ST-Elevation Myocardial Infarction Flashcards
What is the recommended ‘door-to-needle’ time for thrombolysis in STEMI management?
<30 minutes
What is the goal for total ischemic time in STEMI management?
<2 hours, ideally <1 hour
What does the Sgarbossa criteria help diagnose in patients with old LBBB?
STEMI
What score on the Sgarbossa criteria indicates a specificity of 90% for diagnosing MI?
≥3
What defines STEMI according to the 2013 ACC/AHA guidelines?
New ST elevation at the J point in at least two contiguous leads
What are the ST elevation thresholds for STEMI diagnosis in men and women?
- ≥2 mm in V2 to V3 for men
- ≥1.5 mm in V2 to V3 for women
- ≥1 mm in other contiguous leads
What should be started as soon as possible in comatose patients with STEMI and out-of-hospital cardiac arrest?
Therapeutic hypothermia
What is the recommended clopidogrel loading dose for STEMI patients aged 75 years or less?
300 mg
What is the role of CABG in STEMI treatment?
Indicated in failed PCI or high-risk patients
What does the TIMI myocardial perfusion grading (TMPG) system assess?
Myocardial perfusion
What does TMPG grade 0 indicate?
No apparent tissue-level perfusion
What are the relative contraindications to β-blocker therapy in STEMI patients?
- HR < 60 bpm
- Systolic BP < 100 mm Hg
- Moderate or severe LV failure
What should be done for STEMI patients with persistent ST elevations after thrombolysis?
Transfer directly to catheterization laboratory for PCI
What are the contraindications to nitrates in STEMI patients?
- Hypotension
- Marked bradycardia or tachycardia
- Recent phosphodiesterase 5 inhibitor use
What is the ACC/AHA recommendation for routine use of aspiration thrombectomy?
Class III
What does the term ‘facilitated PCI’ refer to?
Full- or half-dose fibrinolysis with immediate transfer for planned PCI
What were the findings regarding bivalirudin vs. heparin plus a IIb/IIIa inhibitor in STEMI patients?
No significant difference for MACE or stroke
What is the risk associated with delayed β-blocker therapy in high-risk STEMI patients?
Cardiogenic shock
What complication is associated with holosystolic murmur in late presenters of STEMI?
Ventricular septal rupture or acute mitral regurgitation
What is the ACC/AHA Class I recommendation regarding the use of parin at the time of PCI?
Parin with or without a IIb/IIIa inhibitor or bivalirudin is recommended.
What indicates a high risk for mechanical complications in a patient presenting with anterior Q wave and shortness of breath?
Late presentation, evidenced by 3-day symptoms.
What is a common sign of ventricular septal rupture (VSR)?
Holosystolic murmur.
What should be confirmed immediately in a patient suspected of having VSR?
Echocardiogram.
What are the indications for emergent CABG?
Ventricular septal rupture (VSR).
What can be used as a bridge to surgery in cases of VSR?
IABP, inotropes, and vasodilators.
In the TRANSFER AMI trial, what were the three strategies for transferring high-risk STEMI patients?
- Immediate transfer for PCI within 6 hours of thrombolysis, 2. Delayed transfer for persistent ST elevations or instability, 3. Delayed transfer for angiography >24 hours after thrombolysis.
What was the conclusion regarding immediate transfer to a PCI-capable hospital for STEMI patients?
Recommended for suitable patients who develop cardiogenic shock or acute severe heart failure.
What is the Class I indication for patients who receive fibrinolytics?
Immediate transfer to a PCI-capable hospital for coronary angiography.
Which contrast agents have a Class I recommendation for angiography in patients with chronic kidney disease?
Isosmolar and lower molecular weight contrast agents.
What is the effect of drug-eluting stents (DES) compared to bare-metal stents (BMS)?
DES decreases restenosis rates without affecting mortality.
What is the recommendation for using DES in patients who cannot comply with dual antiplatelet therapy?
Should be avoided.
What were the key findings of the HORIZONS-AMI trial comparing bivalirudin and heparin?
Bivalirudin and heparin showed comparable outcomes in STEMI.
What is the significance of symptom-to-balloon time in STEMI patients?
For every 30-minute delay from symptom onset to balloon inflation, the risk of 1-year mortality increases by 7.5%.
What is ischemic preconditioning?
Brief nonlethal episodes of ischemia protect the myocardium before a prolonged ischemic event.
What are the most frequent presenting symptoms of acute MI in women according to McSweeney et al.?
Shortness of breath, weakness, and fatigue.
What is the recommendation for administering β-blockers in the acute phase of STEMI?
Part of the standard of care to reduce myocardial oxygen demand and improve perfusion.
What did the Preventive Angioplasty in Acute Myocardial Infarction (PRAMI) trial find regarding multivessel PCI?
Associated with a reduction in composite outcomes compared to infarct-only PCI.
What is the ‘no-reflow’ phenomenon?
Suboptimal myocardial perfusion despite restoration of epicardial flow.
What is the indication to stop fibrinolysis during thrombolysis?
An abrupt decline in consciousness or new central nervous system deficit.
What are some vasodilators used for treatment of no-reflow?
Nitroprusside, adenosine, verapamil
These medications have variable success in treating no-reflow (Rezkalla SH, et al. JACC Cardiovasc Interv 2017;10(3):215–223).
What should be done if there is an abrupt decline in consciousness during thrombolysis?
Stop fibrinolysis, anticoagulation, antiplatelet agents; draw PT, aPTT, platelets, fibrinogen; obtain STAT brain imaging and neurology consultation
This is based on the algorithm for evaluation of intracranial hemorrhage complicating fibrinolytic therapy for STEMI (ACC/AHA, 2004).
What do the ACC/AHA 2013 guidelines recommend regarding noninvasive testing for ischemia before discharge?
Should be performed to assess inducible ischemia in patients with STEMI without coronary angiography and without high-risk features
Exercise stress testing is preferred over pharmacologic testing unless the patient cannot exercise.
What is the U-shaped relationship observed in critically ill patients related to glucose levels?
Mortality and glucose level
Tight glucose control (81 to 108 mg/dL) was associated with increased mortality compared to modest control (180 mg/dL) in the NICE-SUGAR trial (N Engl J Med 2009;360(13):1283–1297).
What did the EPHESUS trial demonstrate regarding heart failure and MI treatment?
Reduced mortality with aldosterone antagonist added to beta-blocker and angiotensin inhibitor
An aldosterone antagonist is recommended for STEMI patients with no contraindications who are on an ACE inhibitor and beta-blocker with ejection fraction ≤ 0.40.
What is indicated for a patient requiring triple therapy?
Warfarin, aspirin, P2Y12 inhibitor
Clopidogrel is recommended in triple therapy as per ACC/AHA 2016 guidelines on duration of DAPT (Levine GN, et al. Circulation 2016;134(10):e123–e155).
What is the recommended duration for DAPT in patients with STEMI?
1 year regardless of reperfusion strategy
Clopidogrel is the only P2Y12 inhibitor studied with fibrinolytics.
Fill in the blank: An IV form of P2Y12 inhibitor that is used if oral agents are contraindicated is _______.
Cangrelor
Cangrelor has not been studied with triple therapy and is not available in oral form for long-term use.
True or False: Ticagrelor and prasugrel are associated with a lower risk of bleeding compared to clopidogrel.
False
Ticagrelor and prasugrel are more potent but associated with a higher risk of bleeding.
What should be given if indicated during thrombolysis complications?
Protamine, cryoprecipitate, fresh frozen plasma, platelets
These should be given where clinically indicated.
