S2 L2.5: Syndromes of CAD

Question 1

T/F
1. CAD can be classified into acute or chronic
2. There are 5 types of MI under actue

Answer 1

1. T
2. T

Question 2

Most commonly caused by obstruction by atherosclerotic plaque (chronic)

Answer 2

CHRONIC STABLE ANGINA

Question 3

Risk factors similar to atherosclerosis

Answer 3

CHRONIC STABLE ANGINA

Question 4

Progressive if not managed optimally and progresses if not managed early

Answer 4

CHRONIC STABLE ANGINA

Question 5

T/F

Natural course of chronic stable is that pain worsens over time, which
means progression in blockage of arteries →
progression in Canadian Classification (ex. Class 1 to Class 2) but does not suffer from any heart attack or acute myocardial injury (only d/t the obstruction getting bigger)

Answer 5

True

Question 6

Tantamount to “heart attack”/myocardial infarction

Answer 6

ACUTE CORONARY SYNDROME

Question 7

Pain is longer than 30 min or shorter but with severe damage as compared to angina pectoris

Answer 7

ACUTE CORONARY SYNDROME

Question 8

Prolonged ischemic discomfort

Answer 8

ACUTE CORONARY SYNDROME

Question 9

What is the WHO criteris for MI?

Answer 9

WHO criteria for MI (2 out of 3):
○ characteristic ischemic symptoms
○ significant ECG changes (also blood test to confirm
diagnosis of myocardial infarction)
○ typical rise and fall of cardiac biomarkers

Question 10

REVISED DEFINIONT OF MYOCARDIAL INFARCTION (MI)

CRITERIA FOR ACUTE, EVOLVING, OR RECENT MI

EITHER OF THE FF CRITERIA SATISIFIES THE DIAGNOSIS FOR ACUTE, EVOLVING, OR RECENT MI:
1. Typical ______ and/or ______ of biochemical markers of
myocardial ______
2. _______ findings of an acute myocardial infarction

Answer 10

1. Typical rise and/or fall of biochemical markers of
   myocardial necrosis
2. Pathological findings of an acute myocardial infarction

Question 11

In the revised criteria for diagnosis for acute, evolving, or recent MI, at least one (1) of the following should be detected:

a) _____ symptoms
b) development of ______ __ waves in the ECG
c) ECG changes indicative of ischemia (___ _____ ______ or _____)
d) Imaging evidence of new _____ of ____ _______ or new _______ ___ motion abnormally

Answer 11

a) Ischemic symptoms
b) Development of pathological Q waves in the ECG
c) ECG changes indicative of ischemia (ST segment
elevation or depression)
d) Imaging evidence of new loss of viable myocardium or new regional wall motion abnormally

Question 12

The following are signs and symptoms of ACS, EXCEPT:
a. Incessant anginal pains
b. Diaphoresis
c. Pale cool skin
d. Sinus tachycardia
e. A third and/ or fourth heart sound (rales/crackles)
f. Basilar rales
g. Hypertension
h. none of the above

Answer 12

G. HyPOtension not hypertension

THE REST ARE SIGNS AND SYMPTOMS OF ACUTE CORONARY SYNDROME

Question 13

T/F regarding signs and symptoms of ACS

1. Basilar rales (weak heart → heart failure; there’s already fluid flooding the pulmonary bed)
2. Hypotension (sign of medical emergency if occurred
   during assessment; coronary angiography is done; ↓ CV, ↓ CO, ↓ BP)

Answer 13

TT

Question 14

Also a form of heart attack

Answer 14

Unstable angina and NSTEMI

Question 15

Less severe ischemia and myocardial damage (still managed as a heart attack)

Answer 15

Unstable angina

Question 16

More severe ischemia and myocardial damage

Answer 16

NSTEMI

Question 17

Clinical features of UA

Answer 17

NSTEMI

Question 18

ECG changes may be ischemic or nonspecific (CKMB
blood test, Troponin I, C & T)

Answer 18

NSTEMI

Question 19

Evidence of myocardial necrosis, as reflected in elevated cardiac biomarkers

Answer 19

NSTEMI

Question 20

Angina pectoris or equivalent ischemic discomfort with at least one of what features? Enumerate them

Answer 20

○ It occurs at rest (or with minimal exertion), usually lasting >10 min
○ It is severe and of new onset (i.e., within the prior 4–6 weeks)
○ It occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or frequent than previously)

*Inform MD immediately that the pt needs to be brought to the ER even if it was just the first time you observed it worsen on the pt; Stop therapy and bring the pt to ER

Question 21

T/F regarding NSTEMI:
1. There is elevated troponin I & T
2. We use Troponin I & Troponin T to tell us if there is a myocardial injury
3. With ECG na not specific for an acute MI we call is ST elevation MI or STEMI
4. We check an ECG and check for a specific segment in the ECG and that will tell us if it’s an ST elevation MI or non ST elevation MI
5. Checking of ECG results of the patient is not important in PT

Answer 21

1-2. True
3. False. With ECG na not specific for an acute MI we call is non ST elevation MI or NSTEMI
4. T
5. F. Important to know because it will tell us what intervention to do

Question 22

The following are ECG changes in UA/NSTEMI, EXCEPT (there can be more than 1 answer):
A. Major diagnositc tool in heart and
B. ST-segment depression (50%)
C. TG-wave inversion (40%)
D.Transient ST-segment elevation (10%)
E. None of the above

Answer 22

B, C, D

It should be:
ST-segment depression (30%)
TG-wave inversion (20%)
Transient ST-segment elevation (5%)

Question 23

Complete occlusion of an epicardial artery

Answer 23

STEMI

Question 24

Worse, prolonged anginal pains at rest or precipitated by exertion

Answer 24

STEMI

Question 25

T/F about STEMI:

Re-establish perfusion right away because if we don’t
do that the heart muscle will die immediately

Answer 25

True

Question 26

What is the golden period when we can do an intervention and
prevent permanent necrosis?

Answer 26

6 - 12 hrs

Question 27

Also has ST elevation on ECG and elevated cardiac biomarkers

Answer 27

STEMI

*for more info about STEMI, kindly review the figure (yung green na parang concept map :> )

Question 28

Modified T/F about the STEMI ECG FINDINGS:
1. ST segment elevation of at least 1 mm in two or more limb lead
2. At least 2 mm ST segment elevation in two or more precordial leads

Answer 28

TT

Question 29

What are the two (2) pathologic and clinical presentations of ACS and their management?

Answer 29

● Non ST elevation - non subtotal occlusion and
management is gamot-gamot lang
● ST elevation total occlusion - coronary angiogram and
possibly coronary angioplasty

Question 30

Give me the six (6) missing complications of acute myocardial infarction (AMI) from the list:

1. LV dysfunction
2. Pump failure
3. CHF
4. Cardiogenic Shock
5. RV infarction
6. Arrhythmias
7. Pericarditis

Answer 30

8. LV aneurysm
9. Thromboembolism
10. Papillary rupture
11. VSD (ventricular septum defect)
12. Myocardial rupture
13. Death

Question 31

COMPLICATIONS OF AMI

This is caused by a damaged conduction system of the heart; could be
deadly

Answer 31

Arrhythmias

Question 32

COMPLICATIONS OF AMI

Inflammation of pericardium

Answer 32

Pericarditis

Question 33

COMPLICATIONS OF AMI

Heart becomes weaker

Answer 33

LV dysfunction

Question 34

COMPLICATIONS OF AMI

Orthopnea, Dyspnea, Paroxysmal nocturnal dyspnea

Answer 34

CHF

Question 35

COMPLICATIONS OF AMI

Any part of the muscle is ruptured (e.g. septum)

Answer 35

Myocardial rupture

Question 36

COMPLICATIONS OF AMI

If not given intervention immediately, this can happen

Answer 36

Death

Question 37

Give me the 13 complications of AMI

Answer 37

1. LV dysfunction
2. Pump failure
3. CHF
4. Cardiogenic Shock
5. RV infarction
6. Arrhythmias
7. Pericarditis
8. LV aneurysm
9. Thromboembolism
10. Papillary rupture
11. VSD (ventricular septum defect)
12. Myocardial rupture
13. Death

Question 38

The following are complications of AMI, EXCEPT:

A. LV aneurysm
B. LV Dysfunction
C. Thromboembolism
D. Papillary rupture
E. Pump failure
F. CHF
G. Death
H. None of the Above

Answer 38

H. None of the above

Question 39

HEMODYNAMIC CONSEQUENCES OF ACUTE MI

______ _________ because MI is an inflammatory process pronounce all inflammatory elements (_____, iNOS, NO,
________) → _______ so that you could provide more blood (trying to bring back to normal) → however, because it’s a cycle, it will make heart ____ _____ (_______ ______)

Answer 39

SYSTEMIC INFLAMMATION bc MI is an inflammatory process
pronounce all inflammatory elements (CYTOKINES, iNOS, NO, PEROXYNITRITE) → VASODILATE so that you could provide more blood (trying to bring back to normal) → however, because it’s a cycle, it will make heart PUMP MORE (MYOCARDIAL DYSFUNCTION)

Question 40

HEMODYNAMIC CONSEQUENCES OF ACUTE MI

Systolic (↓ ____ ______, stroke output) →
________ = blood itself is working hard but not
getting the blood it needs that time (↓ _____
______ _______) → promoting ____ ______
(cycle, promote more myocardial dysfunction) → if left untreated, _____

Answer 40

Systolic (↓ CARDIAC OUTPUT, stroke output) →
HYPOTENSION = blood itself is working hard but not
getting the blood it needs that time (↓ CORONARY PERFUSION PRESSURE ) → promoting MORE ISCHEMIA
(cycle, promote more myocardial dysfunction) → if left untreated, death

Question 41

HEMODYNAMIC CONSEQUENCES OF ACUTE MI

Diastolic → ↑ pulmonary _____ and _____ →
_____ → _______ (aggravate the hemodynamic
parameters of the heart)

Answer 41

Diastolic → ↑ pulmonary CONGESTION and CHR →
HYPOXEMIA → ISCHEMIA (aggravate the hemodynamic
parameters of the heart)

REVIEW TIP: Try to understand the figure of Hemodynamic Consequences of Acute MI (better na i-understand din yung pic/figure)