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Flashcards in ACS Deck (40):
1

What is the diagnostic algorithm when a pt comes in with chest pain or SOB?

= ACS
ECG
if ECG shows ST elevation, it is STEMI
if ECG shows no ST elevation, it is NSTEACS
biomarkers
if biomarkers are + it is NSTEMI
if biomarkers are - it is more likely to be unstable angina

2

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
intracoronary thrombus

3

WHat type of MI is most common?

Type 1: spontaneous MI

4

True or False: Isolated troponin elevation is adequate to diagnose myocardial infarction.

FALSE!! ISOLATED TROPONIN ELEVATION IS INADEQUATE TO DIAGNOSE MYOCARDIAL INFARCTION.

5

What are some cardiac causes of elevated troponin (not MI)

CHF, infection, inflammation, trauma, ablation procedures, malignancy, stress CM, infiltrative diseases

6

What are some systemic causes of elevated troponin (not MI)

PE, toxicity, trauma, renal failure, sepsis, stroke, SAH

7

What is the pathological difference underlying NSTEMI vs STEMI?

STEMI - complete arterial occlusion
UA/NSTEMI - still get some patent lumen

8

What are key features of ruptured and vulnerable plaques?

large lipid core
fibrous cap covering core
thrombus

9

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)
N/V
diaphoresis
atypical presentation in young (less than 40), old (greater than 75), diabetics and women

10

When should you consider urgent reperfusion therapy (ie primary PCI or thrombolytic therapy)?

<12 hours since sx onset + ST elevation or new LBBB

11

What are two major determinants of extent of MI:

location of occlusion which defines area at risk
severity and duration of myocardial ischemia

12

True or False :Thrombolytic therapy is superior to PCI.

False. PCI is superior to thrombolytic therapy.

13

What are agents used for thrombolytic therapy?

streptokinase
TPA
reteplase or tenecteplase

14

What is the aim for door to needle time for thrombolytic therapy?

<30 minutes

15

What is the biggest risk associated with thrombolytic therapy and what are predictors?

hemorrhagic stroke
old age, female sex, low body weight, htn, prior CVD

16

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

17

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
questionable Dx

18

When is thrombolytic therapy preferred over PCI?

early presentation - 90 minutes

19

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

20

What is immediate ACS therapy?

don't be A NOOB:

A - antithrombotic and antiplatelet therapy

N - nitrates
O - oxygen
O - opiates
B - beta blockers

21

What is dual antiplatelet therapy?

ASA + P2Y12 receptor agonist (Clopidogrel, Tiacgrelor)

22

What is the MoA of aspirin? When should it be administered?

Cox inhibitor
blocks formation of TXA2 and platelet aggregation
reduces death and MI
administer when ACS suspected

23

What are four examples of anti-thrombotic drugs?

heparin
enoxaparin
fondaparinux
bilvaliruin

24

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

25

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
prognosis

26

What tool is used for risk stratification in pts with ACS?

TIMI score

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.

27

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
failed PCI

28

What are complications of ACS?

HF
cardiogenic shock
arrhythmia
mechanical: MR, free wall rupture, VSD
RV infarct
LV aneurysm, pseudoaneurysm
recurrent ischemia/infarction
pericarditis

29

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

30

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

31

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

32

What do deep and symmetrical T wave inversion in the precordial leads suggest?

Wellens' syndrome
proximal stenosis in LAD

33

What are the most reliable ECG makers of acute myocardial ischemia?

new ST segment shift and T wave changes

34

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

35

True or False: The greater ST depression, the worse the prognosis.

True.

36

What ECG findings are strongly suggestive of ACS?

Inverted T waves
New ST segment depression in two or more contiguous leads

37

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

38

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

39

How many hours after sx onset before a troponin rise in peripheral blood can be detected

3-4 hours

40

What is associated with better outcomes in treatment of NSTEMI: PCI + CABG or conservative management?

PCI + CABG
benefits of an early invasive approach are greatest in the highest risk patients, especially those with elevated troponin and/or ischemic ST depression