ACS Flashcards
(37 cards)
what are CAD risk factors?
- age > 65
- gender (M>F)
- smoking
- dyslipidemia
- HTN
- DM (CAD equiv)
- central obesity
- fam hx of 1st degree relative w/premature MI (men < 55, women <65)
- cocaine
what is ordered upon initial assessment?
Labs:
- CBC with diff
- BMP
- Troponin I or T
- ± CK/MB <b>(with contemporary troponin assays, CK enzymes and myoglobin are not useful for ACS)</b>
- ± Pro BNP
Diagnostics
-12- lead EKG -<b>DONE WITHIN 10 MINUTES </b>
-CXR - <b>portable AP CXR,
Because it is faster and do NOT have to move an unstable patient</b>
what are the lateral leads in EKG?
I, aVL, V5, V6
what are the inferior leads in EKG?
II, III, aVF
what are the anterior/septal leads?
V1, V2, V3, V4
EKG findings with suspected UA/NSTEMI
- can be normal
- ST depressions or transient ST elevations
new T-wave inversions
- T wave inversion in III is normal variant
- NEW T wave inversion is ALWAYS abnormal
- marked T wave inversion > 2mm = ischemia
how often you do repeat EKG for UA/NSTEMI?
15-30 minute intervals during the first hour
if a patient has continued chest pain despite medications, what do you do?
repeat EKG
what should a pt always have when they are having initial ED intervention for chest pain?
peripheral IV access
initial ED intervention
- peripheral IV access
- continuous telemetry monitoring
- supplemental oxygen (if O2 ≤ 90%)
- meds (MONA)
what are the MONA meds?
Morphine (2-4mgPRN - hold if BP <100/50
Oxygen (if O2 ≤ 90%)
NTG (SL 0.4mg q 5 mins - hold if BP <100/50) - always try NTG first before morphine & don’t combine them
ASA - 162-324mg PO
why don’t you give NSAIDs for ACS instead of NTG?
NSAIDs block endothelial prostacyclin, leads to platelet aggregation b/c of an increase in TXA2
what supplemental EKG leads should you obtain for ACS and why?
Obtain supplemental EKG leads V7 to V9 in patients with initial nondiagnostic ECG at intermediate/high risk for ACS
BNP or NT-pro-BNP may be considered when?
BNP or NT-pro-BNP may be considered to assess risk in patient with suspected ACS
how often do you obtain serial cardiac troponin I or T?
at presentation and 3-6 hours after symptoms onset in all pts with ACS symptoms
if pt has possible ACS but non diagnostic EKG & normal initial cardiac markers, what do you do?
Observe serial EKGs and cardiac markers
- If negative study to provoke ischemia or detect anatomic CAD if negative outpatient f/u
- if positive admit to hospital.
Consider MPI to ID rest ischemia
- If positive admit to hospital
- If negative outpatient f/u
any patient with possible ACS needs what within how many hours?
stress test within 72 hours
what represents high likelihood that si/sx’s represent ACS secondary to CAD?
Hx: chest or left arm pain or discomfort as chief sx, reproducing prior documented angina; known hx of CAD including MI
Exam: transient MR murmur, hypotension, diaphoresis, pulmonary edema, or rales
Cardiac markers: <b>elevated cardiac TnI, TnT or CKMB</b>
what represents intermediate likelihood that si/sx’s represent ACS secondary to CAD?
Hx: chest or L arm pain or discomfort as chief sx, age >70, male sex, DM
Exam:
-fixed q waves, ST depressions or T wave inversion
Cardiac markers: normal
what represents low likelihood that si/sx’s represent ACS secondary to CAD?
Hx: probable ischemic sx in absence of any of the intermediate characteristics, recent cocaine use
Exam: T wave flattening or inversion in leads with dominant R waves or normal EKG
Cardiac markers: normal
HEART risk assessment
History, ECG, Age, Risk Factors, Troponin
- ID’s pts with unknown ACS, probably the best, TIMI #2
- better suited for undifferentiated pt with possible ACS -> CP or angina equivalents
- none talk about discharging the patient from the ED besides HEART
- also the only one that takes into account clinical history
TIMI risk assessment
Thrombolysis in myocardial infarction
- most popular, validated, for people with known hx of ACS
- First widely used and most well known
- Better suited for patients with confirmed NSTEMI or known UA
- Help risk stratify patients with angina sx
GRACE risk assessment
Global Registry of Acute Coronary Events
- not easily done at bedside, COMPLEX
- for pts with CONFIRMED ACS
PURSUIT risk assessment
outdated
