STEMI, NSTEMI, UA

Question 1

What portion of patients will die from acute MI before reaching hospital - and usually from what?

Answer 1

1/5

usually of ventricular fibrillation

Question 2

What portion of acute MI’s are “silent” - minor pain, attributed to GI tract

Answer 2

1/3

Women, elderly, diabetes patients

Question 3

Result of prolonged myocardial ischemia

- usually result of thrombus formation on atherosclerotic plaque

Answer 3

Myocardial Infarction

Question 4

Most common presenting factor in ACS

Answer 4

Nontraumatic chest pain

Question 5

Other typical chest pain feature of ACS

Answer 5

Crushing retrosternal pain / pressure

Heaviness or tightness

Unexplained indigestion / epigastric pain

Question 6

Describe progression of pain in acute MI

Answer 6

Increasingly severe, prolonged (>30min) anterior chest pain at rest

Most often during early morning hours

Question 7

Be sure to ask specifically about these 5 things in PMH history:

Answer 7

1. Prior coronary bypass graft
2. Percutaneous coronary intervention (catheterization)
3. Angina on effort
4. MI

Question 8

Vital signs in MI?

Answer 8

Bradycardic or Tachycardic

Hypotensive or Hypertensive

Question 9

Cardiovascular exam in MI?

Answer 9

MAY BE NORMAL

1. Possible JVD
2. Soft heart sounds
3. transient murmur of MITRAL REGURGITATION
4. S4 gllop

Question 10

What kind of murmur might you hear in someone with acute MI?

Answer 10

Mitral Regurgitation

Question 11

What extra heart sound might you hear in someone w acute MI?

Answer 11

S4 gallop

Question 12

Syndrome which includes pericarditis, fever, leukocytosis, pericardial or pleural effusion that develops 1-2 weeks post-MI

Answer 12

Dressler’s syndrome

Question 13

Fever in MI?

Answer 13

YES - low grade fever may develop after 12 hours and last a few days

Question 14

EKG identification of STEMI

Answer 14

ST-segment elevations of >1mm in TWO contiguous leads

Question 15

Describe the classic progressive changes found in EKG over hours to days in STEMI

Answer 15

Peaked T waves > ST-segment elevations > Q waves > T-wave inversion

not present in all cases of MI!!

Question 16

How would you consider a patient presenting with chest pain and an EKG with ST-segment depression?

Answer 16

Unstable Angina or NSTEMI

Question 17

What would cause you to diagnose this patient with ST-segment depression with NSTEMI?

Answer 17

If cardiac biomarkers become elevated during evaluation

Question 18

How do EKGs of NSTEMI patients develop?

Answer 18

Usually will develop EKG evidence of non-Q-wave MI

25% will develop EKG evidence of Q-wave MI

Question 19

Timing of initial elevation of Troponin T/I?

Answer 19

3-12 hours

Question 20

Peak elevation of Troponin T/I

Answer 20

12-48 hours

Question 21

When should Troponin T/I be measured?

Answer 21

12 hours after onset of pain, then repeated every 8-12 hours

Question 22

Highly sensitive test to quantify extent of infarction?

Answer 22

MRI with gladonium contract

Question 23

What all patients with ACS and ongoing discomfort should receive

Answer 23

IV Fluids
O2
NTG (0.4mg sublingual every 5 mints x3)
Morphine

Oral Beta Blocker within first 24 hours, unless contraindicated (HF, brady, heart block)

Question 24

When is IV NTG indicated?

Answer 24

In first 48 hours for treatment of persistent ischemia, heart failure, or HTN

Question 25

TIMI test for risk (of death) stratification

MACES 65 3+

Answer 25

Thrombolysis In Myocardial Infarction

1 point for each of the following - score 3 or more considered high risk:

1. More than one episode rest angina in past 24 hrs
2. Aspirin within past 7 days
3. Known CAD with stenosis 50%+
4. Elevated cardiac markers
5. ST-segment deviation
6. > 65 years
7. 3+ risk factors for CAD

Question 26

GRACE test prediction

Answer 26

6-month risk of death after discharge

Global Registry of Acute Coronary Events

Age, gender, vital signs, ST-segment changes, historical factors

Question 27

Immediate treatment of STEMi

Answer 27

1. Aspirin and clopidogrel

2. Coronary angiography and Primary PCI (balloon angioplasty / stent) within 90 mins

Question 28

Immediate treatment of UA/NSTEMI

Answer 28

1. Conservative management appropriate for low-risk patients based on TIMI or GRACE scores

• Aspirin and clopidogrel
• Anticoagulation

2. Invasive treatment for high risk patients or patients with progressive symptoms / EKG findings
   - Cardiac catheterization (Angiography, PCI)