NSTEMI, STEMI, Cardiac Shock Flashcards
Initial steps in management of CP include:
M, O, N, A
ECG
Labs
P2Y12 inhibitors to know (2)
Clopidogrel
Ticagrelor
When should GpIIB/IIIA inhibitors be given?
What are some? (3)
In high risk NSTE-ACS
Tirofiban
Eptifibatide
Abciximab
2 common drugs used in anti-coagulation therapy
IV heparin
Enoxaparin
Patients who are risk for MI should receive:
Patients who are low risk:
PCI
Stress test
In what cardiac event should a fibrinolytic/thrombolytic absolutely NOT be given?
When is it OK?
ACS w/o ST elevation
Beneficial in STEMI
3 pieces of the “mainstays” of treatment of NSTE-ACS:
Anti-platelet therapy
Anti-coagulation therapy
Coronary intervention
4 ECG changes w/ STEMI
ST elevation
Peaked T waves
Q waves
T wave inversion
What are lab findings in a STEMI?
Cardiac enzymes might be OK if presenting early enough. They can become positive by 4-6 hrs.
Troponin can be elevated for 5-7 days.
Management of a patient with a STEMI (3)
Aspirin
P2Y12 inhibitors
Reperfusion therapy (PCI or thrombolytics)
What must be the door to balloon time for PCI?
90 min or less
If the patient presents to a hospital without PCI abilities, how long do they have to transfer them?
120 min, PCI is still preferred to thrombolytics
When would you use thrombolytics in a patient with STEMI?
If there is not PCI abilities within 120 min away
Absolute C/I for thrombolytic therapy (6)
Previous hemorrhagic stroke Other strokes within 1 year Intracranial neoplasm Head traume Active internal bleed Aortic dissection
Patients being discharged post STEMI should be given which meds?
BB
ACE-I/ARB
Post MI complications (5)
Post infarct ischemia Arrhythmias RV infarct Mechanical complications Myocardial dysfunction
When is post infarct ischemia seen? (2)
After thrombolytic therapy for STEMI
After NSTEMI treated medically
Treatment for post infarct ischemia
Vigarous medical therapy
If refractory, should undergo early coronary angiography and revascularization
Kinds of arrhythmias seen post MI (4)
Sinus bradycardia
SVT including AFib
Conduction problems
Ventricular arrhythmias
When is sinus bradycardia seen mostly?
After an inferior MI or w/ meds
SVT and AFib should be treated with:
Metoprolol or CCBs
Can do a cardioversion if pt. is hemodynamically unstable
Amiodarone if the patient is in HF
1st degree AV block
Most common, no Tx
2nd degree AV block (Mobitz type 2) - Wenckebach
Transient and usually no Tx unless symptomatic
Complete AV block
More common in inferior MI which may be transient
Prognosis with anterior MI is worse, as it is a sign of significant infarct and needs permanent pacing
Hemodynamically significant ventricular arrhythmias (VT/VF) should be treated with:
What about hemodynamically stable ventricular tachy?
Prompt defibrillation
Anti-arrhythmic (Amiodarone)
Rv infarct occurs in a 1/3 of…
What does it present with?
What should be avoided?
What suggests Dx?
Treat with:
Inferior MIs
Hypotension with normal Lv function, elevated JVP and clear lungs
Avoid VDs including NTG
ST elevation in right anterior leads
IV fluids
Lv aneurysms occurs in…
Completed infarctions
Pericarditis is treated with…
High dose aspirin
Mural thrombus occurs most in…
What is the Tx?
Large anterior infarctions
Anti-coagulation therapy
Myocardial dysfunction presents with…
What should you do?
Acute LV failure presents with:
Hypotension not responsive to fluid resuscitation, refractory HF or cardiogenic shock
Urgent echo: RV, LV and r/o mechanical complications
Pulm edema
Cardiogenic shock is defined as:
Does it respond to fluids?
What should be done if that is the Dx?
How is LV function usually?
Systolic Bp < 90 mmHg and signs of diminished perfusion
Does not respond to fluids
Urgent coronary angio, revascularization and possible placement of intra-aortic balloon pump
LV function is usually moderately to severely reduced
What is the treatment for cardiogenic shock?
What is the prognosis?
If not as sick, give IV diuretics
Give inotropic support with dobutamine, NE or dopamine
Poor, 30 day mortality is 40-80%
Hypovolemic shock
How does it occur?
Tx?
Decreased intravascular volume secondary to loss of blood/fluids
Blood loss or dehydration
Replete intravascular vol
Obstructive shock causes
Cardiac tampanade
Tension PTX
Massive PE
Underlying cause should be treated
Most common type of shock is….
Distributive shock
Septic shock requirements
What causes it?
Fluid-unresponsive hypotension (SBP < 100 mmHg)
Serum lactate > 2 mmol/L
Need for vasopressors to keep MAP above 65 mmHg
G+ or G- orgs
Tx for septic shock
Initial resuscitation
Ventilation
Cardiac monitoring
IV access and fluid restriction
Hemodynamic measurements in cardiogenic shock (5)
Reduced CO, CI
Elevated SVR, CVP and PCWP
Hemodynamic measurements in septic shock (5)
CO and CI increase first, but in severe cases they can be lowered due to myocardial depression
Low SVR, CVP and PCWP.
Mainstay of therapy in septic and hypovolemic shock:
What else should be done?
Vol replacement
Vasoactive therapy w/ NE or dopamine, vasopressin.
Early treatment with empiric broad IV abx.
What areas of the heart are supplied by which vessels?
LAD - apex, LV anterior wall, anterior 2/3 of septum
RCA - RV free wall, LV posterior wall, posterior 1/3 of septum
LCX - LV lateral wall
