes following an Infarction?

Answer 36

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

Question 37

What is the management of a STEMI?

Answer 37

ASA P2Y12 blocker Beta Blocker(less ARR more cardiogenic shock) Unfractionated heparin or bivalrudin if bleeding risk higher

Question 38

What are the benefits of using Fibrinolytic therapy?

Answer 38

Reduces mortality short and long term | Increased risk of stroke or major bleeding

Question 39

What are the contraindications for throobolytic therapy?

Answer 39

Past Intracranial Hemmhorrage | Cerebral vascular lesion...

Question 40

Who are the best candidates of PCI in STEMI

Answer 40

``` Delayed presentation High bleeding risk Lytic contraindication or failed lytic complex coronary disease Shock Compilication diagnosis less certain ```

Question 41

What is a danger of PCI?

Answer 41

Can shower microthrombi downstream when Stent opened

Question 42

What is unique about a NSTEMI?

Answer 42

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)

Question 43

What are the guidelines for Tx for different patients?

Answer 43

VHRP? HRP IRP LRP

Question 44

What are considerations for Post-MI care?

Answer 44

Assess Ejection fraction Assess cardiovascular Risk factors Education(event, meds, CV disease, heart healthy lifestyle) Cardiac Rehab

Question 45

What drugs should be given in post MI care?

Answer 45

Aspirin 81-162 mg for life | P2Y12 inhibitor: Clopidogrel, ticagrelor for 1 year

Question 46

Why is readmission so high post MI?

Answer 46

Polypharmacy Early discharge Side effects Feel overwhelmed and depressed