Flashcards in ACS Deck (40):
What is the diagnostic algorithm when a pt comes in with chest pain or SOB?
if ECG shows ST elevation, it is STEMI
if ECG shows no ST elevation, it is NSTEACS
if biomarkers are + it is NSTEMI
if biomarkers are - it is more likely to be unstable angina
What is definition of myocardial infarction (diagnostic criteria for STEMI or NSTEMI)?
Rise and fall in cardiac enzymes +/- 1 of:
sx of ischemia
new significant ECG changes/Q waves
imaging showing new wall motion abnormality
WHat type of MI is most common?
Type 1: spontaneous MI
True or False: Isolated troponin elevation is adequate to diagnose myocardial infarction.
FALSE!! ISOLATED TROPONIN ELEVATION IS INADEQUATE TO DIAGNOSE MYOCARDIAL INFARCTION.
What are some cardiac causes of elevated troponin (not MI)
CHF, infection, inflammation, trauma, ablation procedures, malignancy, stress CM, infiltrative diseases
What are some systemic causes of elevated troponin (not MI)
PE, toxicity, trauma, renal failure, sepsis, stroke, SAH
What is the pathological difference underlying NSTEMI vs STEMI?
STEMI - complete arterial occlusion
UA/NSTEMI - still get some patent lumen
What are key features of ruptured and vulnerable plaques?
large lipid core
fibrous cap covering core
What is the clinical presentation of ACS?**EXAM
For what groups may you see an atypical presentation?
severe chest pain at rest/minimal exertion
ischemic discomfort - burning, tightness, heaviness
dyspnea at rest with minimal exertion
epigastric discomfort (back discomfort, arm/neck/jaw/wrist pain)
atypical presentation in young (less than 40), old (greater than 75), diabetics and women
When should you consider urgent reperfusion therapy (ie primary PCI or thrombolytic therapy)?
<12 hours since sx onset + ST elevation or new LBBB
What are two major determinants of extent of MI:
location of occlusion which defines area at risk
severity and duration of myocardial ischemia
True or False :Thrombolytic therapy is superior to PCI.
False. PCI is superior to thrombolytic therapy.
What are agents used for thrombolytic therapy?
reteplase or tenecteplase
What is the aim for door to needle time for thrombolytic therapy?
What is the biggest risk associated with thrombolytic therapy and what are predictors?
old age, female sex, low body weight, htn, prior CVD
What are absolute contraindications to a lytic? **EXAM
Dont Have Vascular BITS
D - dissection (Ao)
H - head injury
V - vascular lesion
B - bleeding
I - ICH
T - tumour
S - stroke within 3 months
When is primary PCI preferred over thrombolytic therapy?
skilled lab available
DTB < 90 min
high risk - cardiogenic shock or HF
contraindication to lytic
late presentation - sx onset > 3 hrs
When is thrombolytic therapy preferred over PCI?
early presentation - 90 minutes
What is rescue PCI?
STEMI pts with continuing or recurrent chest pain and ST elevation despite thrombolysis and who are within 12 hours of sx onset should be considered for rescue PCI
What is immediate ACS therapy?
don't be A NOOB:
A - antithrombotic and antiplatelet therapy
N - nitrates
O - oxygen
O - opiates
B - beta blockers
What is dual antiplatelet therapy?
ASA + P2Y12 receptor agonist (Clopidogrel, Tiacgrelor)
What is the MoA of aspirin? When should it be administered?
blocks formation of TXA2 and platelet aggregation
reduces death and MI
administer when ACS suspected
What are four examples of anti-thrombotic drugs?
What is the MoA of heparin? When should it be administered?
binds to and accelerates effects of anti-thrombin
for pts going to PC lab
What is the rationale for risk stratification in pts presenting with ACS?
selection of site of care
selection of medical therapy
invasive vs conservative management strategy
timing of treatment
What tool is used for risk stratification in pts with ACS?
1. age >/- 65 years
2. 3+ coronary artery disease RFs
3. Prior CAD
4. ASA in the past seven days
5. At least two angina-related events in the previous 24h
6. ST segment elevation
7. Elevated cardiac biomarkers
The higher your score, the greater the all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization through 14 days.
What are indications for CBAG in NSTEMI or STEMI?
complex CAD, especially if LV function is poor
mechanical complications, eg VSD, papillary muscle rupture
cardiogenic shock required ventricular assist device implantation
What are complications of ACS?
mechanical: MR, free wall rupture, VSD
LV aneurysm, pseudoaneurysm
How long do patients continue Aspirin, Clopidogrel/Ticagrelor, BB, Statin, ACE-I post ACS?
Aspirin - lifelong
Clopidogrel/Ticagrelor - 1-12 months post discharge
BB - lifelong if red EF
statin - target LDL < 2mmol/L
ACEI esp if dec EF, htn or diabetes
+ smoking cessation, dietary modification, exercise prescription, Rx of Htn/diabetes
What is the DDX for chest pain?
Cardiac: MI (UA, NSTEMI, STEMI), pericarditis, myocarditis, aortic dissection
Lung: PE, pneumonia, pleuritis, pneumothorax
GI: esophageal spasm, esophagitis, gastritis, ulcer, PUD, GERD, pancreatitis, cholecystitis, colic, choledocholithiasis, cholangitis
MSK: costochondritis, rib fracture, chest wall pain, Herpes zoster
Psych: anxiety, panic disorders, somatoform disorders
An acute coronary syndrome should always be suspected if a patient describes:
>/= 15 minutes of ischemic type chest pain at rest
worsening of previously stable effort angina
<2 months onset of CCS class III or IV angina
What do deep and symmetrical T wave inversion in the precordial leads suggest?
proximal stenosis in LAD
What are the most reliable ECG makers of acute myocardial ischemia?
new ST segment shift and T wave changes
How does ST depression and T wave changes correspond with prognosis?
pts with ST depression have a higher risk of subsequent cardiac events and death than pts with T wave changes who have a higher risk than someone with normal ECG
True or False: The greater ST depression, the worse the prognosis.
What ECG findings are strongly suggestive of ACS?
Inverted T waves
New ST segment depression in two or more contiguous leads
An ACS is most often due to an
acute reduction in myocardial oxygen supply caused by rupture or erosion of an atherosclerotic plaque
less commonly, an ACS is triggered by an oxygen supply/demand mismatch
How can morphine aid in Rx of ACS?
analgesic if pain continues despite nitro
opiates have favourable anxiolytic and vasodilator properties and help to reduce myocardial oxygen demand
How many hours after sx onset before a troponin rise in peripheral blood can be detected