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Cardiology > STEMI > Flashcards

STEMI Flashcards

1
Q

What are the symptoms of ACS?

(6)

A
    • Crushing chest pain radiating to left arm/jaw
    • Sweating (marked) : 2nd to high sympathetic drive
    • Nausea + Vomiting
    • Breathlessness
    • Palpitations
    • BP, pulse and oxygen saturations may be normal
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2
Q

What are the atypical symptoms of ACS?

(4)

A
  • Epigastric pain
  • Indigestion-like symptoms
  • Insolated dyspnoea
  • Syncope
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3
Q

What is the common atypical presentation in women?

A

Middle / upper back pain

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4
Q

What is the pathophysiology of a STEMI?

A
  • complete occlusion of a coronary artery secondary to a thrombus
  • Leading to ischaemic and necrosis of myocytes
  • Degree of myocardium damage is dependant on the areas supplied by the coronary artery and efficiency of reperfusion
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5
Q

Which investigation is diagnosic?

A

ECG is diagnostic

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6
Q

How long should CP last for in a STEMI?

A

CP should last for > 20 minutes

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7
Q

What is the criteria for ST elevation on ECG for a STEMI?

(4)

A

ST elevation in two contiguous leads of v2-v3
* >2.5 mm in Men <40
* >2mm in Men >40
* 1.5mm in Women
* 1 mm ST elevation in other leads

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8
Q

What else may indicate a STEMI other than ST elevation on ECG?

A

New LBBB

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9
Q

What ECG changes may be seen in a posterior STEMI?

A

Deep ST segment depression in leads** V1 - V3**

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10
Q

What is the criteria for ‘Pathological’ Q waves?

A
  • Any Q wave in leads v2-v3
  • Deep >1mm in other continuous leads
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11
Q

What do Q waves indicate?

A

may indicate previous ‘silent’ MI

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12
Q

Where are Q waves normally seen on an ECG?

A

normally deep in >2mm in III or avR

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13
Q

What is the criteria for a PCI to be administered?

(3)

A
  • if presented within 12 hours of onset of symptoms
    ** and**
  • PCI can be delivered within 120 minutes of presentation to hospital

OR

  • if signs of on going ischaemia / symptoms or shock or HF / malignant arrhythmias
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14
Q

What is the process of a PCI?

(3)

A
  • Catheter inserted into blood vessels to area of occlusion
  • a balloon is inflated and stent is placed.
  • Right radial access is preferred over femoral access
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15
Q

STEMI : PCI - Management

A
  1. STEMI
  2. Asprin 300mg
  3. 2nd antiplatelet :
    * Praugrel
    * Clopidogrel if high risk of bleeding/concurrent anticoagulant therapy
  4. PCI -
    i) Radial access
    * Unfractionated heparin (Dalteparin/Enoxaparin)
    * Bailout Glycoprotein IIB/IIIA inhibitor (tirofiban and eptifibatide) - if worsening or persistent thrombus
    ii) Femoral access
    * bivalirudin (thrombin inhibitor) with bailout GPI
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16
Q

NSTEMI/Unstable angine : Management

A
  1. NSTEMI/Unstable angina
  2. Asprin 300mg
  3. Fondaparinux if no immediate PCI planned
    * If immediate PCI planned or creatinine >265 then : Unfractionated heparin
  4. GRACE SCORE
    * High - PCI
    * Low - Ticagrelor (2nd antiplatelet)
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17
Q

STEMI : Fibrinolysis management

A
  1. STEMI
  2. Asprin 300mg
  3. Fibrinolysis
    * Antithrombin
  4. Second antiplatelet
    * Ticagrelor - given following procedure
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18
Q

When should dual antiplatelet therapy be administered?

A

To all patients who are due to undergo PCI
* if the patient is not taking an oral anticoagulant: prasugrel
* if taking an oral anticoagulant: clopidogrel

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19
Q

What are the specific indications for giving clopidogrel?

A
  1. High bleeding risk
  2. Patient is already taking an anticoagulant
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20
Q

What is a common drug which interacts with clopidogrel?

A

Omeprazole +Clopidogrel
* Omeprazole interacts with clopidogrel and reduces it effectiveness
* Omeprazole is a P450 inhibitor but not lansoprazole

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21
Q

What is thrombolysis

Include examples of thrombolytic drugs

A
  • Use of thrombolytic drugs to break down blood clots by activating an called plasminogen to form plasmin which degrades blood clots (fibrin)
  • e.g. Alteplase, Streptokinase
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22
Q

What is the criteria behind starting anticoagualation in a patient due to undergo treatment for a STEMI?

A

*If PCI - hold anticoagulant
* If fibrinolysis - start anticoagulant at the same time
e.g. Fondaparinux

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23
Q

What are the main CI for thrombolysis?

(7)

A
  1. Active bleeding, recent haemorrage/surgery/trauma
  2. Stroke <3 months
  3. Bleeding disorder
  4. Aortic dissection
  5. Intra cranial neoplasm/ Recent head injury
  6. Severe hypertension
  7. Concurrent anticoagulation use
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24
Q

What should you do if thrombolysis is CI?

A
  • Chose primary PCI instead regardless of anticipated time to access this intervention
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25
Q

Which is more effective - Thrombolysis or PCI?

A

Thrombolysis has a higher risk of bleeding and less efficacy.

26
Q

When should PCI be offered after thrombolysis?

A

offer angiography if
* ECG 60-90mins post shows residual ST elevation
* Recurrent myocardia ischaemia/chhest pain post fibrinolysis

27
Q

What is a type 1 MI and explain its pathophysiology?

A
  • Non occlusive thrombus that develops in a disrupted atherosclerotic plaque
  • Unstable plaques have soft lipid rich contents covered by a fibrous cap
  • If plaque is disturbed - exposure of the lipid rich core triggers the coagulation cascade
  • Leading to super-imposed thrombus formation
  • Occluding the coronary blood flow
  • Resulting in ischaemia
28
Q

What is a type 2 MI?

Include examples

A
  • MI secondary to increased oxygen demand or reduced supply to the heard
  • Imbalance may be caused by severe anaemia, hypotension, tachycardia
    • Cocaine induced vasospasm
    • Vasculitis
29
Q

What is the pathophysiology of NSTEMI?

A
  • Result of transient or near complete occlusion of the coronary artery
30
Q

What is the clinical definition of an NSTEMI?

A
  • **Chest pain **+ Rise in troponin **+ ECG changes but no ST segment elevation on ECG
31
Q

What is the diagnostic investigation of NSTEMI?

A

Troponin levels

32
Q
A
33
Q

How are troponin results interpreted to confirm the diagnosis of NSTEMI?

A

0 hours troponin level
* > 1 hour of chest pain
Repeat troponin 1 hour after presentation
* If still low; Rule out NSTEMI
* High > 99th percentile of upper reference limit } confirm NSTEMI

34
Q

What may FBC show in an NSTEMI?

A

FBC -
* Thrombocytopenia : NSTEMI increases the risk of bleeding, low platelets is a predictor of poor outcome
* Possible Type 2 MI ; secondary blood loss, anaemia
* Anaemia is common in NSTEMI as associated with increased mortality and major bleeding

35
Q

What are the symptoms of clinical instability in an NSTEMI?

A
  • On going recurrent chest pain
  • Haemodyanmic instability } low BP/SHOCK
  • Dynamic ECG changes
  • LV failure
  • Life threatening arrhythmia } VT or VF
36
Q

What is the management of an UNSTEMI in an unstable patient?

A
  1. 12 lead ECG
  2. Urgent ECHO
    If signs of acute heart failure in haemodynamic instability or cardiac arrest
  3. Antiplatelet therapy - 300mg asprin
  4. Oxygen, GTN, morphine
  5. Immediate ICA with revascularision
37
Q

Management of clinically stable patient

A
  1. Low risk : Conservative management
    if symptoms of ischaemia develop } offer ICA
  2. High or intermediate risk : ICA +/- Revascularisation within 72 hours
38
Q

Post stabilisation of STEMI/NSTEMI

A
  1. Anticoagulation
    If no immediate ICA planned
    - HASBLED
    * Fondaprinux : 2.5mg subcutaneously for unto 8 days or till discharge
    - Significant renal impairment creatinine >265 mcg } Unfractionated heparin isntead
  2. Beta blocker - Bisoprolol 1.25mg OD initially for 1 week } increase gradually to max 10mg

3. Ace inhibitor
Enalapril 2.5mg OD initially / Ramipril 2.5mg BD for 3 days / lisinopril 2.5mg - 5 mg OD } gradually increase depending on response

39
Q

Long term secondary prevention following UNSTEMI/STEMI

(6)

A
  1. **Continue Aspirin **75mg indefinitely

2.** Continue P2Y12 inhibitor** } 12 months
e.g. Ticagrelor 90mg BD / Clopidogrel 75mg OD

  1. **Beta blocker **} 12 months
    - if LVEF reduced } lifelong
  2. Ace inhibitor } life long
  3. Aldosterone antagonist
    - Signs of HF and reduced LVEF
    - After starting ace inhibitor and 3-14 days post NSTEMI

6.** Statins **} all patients
80mg PO OD

40
Q

MI : Secondary prevention life style advise

A
  1. Diet: advise a Mediterranean style diet,
    * switch butter and cheese for plant oil based products.

2 . Exercise: advise 20-30 mins a day until patients are ‘slightly breathless’
* sexual activity may resume 4 weeks after an uncomplicated MI

41
Q

What should be considered in patients with signficant LV dysfunction following MI?

A
  • Patient with significant LV dysfunction ejection fraction of < 35%}
  • consider implantable cardioverter defibrillator for primary and secondary prevention.
42
Q

What are the complications of MI in < 48 hours

(2)

A
  • Pericarditis - < 48 hours post MI
  • VT/VF } majority occur within first 48 hours of admission
43
Q

What does Bradycardia post MI indicate?

A
  1. Complete heart block - caused by damage to the RCA which supplies the AVN node
44
Q

What are the complications of an MI?

(6)

A
    • Cardiac arrest
    • Cardiogenic shock - if a large part of ventricular myocardium is damaged
    • Chronic heart failure
    • Bradyarrhythmia - AV block following inferior myocardial infarctions
    • Left ventricular aneurysm - ischaemic damage weaken the myocardium resulting in aneurysm formation.
    • Acute mitral regurgitation - Common with infers-posterior infarction and may be due to ischaemia or rupture of papillary muscle.
45
Q

Dressler’s syndrome - Incidence

A

2-6 weeks following an MI

46
Q

Dressler’s syndrome - Etiology

A

Autoimmune reaction against injured myocardium as it recovers

47
Q

Dressler’s syndrome - symptoms

A

Fever, pleuritic chest pain worse on inspiration and lying flat

48
Q

Dressler’s syndrome - Investigation results

A
  1. Bloods : raised ESR
  2. ECG : Saddle shaped ST elevation +/- PR depression
49
Q

Dressler’s syndrome - complication

A

Pleural effusion

50
Q

Dressler’s syndrome - management

A

High dose NSAIDs

51
Q

Left ventricular aneurysm - incidence

A

4 - 6 weeks post MI

52
Q

Left ventricular aneurysm - investigation results

(2)

A

ECG : Persistent ST elevation
ECHO : LV failure
CXR : enlarged heart with bulge in left heart border

53
Q

Left ventricular aneurysm - management

A

anticoagulation

54
Q

Left ventricular aneurysm - incidence

A

Incidence : occurs in the first week after a MI attack

55
Q

ACS : Antiplatelet therapy

A
  1. Aspirin (lifelong) & ticagrelor (12 months)
  2. If aspirin contraindicated, clopidogrel (lifelong)
56
Q

PCI : Antiplatelet therapy

A
  1. Aspirin (lifelong) & prasurgrel or ticagrelor (12 months)
  2. If aspirin contraindicated, clopidogrel (lifelong)
57
Q

TIA : Antiplatelet therapy

A
  1. Clopidogrel (lifelong)
  2. Aspirin (lifelong) & dipyridamole (lifelong)
58
Q

Ischaemic stroke: Antiplatelet therapy

A
  1. Clopidogrel (lifelong)
  2. Aspirin (lifelong) & dipyridamole (lifelong)
59
Q

Peripheral arterial disease: Antiplatelet therapy

A
  1. Clopidogrel (lifelong)
  2. Asprin (lifelong)
60
Q

Clopidogrel : MOA

A
  • antagonist of the P2Y12 adenosine diphosphate (ADP) receptor, inhibiting the activation of platelets

Cardiology (25 decks)

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