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ACS/AMI IV Flashcards

1
Q

in post-STEMI pt’s, which media indicated for “infarct size limitation?”

A

BB

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2
Q

can you give clopidogrel at the time of PCI?

A

yes

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3
Q

which trial showed a benefit with prasugrel over clopidogrel for CV death/MI?

A

TRITON TIMI 38

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4
Q

which trial showed that ticagrelor pt’s had less IST than clopidogrel?

A

PLATO

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5
Q

When can you give prasugrel after fibrinolytic therapy?

A

After 24h

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6
Q

which trial showed that clopidogrel lowers CV death/MI/urgent revascularization/recurrent ischemia after lytic therapy?

A

CLARITY TIMI 28

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7
Q

what are the Class I recommendations for GP IIbIIIa inhibitors post STEMI and PCI?

A

none

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8
Q

what is the strongest rec class for GPIIBIIIa inhibitor use?

A

Class IIa

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9
Q

if pt is given fibrinoytic Rx for STEMI, how long do you continue A/C for?

A

at least 48h, preferrably for entire hospitalization, or until PCI

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10
Q

which Anticoagulants should you use if need them for >48h

A

lovenox
fondaparinux
(avoid HIT)

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11
Q

what did HORIZONS-AMI trial show for bivalirudin vs hep + GPIIbIIIa inhibitors?

A

that bivalirudin alone decreased 30d mortality and had less major bleeding.

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12
Q

although bivalirudin alone is superior to Hep + GP2b3a, why was there an early hazard with it?

A

due to no preload of thienopyridine

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13
Q

name 5 factors that increase the risk of cardiogenic shock during STEMI

A

age > 70
HR < 60 or HR>110
late stemi
SBP < 120

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14
Q

when are ACEI a Class I rec in AMI?

A

STEMI

AMI w/ EF<40%

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15
Q

list the 5 known mech complications of AMI

A 
shock
RV infarct
free wall rupture
VSD
pap m. rupture
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16
Q

Dr. Killip classification

A

I - no S3 or rales
II- basilar rales not above 1/2 lung fields
III- rales above 1/2 lung fields
IV- cardiogenic shock

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17
Q

Bezold-Jarish reflex

A

HoTN/bradycardia s/p RCA PCI

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18
Q

hemodynamic criteria for shock

A

PCWP > 15

CI < 2.2

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19
Q

what do you have to rule out before diagnosing cardiogenic shock?

A

hypovolemia
brady or tachyarrhythmias
Bezold-Jarish reflex

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20
Q

incidence of cardiogenic shock post MI?

A

10%

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21
Q

mortality of ? in cardiogenic shock with conservative therapy?

A

80%

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22
Q

*does thrombolytic therapy alone in cardiogenic shock improve survival?

A

No!

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23
Q

when is non culprit PCI ok to do?

A

shock

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24
Q

5 causes of cardiogenic shock in Shock Trial Registry (in order of most common to least)

A 
LV failure
Acute MR
VSD
RV infarct
Tamponade
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25
Q

Shock trial results

A

emergency early revasc (PCI or CABG) in AMI and shock reduced mortality by 20% c/t thrombolysis or just medical stabilization at 6 months

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26
Q

in Shock trial, which subset of pt’s did worse with emergency revascularization?

A

age > 75

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27
Q

from the Shock trial, what is the window of time to revascularize in STEMI w/ shock? (Class I)

A

36h

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28
Q

in STEMI and shock, should outside institutions give both thrombolysis and IABP?

A

yes

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29
Q

in whom do you suspect RV infarction?

A

inferioir MI and HoTN

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30
Q

ekg in RV infarction

A

ST elev in V3R and V4R

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31
Q

hemodynamics in RV infarction

A

RA > 12
CI < 2.2
PCWP<12

32
Q

echo findings in RV infarction

A

RV dilation and HK

33
Q

4 PE findings in RV infarction

A

hypotension
JVD (b/c RAP>12)
TR murmur (possible)
clear lungs and CXR

34
Q

RV infarction Rx

A

PCI
IVF’s to PCWP of 18
dobutamine (dopa if BP<90)

35
Q

how long can it take to see signs of RV infarct resolution?

A

2-3d

36
Q

when, after an AMI, does free wall LV rupture occur?

A

two peaks: within 24h and again at 4-7d

37
Q

risk factors for free wall rupture post-MI

A 
steroids
female
large MI w/ minimal salvage (late)
age> 70
HTN during STEMI
38
Q

what is the different in wall composition of true vs pseudo LV aneurysms?

A

true- myocardium

pseudo thrombus and pericardium

39
Q

which is more likely to rupture: true or pseudo LV aneurysm?

A

pseudo

40
Q

does a true LV aneurysm have a high or low risk of rupture?

A

low

41
Q

acute VSD clinical presentation (triad)

A

HoTN
new pan systolic murmur w/ thrill
RV failure

42
Q

2 risk factors for acute VSD

A

transmural MI

HTN

43
Q

swan finding in acute VSD

A

step up in O2

44
Q

true/false: ALL post-MI VSD’s need to be surgically closed

A

true (b/c shear forces can suddenly enlargen it and destabilize)

45
Q

Rx for post-MI VSD

A

IABP and Sx

46
Q

when does post-MI MR occur?

A

within 1 week

47
Q

size of infarct in patients w post-MI pap m rupture/MR

A

can be small

48
Q

does loudness of MR murmur correlate with severity?

A

no

49
Q

how often are thrills present in post-MI MR?

A

rarely

50
Q

clinical hallmark of post-MI papillary m rupture

A

sudden pulmonary edema

51
Q

causes of acute MR post-MI

A

pap m ischemia/fibrosis
pap m rupture (partial or full)
dilation of mitral annulus 2/2 to LV failure

52
Q

which papillary m accounts for 90% of post- MI rupture? which vessel supplies it?

A

Posteromedial

PDA

53
Q

why is rupture of the posteromedial pap m survivable?

A

multiple heads

54
Q

which papillary m accounts for just 10% of post-MI ruptures? what is its blood supply?

A

anterolateral

LAD and LCX

55
Q

on hemodynamics, what is a rare finding that can confuse acute post-MI MR and VSD

A

O2 step up if the MR is transmitted to PA

56
Q

*what are mortality rates, even with Sx, for pap m. rupture?

A

40-90%

57
Q

what is surgical mortality for post MI VSD?

A

50%

58
Q

what is mortality on medical Rx for post-MI VSD, free wall rupture, or pap m rupture?

A

90%

59
Q

4 class I indications for IABP

A

cardiogenic shock
refractory post-MI angina (until revasc)
mech complications post-MI
intractable ventricular arrhythmias w/ hemodynamic instability

60
Q

75-75 rule

A

if a pt is >75 y/o and got lytics, give only 75mg plavix (no load)

61
Q

What is the class I rec for loading dose of Plavix WITHIN 24h after fibrinolytics in age<75?

A

300mg

62
Q

How much Plavix load do you give for PCI >24h after fibrinolytics?

A

600mg

63
Q

Bivalirudin dosing

A

.75mg/kg bolus then 1.75 mg/kg/hr (1mg/kg/h if CrCl<30)

64
Q

Lovenox dosing after fibrinolytic therapy

A

If age >75 : no bolus, .75mg Q12

If age < 75: 30mg IV Bolus, then 1mg/kg Q12

(If CrCl< 30 : 1mg/kg qd)

65
Q

Class I indication for giving eplerenone in STEMI

A

If EF<40% AND HF sxs or DM

66
Q

Ephesus trial showed what as optimal time to start eplerenone post MI to reduce mortality?

A

Within 7 days

67
Q

What are the high dose statins (w/ doses)? How much do they lower LDL by?

A

Atorvastatin 40-80mg
Rosuvastatin 20-40mg

> 50%

68
Q

Are Zocor and Pravachol high dose statins?

A

No

69
Q

Is cardiogenic shock increasing or decreasing in incidence?

A

Decreasing

70
Q

What class rec is IABP in shock post STEMI?

A

IIa

71
Q

Most sensitive ECG findings in RV infarction?

A

> 1mm ST Elev in V1, V4R

72
Q

DDx of RV Infarction

A

PE
constrictive pericarditis
Tamponade

73
Q

Telemetry finding with free wall LV rupture

A

PEA

74
Q

Time frame for post STEMI VSD

A

3-5d (<24h w/ fibrinolytics)

75
Q

Should all post-MI VSDs be closed?

A

Yes

76
Q

What region of myocardium that has a STEMI is most likely to cause acute MR from pap m rupture?

A

Inferior wall

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