Session 4 - MI Flashcards
In the assessment of chest pain, what indicators would make you think of cardiac ischemia?
Site- most often central
Onset- gradually over a few MINUTES! if Angina, will come on exertion.
Character- crushing, tightness, heavy, compressing. Not likely sharp, shouldn’t be reproducible on palpation.
Radiation- often radiates to (left) arm or neck and jaw in MI
Associated symptoms- sweating, N/V, going grey, SOB, syncope
Timing- if it lasts around 15-20 mins or more, likely Ischemic. so not chronic or quickly coming and going.
Exacebators/Eleviators- angina, exacerbated by exertion, elevate by rest or GTN spray
Severity- high for MI
In the assessment of chest pain, what indicators would make you think of cardiac ischemia?
Site- most often central
Onset- gradually over a few MINUTES! if Angina, will come on exertion.
Character- crushing, tightness, heavy, compressing. Not likely sharp, shouldn’t be reproducible on palpation.
Radiation- often radiates to (left) arm or neck and jaw in MI
Associated symptoms- sweating, N/V, going grey, SOB, syncope
Timing- if it lasts around 15-20 mins or more, likely Ischemic. so not chronic or quickly coming and going.
Exacebators/Eleviators- angina, exacerbated by exertion, elevate by rest or GTN spray
Severity- high for MI
When taking a history of chest pain, you should concentrate on?
history of the pain (SOCRATES)
cardiovascular risk profile (QRISK2)
previous personal or family history of IHD
what does the QRISK2 score measure?
probability of having a cardiovascular event (MI or stroke) in the next 10 years based on someones risk factors
differential diagnosis of chest pain includes?
ACS/MI stable angina pericarditis aortic dissection PE
pleuritis
pneumonia
pneumothorax
oesophageal spasm
GORD
risk factors for IHD include:
non-modifiable: age, male, family history of IHD, personal history of IHD
Clinical: hypertension, hyperlipedemia, diabetes
modifiable: sedentary lifestyle, poor diet, smoking, high alcohol intake, obesity,
‘Type A personality’?- aggressive/ambitious
what are you looking for in the ECG of someone having a STEMI?
Tall T waves
T wave inversion
ST elevation!!!! (hence STEMI)
pathological Q waves
what are you looking for in the blood results of someone with suspected NSTEMI?
raised troponin I/T
troponin is a contractile protein which is not normally found in the serum, it is only released during myocardial necrosis. Should see a rise and fall within serial tests.
what are you looking for in the blood results of someone with STEMI?
raised troponin I/T
raised creatinine kinase
When taking a history of chest pain, you should concentrate on?
history of the pain (SOCRATES)
cardiovascular risk profile (QRISK2)
previous personal or family history of IHD
what does the QRISK2 score measure?
probability of having a cardiovascular event (MI or stroke) in the next 10 years based on someones risk factors
differential diagnosis of chest pain includes?
ACS/MI stable angina pericarditis aortic dissection PE
pleuritis
pneumonia
pneumothorax
oesophageal spasm
GORD
risk factors for IHD include:
non-modifiable: age, male, family history of IHD, personal history of IHD
Clinical: hypertension, hyperlipedemia, diabetes
modifiable: sedentary lifestyle, poor diet, smoking, high alcohol intake, obesity,
‘Type A personality’?- aggressive/ambitious
Management of acute MI?
brief history and physical, ECG and bloods
M- morphine (+antiemetics)
O- oxygen
N- nitrates
A- aspirin
try to get to PCI (percutaneous coronary intervention - i.e. sending within 2 hours)
if can’t, fibrinolysis with streptokinase/tissue plasminogen activator
what are you looking for in the ECG of someone having an acute MI?
Tall T waves
T wave inversion
ST elevation!!!! (hence STEMI)
pathological Q waves
what are you looking for in the blood results of someone with STEMI?
raised troponin I/T
raised creatinine kinase
How is an NSTEMI treated differently to a STEMI?
as there is no ECG indication of MI, rely more on troponin in blood tests to diagnose.
still get MONA, but rather than referring them to a PCI centre, use anticoag: LMW heparin.
then they are discharged with preventative drugs: ACE-i, beta blockers, statins
what secondary prevention lifestyle advice would you give to someone post-MI?
lifestyle changes: quit smoking, more exercise, less alcohol, better diet (less fat, more veg) lose weight if they are overweight (put them in cardiac rehabilitation programme)
what drugs should be given to someone to take home, post MI?
should all be discharged with the following:
ACE-I or Calcium Channel Blocker - treat hypertension
Beta Blockers - negative into and chronotropes, reduce workload on heart
Statins - to lower LDL, reduce plaque formation
Aspirin - anti platelet, prevent clotting
(GTN spray if they get angina)
How do you decide whether to give someone an ACE-I or a calcium channel blocker to treat their hypertension? give example of each
age/ethnicity
if they are under 55 and not afrocaribean, give ACE-I such as ramipril/enalapril
if they are over 55 or afrocarribean give calcium channel blocker such as amlodipine/nifedipine
What is the pathophysiology of an MI?
Normally by mechanism of atherosclerosis
High LDL levels, deposited in the walls of coronary artery, oxidises, which causes expression of adhesion molecules, allowing macrophages come in
Macrophages take up the LDL, but they form foam cells and also get stuck. in the lipid core.
Other cytokines are released by the endothelial cells and cause smooth muscle proliferation, which then synthesises collagen and forms a fibrous cap, which overlies the lipid core.
The lipid core continues to grow if there is a high serum level of LDL, so inflammation continues and the T lymphocytes activate the macrophages to release matrixmetalloproteinases, which weaken the fibrous cap.
This leads to plaque rupturing, causes thrombosis, leads to partial/total occlusion of the coronary artery, ischemia of the myocardium, myocardial necrosis occurs
