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ACS Flashcards

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1
Q

Dressler’s

A

Post-infarction pericarditis

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2
Q

Vulnerable plaque

A

large lipid core, thin fibrous cap, increased macrophages, evidence of inflammation

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3
Q

Post lytic cath

A

Resolution of symptoms, improvement of ST-segment elevation by at least 50%, and reperfusion arrhythmias (e.g., accelerated idioventricular rhythm) are indicative of epicardial coronary patency. If there is clinical uncertainty about the status of reperfusion, emergent coronary angiography is warranted (e.g., rescue percutaneous coronary intervention). Most patients following STEMI treated with lytic therapy will undergo elective coronary angiography to define the coronary anatomy within a day of presentation (Class IIa). In high-risk scenarios like shock, heart failure, or recurrent chest pain, urgent coronary angiography is recommended (Class I).

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4
Q

Mortality benefit of radial access

A

STEMI cases ONLY

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5
Q

Definition of MI

A

MI is diagnosed when there is an elevation of cardiac-specific biomarkers >99% above the upper reference limit and at least one of the following: 1) symptoms of ischemia, 2) new or presumed significant ST-segment–T wave (ST–T) changes or new left bundle branch block (LBBB), 3) development of pathological Q waves in the ECG, 4) imaging evidence of new loss of viable myocardium, 5) a new regional wall motion abnormality, or 6) identification of an intracoronary thrombus by angiography or autopsy.

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6
Q

Ischemic Cascade

A

Perfusion defect, diastolic dysfunction, systolic dysfunction, ecg changes, chest pain

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7
Q

Single vessel CAD

A

similar outcomes PCI vs CABG (cabg more stroke less TVR)

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8
Q

Medical Therapy Post STEMI

A

Class I

1) Beta blockade
2) ACEi if AWMI, HF, EF<40%

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9
Q

Coronary Microvascular Dysfunction

A

Coronary Flow reserve <2.5 in setting of normal epicardial coronary vessels= positive coronary microvascular dysfunction
Outcomes of patients with CMD evidence of ishemia on stress test, angina and normal coronaries WORSE than patients without angina

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10
Q

Stress with imaging

A

1) Pre-excitation
2) LBBB
3) paced rhythm
4) >1mm ST depression

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11
Q

Fibrinolytic related hemorrhagic stroke

A

1) cessation lytics
2) Protamine to reverse heparin
3) FFP to give FV,VIII
4) Platelets
5) Prothrombin complex concentrate
6) NSx

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12
Q

MC Complication of Cath

A

Vascular access site complication

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13
Q

CABG

A

Pt with diabetes and significant left main coronary artery disease (=50%) or severe coronary artery disease (=70%) in three major coronary arteries or involving the proximal LAD plus one other coronary artery, coronary artery bypass grafting is the recommended revascularization strategy and has been shown to improve survival but higher CVA risk
Class I to CABG for anginal improvement
IIa - cabg to improve mortality in pt with low EF, severe LV dysfxn, CAD

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14
Q

Viability testing

A

STITCH trial - viability testing didn’t identify patients with a differential survival benefit with CABG

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15
Q

Cocaine or methamphetamine induced MI

A 
Give benzo(ie lorazepam)/nitro
No BB - potentiates coronary vasospasm
NO nifedipine in acute MI
No nitro gtt in patient on sildenafil or viagra
give benzo (lorazepam)

if need BB - labetolol or carvedilol - both alpha AND BB so less coronary vasospasm - no metoprolol

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16
Q

Prasugrel

A

Do not administer prior to cath

Do not give with h/o CVA/TIA

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17
Q

TIMI Risk score

A

Score >=3 benefit early invasive, IIb/IIIa, LMWH
Age ≥65 years.
Presence of ≥3 risk factors for CAD (i.e., diabetes, cigarette smoking, hypertension, hypercholesterolemia, family history of premature CAD).
Known CAD (coronary artery stenosis ≥50%).
Aspirin use in the past 7 days.
≥2 episodes of angina within 24 hours.
ST changes ≥0.05 mV.
Positive cardiac markers.

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18
Q

Grace score

A

Score >140 = early invasive strategy

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19
Q

Low risk patients TIMI<=2

A

Ischemia guided strategy - stress test ok (risk stratification) - stress test before discharge or w/in 72 hrs of d/c as outpatient

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20
Q

Post PCI NSVT w/in 24hrs

A

Reperfusion rhythm - no tx needed

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21
Q

Guideline for revasc of stable angina

A

trial of OMT

2 max tolerated anti-anginals (BB, CCB, long acting nitrates, ranolazine)

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22
Q

Mod to severe ischemia on Nuc

A

> 10% - better with revasc

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23
Q

U/A, NSTEMI - conseravtive tx

A

ASA lifetime
heparin/enox/fonda x up to 8 days
Plavix x (at least 30 days) ideally 1 year

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24
Q

MI VSD

A

Sudden hypotension after late AWMI
New murmur (holosystolic thrill)
best to repair immediately (surgically)

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25
MI Acute MR
less likely with LAD infarct as ANTERLAT PAP has dual blood supply AND would not have murmur as acute MR has rapid equalization of LA/LV pressures Sx flash pulm edema and hypoxia not just hypotension more likely with IWMI - posteromedial pap has single blood supply
26
MI Acute Free wall rupture
``` Late presenting Cx MI or AWMI - first CAD in older Females Effusion on echo muffled heart sounds Clear lungs Inc'd JVP ```
27
RV infarct
usually not late presentation
28
STEMI within 12 hrs
``` Urgent reperfusion therapy PCI/lytics to prevent risk of cardiac rupture Risk factors for ruputure -female, older age, Q waves on ecg, absense of collaterals, no prior h/o MI, HTN, use of steroids or NSAIDs, lytics >14 hours after start of sx ```
29
Timing of free wall rupture
Pre-lytic era - 5 days | Reperfusion era - 48hrs
30
STEMI acute HF
Lasix (since patient needs to lie flat during PCI) DO NOT USE BB (can cause CV shock) No reason for IV ACEi (enalaprit) No lytics if awaiting urgent primary PCI
31
Lytics
>75yo - load 75 plavix then 75 daily with lytics <75yo - load 300 plavix then 75 daily with lytics No enoxaparin as antithrombitc if CrCl<30 (use UFH)
32
RV infarct
``` hypotension after IWMI clear lung fields inc'd JVD evidence of poor perfusion tx - early reperfusion, volume/ionotrope support ```
33
Syntax
Low <22 - same outcomes pCI/CABG Int 23-32 High >33 - lower mortaility with CABG
34
STEMI
FMC to PCI <120 minutes then ASA,plavix tx for PCI | Also transfer if high risk for bleed (ie on coumadin) - less good to do lytics if INR could be elevated
35
Facilitated PCI
Lytics then immediate tx for PCI
36
Selection of Reperfusion strategy STEMI
1) Time from onset sx (w/in 3 hours good for lytics) 2) Risk level of STEMI 3) Risk of bleedign 4) Time to tx to PCI facility 12-24 hrs from sx - transfer for PPCI if HD unstable, sev CHF, HD or electrical instability, persistent ischemic sx >12 Asx - no PPCI PPCI over lytics for high risk STEMI TIMI>5 Pulm edema HD/electrical instability
37
Contraindications to lytics
``` h/o ICH active bleeding suspected Ao Dissection Known cerebrovasc malformation known malignant intracranial neoplasm (primary or metastatic) ```
38
RP Bleed
Tirofiban enhanced effectiveness with dec'd renal fxn No plts with tirofiban or eptifibide (rev binding with plts) Abciximab - irrev binding to plt - need plt tx if bleeding
39
Third universal definition of MI
1) Elevation of troponins | 2) Sx/Si of ischemia (new signficiant ST/T wave changes, new LBBB, new pathologic Q's, new WMA, intracoronary thrombus
40
2nd Universal MI def
Supply demand mismatch (ie hypovolemia, GIB, rapid AF)
41
Type 1 MI
Plaque rupture
42
Dx criteria for STEMI
>2mm V2-3 (1.5 for F) >1mm in other leads Scarbossa concordent ST elev >1mm with LBBB in 2 leads any lead with positive QRS def discordent ST dpression >1mm V1-3 Discordent ST elev >5mm - any lead with neg QRS def
43
SYNTAX study
less TVR in 3vz DM patients with CABG than PCI
44
FREEDOM
DM & MV disease | Lower rate of death, non-fatal MI in CABG
45
Pre-op CV testing
Non-invasive testing should only be performed if a rationale exists to do so independent of pre-op eval OR if fxn status poor or unable to ascertain (cannot walk pre-fem pop ie) TTE for patients with known valve disease if no TTE w/in 1 year Revascularization should only be performed if would be done independent of propopsed non-cardiac surgery
46
Choice of DAPT
Prasugrel - NO if h/o CVA, >75yo, low BMI | Ticagrelor - NO if asthmatic or bradycardia, h/o ICH, liver dysfxn
47
CCTA
high sensitivity and NPV rule out CAD in low to int risk patients DO NOT USE if high pretest prob
48
Bayes theorum
Post test probability of CAD depends on stress results AND pre-test probability (ie neg ECG stress shifts a high pretest patient ie 60yo M Obesity, tob, HTN, HLD with typical angina - little change in probability - still very high...
49
Excercise Treadmill Stress Test
bad for women <60 with NON-anginal pain (low risk) or men >50yo with typical angina
50
Troponin
even if neg in first 6 hours -> trend
51
CPR
Epi then vasopresssin then antiarrythmics (amio) | Vasopressors before antiarrhtymics
52
Stent thrombosis
Resistance to clopidogrel 2/2 inability to convert drug to active form from genetic polymoprhism
53
Angina with CABG (LIMA) and diminished L radial pulse
r/o L SCA stenosis proximal to LIMA Get vertebral artery duplex -> if see reversal of flow then can assume L SCA stenosis Subclavian steal syndrome
54
CT Coronary for stable angina
+LAD - first start meds then consider cath...
55
Post CV arrest
STEMI after return of sponatenous circulation EMERGENCY CATH If NSTEMI with HD/electrical instability -> EMERGENCY CATH Neuro exam post arrest unreliable (improved at 72h hours)
56
STEMI with afib
rate control with BB with HTN crisis or tachyarrythmia NO SHORT ACTING NIFEDIPINE NO CCB if systolic dysfxn NO IBUTILIDE - no need for cardioversion
57
Cocaine induced MI
``` use only carvediolo or labetolol because block catecholamine surge (beta blockade) and prevent coronary vasosapsm (alpha blockade) Use benzo (lorazepam) ```
58
Vorapaxar
PAR-1 inhibitor - thormbin rct on plts - added to DAPT in pts with heart attack/PAD contraindicated with h/o TIA or stroke - excessive risk of intracranial hemorrhage
59
Mechanical complications of MI
Pap muscle rupture - inferior MI and pulmonary edema - no murmur 2/2 sudden equalization of LA/LV pressure - 2-7 days post MI, CV shock VSD - usually AWMI 3-5 days RV infarct - IWMI - clear lung fields
60
Ticagrelor
less stent thrombosis | s/e bradycardia and dyspnea
61
Lipids in ACS
check lipids w/in 24hr | treat with high intensity for all patients with ASCVD <75yo (if >75yo mod intensity)
62
Plaque rupture
inflammation (macrophages) integrity of fibrin cap plaque lipid contnet plaque location
63
Plaque histopathy
1) MMP degrade fibrous cap - plaque reputure 2) Majority of plaque rupture at plaque shoulder - greatest tensile force from blood flow 3) Branch points of coronaries have low shear stress allowing atheroscleortic plque formation and inflitration of monocytes that promote plque rupture 4) Neutrophils/macros - have myeloperoxidase -free radicles that promote inflammation/plque ruputre 5) Coronary calcium found in 80% ruptured plaques
64
Bare metal stent and urgent surgery
need to wait 4 weeks before d/c plavix
65
Ticagrelor
metabol by CYP450 | reduced effect with rifampin,phenytoin, carbamaepine, phenobarbital, dexamethasone
66
Cardiac biomarkers
Use Troponin I | DO NOT USE CK-MB or myoglobin (Class III)
67
Risk scores
Heart - history, ECG, Age, risk factors, troponin ER risk stratification for Chest pain - major events w/in 6 weeks TIMI/GRACE - risk of death/MI in patients with ACS Framingham - risk of MI in 10 years in stable patient
68
high pre-test ACS patient with silent ECG
check posterior leads r/o posterior MI
69
Out of hospital arrest
Class I hypothermia for comatose patients
70
Platelet reactivity testing P2Y12
not indicated (studies inconclusive)

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