Myocardial Infarction/Acute Coronary Syndromes

Question 1

MI/CAS

Answer 1

Contributing to the leading cause of death in adults in the United States
Sudden cardiac death: one, coronary artery disease, and two, cardiomyopathies

Question 2

MI signs/symptoms

Answer 2

1/3 of patients giving history of alteration in typical anginal pain
Most infections occur at restColon pain similar to angina but more severe
Nitroglycerin has little effect
Cold sweats; weakness
Impending doom
Apprehension
Lightheadedness
Syncope
Dyspnea
Cough
Nausea and vomiting

Question 3

MI physical findings

Answer 3

Dysrhythmia common
S4 very common
Wheezing
Pulmonary crackles
Low-grade fever during first 48 hours
Tachycardia

Question 4

MI lab/diagnostics

Answer 4

EKG changes almost always; note 30% of patients have no initial EKG changes
Peaked T waves, ST elevations, Q wave development (30%-50% of patients do not have it)
Cardiac enzymes elevations above normal within 4 to 6 hours troponin I, CK Dash MB and remain high for several days
Echocardiogram
Leukocytosis 10–20 on the second day
Monitor for specific heart blocks

Question 5

Lateral Infarct

Answer 5

I, aVL

Question 6

Inferior Infarct

Answer 6

II,III, aVF

Question 7

Anterior Infarct

Answer 7

V leads, or V3 and V4

Question 8

1st degree AV block

Answer 8

PR interval >0.20 seconds

Question 9

Type 1 2nd° AV block (winky Bach or Mobitz type one)

Answer 9

The PR interval gradually gets longer until a QRS complex is dropped

Question 10

Type 2 2nd° AV block (Mobitz type two)

Answer 10

The atrial rhythm is regular, the PR interval is constant, but the ventricular rhythm is irregular; dropped QRS complexes occur

Question 11

3rd° AV block

Answer 11

The atrial and ventricular rhythm are regular, PR interval varies with no regularity, the P and R waves can walk across the strip in rhythm, some P waves may be buried and QRS complex or T-wave; no relationship between the P-wave and the QRS complex

Question 12

MI Management

Answer 12

Aspirin 325 mg tablet to chew
Nitroglycerin sublingual every five minutes times three
Begin O2 therapy; IV access
12 lead EKG and cardiac monitor
Morphine 2–4 mg IV
Furosemide of pulmonary edema presents 40 mg IVP
If not contraindicated, consider 5 mg metoprolol IV times three doses at two minute intervals, then 50 mg orally every six hours starting 15 minutes after the last IV dose
Ace inhibitors are most beneficial when the patient has failure or a large infarction to help prevent ventricular remodeling
Heparin versus low molecular weight heparin
Monitor therapeutic coagulation values

Question 13

INR

Answer 13

Normal 0.8-1.2
MI 2.5 - 3.5 x normal
Coumadin 2-3

Question 14

Activated Coagulation Time (ACT)

Answer 14

Normal 70-120 sec

150-190 or >300 sec post PTCA/stent

Question 15

Activated Partial Thromboplastin Time (aPTT)

Answer 15

Normal 28-38 sec

Therapeutic values 1.5-2.5 x normal

Question 16

PT

Answer 16

Normal 11-16 sec

Therapeutic 1.5-2.5 x normal

Question 17

PTT

Answer 17

Normal 60-90 sec

Thera 1.5-2.5 x normal

Question 18

Indications for pharmacologic revascularization

Answer 18

Unrelieved chest pain greater than 30 minutes and less than six hours with
ST segment elevation greater than 0.1 MV in two or more contingent leads

Question 19

Contraindications for pharmacologic revascularizations

Answer 19

Prior ICH
Structural cerebral vascular lesion or malignant intracranial neoplasm
Ischemic stroke within three months
Suspected aortic dissection
Active bleeding or bleeding diathesis
Significant closed head trauma or facial trauma within three months
Intracranial or intra-spinal surgery within two months
Severe uncontrolled hypertension greater than 185/110
Active bleeding or risk thereof including a normal coagulation values