3 Acute Coronary Syndrome, part 1 Flashcards
Remarks on bradycardia in ACS
- Bradycardic rhythms are more common with INFERIOR wall myocardial ischemia
- In the setting of an acute ANTERIOR wall infarction, bradycardia or new heart block is a poor prognostic sign
remarks on a new systolic murmur in ACS
The presence of a new systolic murmur is an ominous sign because it may signify
- papillary muscle dysfunciton
- flail leaflet of the MV with resultant MR
- VSD
Remarks on the ACS spectrum
STEMI is based on the ECG,
NSTEMI is based on cardiac biomarkers,
and unstable angina is based on history.
All in the setting of symptoms suggestive of ACS.
The single best test to identify patients with AMI upon ED presentation
12-lead ECG
Ideally obtain ECG within 10 minutes of presentation in those patients with symptoms suggestive of myocardial ischemia.
ECG findings of a true posterior MI
Initial R waves in V1 and V2 >0.04 s and R/S ratio ≥1;
Right-sided ECG shows 0.5-mm ST elevation in V7-V9
A posterior wall infarction does not produce Q-wave abnormalities in conventional leads and is diagnosed in the presence of tall R waves in V1 and V2
ECG findings of RV MI
ST elevation in II, III, and aVF
ST depression in lateral leads
ST elevation in RV leads V3R-V6R
ST-segment elevation in _____ is highly suggestive of right ventricular infarction
V4R
This finding predicts a right coronary artery occlusion in inferior wall AMIs
presence of STE in in lead III greater than that in lead II
ECG findings for anterior STEMI
from proximal LAD
STE in V1, V2, and V3 plus
STE of >2.5 mm in lead V1, or RBBB with Qwave, or both; or
ST-segment depression of >1 mm in leads II, III, aVF
ECG findings for anterior STEMI
from distal LAD
STE in V1, V2, and V3 plus
≤1 mm STdepression in leads II, III, aVF,
or STE in II, III, aVF
Findings that are suggestive of AMI in ECGs with LBBB
Concordant STE (strongly suggestive of AMI)
Concordant ST-segment depression (suggestive of AMI)
Excessive (>5 mm)) discordant STE (weakly suggestive of AMI)
[Sgarbossa criteria]
remarks on LBBB in ACS
Recognizing STEMI in the presence of LBBB is difficult, and due to this uncertainty and false catheterizaiton lab activation, new or susptected new LBBB alone has been removed from the most recent recommendations for emergency perfusion.
What matters in patients with LBBB is the presence of history suggestive of ACS.
ECG findings of Wellens’ syndrome
Deeply inverted or deep biphasic T waves
most prominent in V2 and V3,
often in V1 and V4,
and occasionally in V5 and V6
Significance of Wellens’ syndrome
Assoc’d with critical stenosis of LAD
Considered an ACS equivalent
Because of the high incidence of critical coronary stenosis and the potential for acute infarction, patients with Wellen’s syndrome should receive early interventional management
Chest pain in Wellen’s syndrome
T waves of Wellens’ syndrome are usually visible when the patient is pain free and may normalize when pain recurs
- repeating the ECG when pain resolves or recurs can aid in detection of tehse dynamic changes
