ACS

Question 1

Define acute coronary syndrome

Answer 1

1. Any constellation of symptoms that are compatible with acute myocardial ischemia
2. Spectrum that includes unstable angina, NSTEMI, and STEMI

Question 2

How does the body respond to damage to the endothelium?

Answer 2

1. Platelets
2. Vasoconstriction
3. Cascade

Question 3

How is ACS diagnosed?

Answer 3

1. History
2. Clinical presentation
3. 12 lead EKG
4. Cardiac injury panel

Question 4

What does an inverted T wave correlate to?

Answer 4

Ischemia

Question 5

Where can you look for the baseline of an EKG?

Answer 5

T-P segment

Question 6

What EKG findings indicate ischemia?

Answer 6

T wave inversion, transient ST elevation or depression

Question 7

How many Unstable angina pts continue on to nstemi/stemi?

Answer 7

The diagnosis of Unstable angina confers a 10-20% risk of MI in the untreated pt

Question 8

What is included in the TIMI score?

Answer 8

1. Age > 65
2. Three CAD risk factors
   A. Smoking, wt, hyperlipidemia
3. ST segment deviation
4. ASA use in past 7 days
5. Positive cardiac enzymes

Question 9

Who are high risk pts?

Answer 9

1. resting angina
2. Resting angina
3. Asst. ekg changes
4. Continued sxs despite initiation of medical therapy
5. TIMI score of >6

Question 10

How is ACS treated?

Answer 10

1. ASA
2. Clopidogrel (plavix): ADP inhibitor
3. Heparin
4. Beta blocker, calcium channel blockers: Blood pressure control
5. Nitro/morphine: pain control
6. Oxygen
7. GP IIb/IIIa antagonists: abciximab

Question 11

What is the dominant coronary artery?

Answer 11

Right coronary artery bc it supplies the SA Node

Question 12

What are the goals of therapy?

Answer 12

1. Prevention of a thrombus
2. Restoration of coronary flow
3. reduction of myocardial oxygen demand

Question 13

What are the indications for CABG?

Answer 13

1. significant left main diz

2. three vessel dz and abnormal LV function (EF

Question 14

How can ACS be prevented?

Answer 14

1. Risk factor modification
A. Smoking cessation
B. HTN control
C. Hyperlipidemia control
D. Wt reduction
E. DM control

Question 15

How should hypovolemia be treated in the context of MI?

Answer 15

FLUIDS - NOT Pressors!!!

Question 16

What is the pathophys of ACS?

Answer 16

1. Thrombus formation is the underlying mechanism.
2. UA/NSTEMI most often represent acute atherosclerotic plaque rupture with exposure of thrombogenic subendothelial matrix. But may also be due to progressive mechanical obstruction from underlying atherosclerotic disease.
3. Causes other than plaque rupture may be due to Vasospasm (Prinzmetal Angina) and Cardiac inflammation or infection.

Question 17

What ekg changes may be seen with classic angina (noninfarction subendocardial ischemia)?

Answer 17

Transient ST depressoins

Question 18

What ekg changes may be seen with noninfarction transmural ischemia?

Answer 18

1. Transient ST elevations

2. Paradoxical T wave normalization, sometimes followed by T wave inversions

Question 19

What ekg changes may be seen with NSTEMI?

Answer 19

1. ST depression
2. T wave inversion
3. No q waves

Question 20

What ekg changes may be seen with STEMI?

Answer 20

1. New q waves preceded by hyperacute T waves/ST wave elevations and followed by T wave inversions

Question 21

What is the timeline for troponin elevations?

Answer 21

1. Troponin T or I levels increase 3-12 hours after the onset of MI
2. peak at 24-48 hours
3. return to baseline over 5-14 days

Question 22

What is the timeline for myoglobin?

Answer 22

1. Myoglobin is not a cardiac marker but is released more rapidly from Infarcted Myocardium than CK-MB or Troponins.
2. It may be detected as early as 2 hours after the onset of MI.
3. Limited use because of brief duration of its elevation (

Question 23

Who are low risk ACS pts?

Answer 23

1. Observation in Chest pain observation unit.
2. If remains pain free, No ECG changes, Negative cardiac markers at 6-12 hours, a stress test can be performed.
3. If stress test is negative manage as outpatient

Question 24

What is the management for intermediate risk pts?

Answer 24

1. Should be admitted to hospital. If symptoms free admit to Telemetry.
2. If remain symptomatic, should be admitted to ICU.

Question 25

What is early conservative therapy for ACS? Who is it for?

Answer 25

1. Medical Therapy at Maximally Tolerated Doses. 2. The Coronary Angiography is reserved for patients with recurrent Ischemia despite Medical Therapy, Strongly Positive Stress Test. 3. Is for low risk patients and selective Intermediate risk patients

Question 26

Who is the early invasive therapy for?

Answer 26

1. High Risk Patients. 2. Recurrent Ischemia despite on Medical Therapy. 3. Evidence of Congestive Heart Failure. 4. LV Dysfunction. 5. Sustained Ventricular Tachyarrhythmia's. 6. Prior Coronary Revascularization (PCI within 6 months or CABG).

Question 27

What is anti-pltlt therapy?

Answer 27

1. Aspirin. All patients should receive Aspirin unless contraindicated. 2. Clopidogrel. 3. Glycoprotein (GP) IIb/IIIa Antagonists

Question 28

What is anti coagulant therapy?

Answer 28

1. Treatment with Heparin has shown to reduce the death or MI by 60 %. 2. Enoxaprin or Intravenous UFH.

Question 29

What is anti-ischemic therapy?

Answer 29

1. Nitroglycerin. 2. B-Adrenergic Blockers. 3. Calcium Channel Antagonists. 4. ACE Inhibitors. 5. Thrombolytic Therapy (Not Indicated for UA or NSTEMI).