ACS/AMI IV Flashcards Preview

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Flashcards in ACS/AMI IV Deck (76):
1

in post-STEMI pt's, which media indicated for "infarct size limitation?"

BB

2

can you give clopidogrel at the time of PCI?

yes

3

which trial showed a benefit with prasugrel over clopidogrel for CV death/MI?

TRITON TIMI 38

4

which trial showed that ticagrelor pt's had less IST than clopidogrel?

PLATO

5

When can you give prasugrel after fibrinolytic therapy?

After 24h

6

which trial showed that clopidogrel lowers CV death/MI/urgent revascularization/recurrent ischemia after lytic therapy?

CLARITY TIMI 28

7

what are the Class I recommendations for GP IIbIIIa inhibitors post STEMI and PCI?

none

8

what is the strongest rec class for GPIIBIIIa inhibitor use?

Class IIa

9

if pt is given fibrinoytic Rx for STEMI, how long do you continue A/C for?

at least 48h, preferrably for entire hospitalization, or until PCI

10

which Anticoagulants should you use if need them for >48h

lovenox
fondaparinux
(avoid HIT)

11

what did HORIZONS-AMI trial show for bivalirudin vs hep + GPIIbIIIa inhibitors?

that bivalirudin alone decreased 30d mortality and had less major bleeding.

12

although bivalirudin alone is superior to Hep + GP2b3a, why was there an early hazard with it?

due to no preload of thienopyridine

13

name 5 factors that increase the risk of cardiogenic shock during STEMI

age > 70
HR < 60 or HR>110
late stemi
SBP < 120

14

when are ACEI a Class I rec in AMI?

STEMI
AMI w/ EF<40%

15

list the 5 known mech complications of AMI

shock
RV infarct
free wall rupture
VSD
pap m. rupture

16

Dr. Killip classification

I - no S3 or rales
II- basilar rales not above 1/2 lung fields
III- rales above 1/2 lung fields
IV- cardiogenic shock

17

Bezold-Jarish reflex

HoTN/bradycardia s/p RCA PCI

18

hemodynamic criteria for shock

PCWP > 15
CI < 2.2

19

what do you have to rule out before diagnosing cardiogenic shock?

hypovolemia
brady or tachyarrhythmias
Bezold-Jarish reflex

20

incidence of cardiogenic shock post MI?

10%

21

mortality of ? in cardiogenic shock with conservative therapy?

80%

22

*does thrombolytic therapy alone in cardiogenic shock improve survival?

No!

23

when is non culprit PCI ok to do?

shock

24

5 causes of cardiogenic shock in Shock Trial Registry (in order of most common to least)

LV failure
Acute MR
VSD
RV infarct
Tamponade

25

Shock trial results

emergency early revasc (PCI or CABG) in AMI and shock reduced mortality by 20% c/t thrombolysis or just medical stabilization at 6 months

26

in Shock trial, which subset of pt's did worse with emergency revascularization?

age > 75

27

from the Shock trial, what is the window of time to revascularize in STEMI w/ shock? (Class I)

36h

28

in STEMI and shock, should outside institutions give both thrombolysis and IABP?

yes

29

in whom do you suspect RV infarction?

inferioir MI and HoTN

30

ekg in RV infarction

ST elev in V3R and V4R

31

hemodynamics in RV infarction

RA > 12
CI < 2.2
PCWP<12

32

echo findings in RV infarction

RV dilation and HK

33

4 PE findings in RV infarction

hypotension
JVD (b/c RAP>12)
TR murmur (possible)
clear lungs and CXR

34

RV infarction Rx

PCI
IVF's to PCWP of 18
dobutamine (dopa if BP<90)

35

how long can it take to see signs of RV infarct resolution?

2-3d

36

when, after an AMI, does free wall LV rupture occur?

two peaks: within 24h and again at 4-7d

37

risk factors for free wall rupture post-MI

steroids
female
large MI w/ minimal salvage (late)
age> 70
HTN during STEMI

38

what is the different in wall composition of true vs pseudo LV aneurysms?

true- myocardium
pseudo thrombus and pericardium

39

which is more likely to rupture: true or pseudo LV aneurysm?

pseudo

40

does a true LV aneurysm have a high or low risk of rupture?

low

41

acute VSD clinical presentation (triad)

HoTN
new pan systolic murmur w/ thrill
RV failure

42

2 risk factors for acute VSD

transmural MI
HTN

43

swan finding in acute VSD

step up in O2

44

true/false: ALL post-MI VSD's need to be surgically closed

true (b/c shear forces can suddenly enlargen it and destabilize)

45

Rx for post-MI VSD

IABP and Sx

46

when does post-MI MR occur?

within 1 week

47

size of infarct in patients w post-MI pap m rupture/MR

can be small

48

does loudness of MR murmur correlate with severity?

no

49

how often are thrills present in post-MI MR?

rarely

50

clinical hallmark of post-MI papillary m rupture

sudden pulmonary edema

51

causes of acute MR post-MI

pap m ischemia/fibrosis
pap m rupture (partial or full)
dilation of mitral annulus 2/2 to LV failure

52

which papillary m accounts for 90% of post- MI rupture? which vessel supplies it?

Posteromedial
PDA

53

why is rupture of the posteromedial pap m survivable?

multiple heads

54

which papillary m accounts for just 10% of post-MI ruptures? what is its blood supply?

anterolateral
LAD and LCX

55

on hemodynamics, what is a rare finding that can confuse acute post-MI MR and VSD

O2 step up if the MR is transmitted to PA

56

*what are mortality rates, even with Sx, for pap m. rupture?

40-90%

57

what is surgical mortality for post MI VSD?

50%

58

what is mortality on medical Rx for post-MI VSD, free wall rupture, or pap m rupture?

90%

59

4 class I indications for IABP

cardiogenic shock
refractory post-MI angina (until revasc)
mech complications post-MI
intractable ventricular arrhythmias w/ hemodynamic instability

60

75-75 rule

if a pt is >75 y/o and got lytics, give only 75mg plavix (no load)

61

What is the class I rec for loading dose of Plavix WITHIN 24h after fibrinolytics in age<75?

300mg

62

How much Plavix load do you give for PCI >24h after fibrinolytics?

600mg

63

Bivalirudin dosing

.75mg/kg bolus then 1.75 mg/kg/hr (1mg/kg/h if CrCl<30)

64

Lovenox dosing after fibrinolytic therapy

If age >75 : no bolus, .75mg Q12

If age < 75: 30mg IV Bolus, then 1mg/kg Q12

(If CrCl< 30 : 1mg/kg qd)

65

Class I indication for giving eplerenone in STEMI

If EF<40% AND HF sxs or DM

66

Ephesus trial showed what as optimal time to start eplerenone post MI to reduce mortality?

Within 7 days

67

What are the high dose statins (w/ doses)? How much do they lower LDL by?

Atorvastatin 40-80mg
Rosuvastatin 20-40mg

> 50%

68

Are Zocor and Pravachol high dose statins?

No

69

Is cardiogenic shock increasing or decreasing in incidence?

Decreasing

70

What class rec is IABP in shock post STEMI?

IIa

71

Most sensitive ECG findings in RV infarction?

>1mm ST Elev in V1, V4R

72

DDx of RV Infarction

PE
constrictive pericarditis
Tamponade

73

Telemetry finding with free wall LV rupture

PEA

74

Time frame for post STEMI VSD

3-5d (<24h w/ fibrinolytics)

75

Should all post-MI VSDs be closed?

Yes

76

What region of myocardium that has a STEMI is most likely to cause acute MR from pap m rupture?

Inferior wall