ACS/AMI IV

Question 1

in post-STEMI pt’s, which media indicated for “infarct size limitation?”

Answer 1

BB

Question 2

can you give clopidogrel at the time of PCI?

Answer 2

yes

Question 3

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

Answer 3

TRITON TIMI 38

Question 4

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

Answer 4

PLATO

Question 5

When can you give prasugrel after fibrinolytic therapy?

Answer 5

After 24h

Question 6

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

Answer 6

CLARITY TIMI 28

Question 7

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

Answer 7

none

Question 8

what is the strongest rec class for GPIIBIIIa inhibitor use?

Answer 8

Class IIa

Question 9

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

Answer 9

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

Question 10

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

Answer 10

lovenox
fondaparinux
(avoid HIT)

Question 11

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

Answer 11

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

Question 12

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

Answer 12

due to no preload of thienopyridine

Question 13

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

Answer 13

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

Question 14

when are ACEI a Class I rec in AMI?

Answer 14

STEMI

AMI w/ EF<40%

Question 15

list the 5 known mech complications of AMI

Answer 15

shock
RV infarct
free wall rupture
VSD
pap m. rupture

Question 16

Dr. Killip classification

Answer 16

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

Question 17

Bezold-Jarish reflex

Answer 17

HoTN/bradycardia s/p RCA PCI

Question 18

hemodynamic criteria for shock

Answer 18

PCWP > 15

CI < 2.2

Question 19

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

Answer 19

hypovolemia
brady or tachyarrhythmias
Bezold-Jarish reflex

Question 20

incidence of cardiogenic shock post MI?

Answer 20

10%

Question 21

mortality of ? in cardiogenic shock with conservative therapy?

Answer 21

80%

Question 22

*does thrombolytic therapy alone in cardiogenic shock improve survival?

Answer 22

No!

Question 23

when is non culprit PCI ok to do?

Answer 23

shock

Question 24

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

Answer 24

LV failure
Acute MR
VSD
RV infarct
Tamponade

Question 25

Shock trial results

Answer 25

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

Question 26

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

Answer 26

age > 75

Question 27

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

Answer 27

36h

Question 28

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

Answer 28

yes

Question 29

in whom do you suspect RV infarction?

Answer 29

inferioir MI and HoTN

Question 30

ekg in RV infarction

Answer 30

ST elev in V3R and V4R

Question 31

hemodynamics in RV infarction

Answer 31

RA > 12 CI < 2.2 PCWP<12

Question 32

echo findings in RV infarction

Answer 32

RV dilation and HK

Question 33

4 PE findings in RV infarction

Answer 33

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

Question 34

RV infarction Rx

Answer 34

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

Question 35

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

Answer 35

2-3d

Question 36

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

Answer 36

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

Question 37

risk factors for free wall rupture post-MI

Answer 37

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

Question 38

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

Answer 38

true- myocardium | pseudo thrombus and pericardium

Question 39

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

Answer 39

pseudo

Question 40

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

Answer 40

low

Question 41

acute VSD clinical presentation (triad)

Answer 41

HoTN new pan systolic murmur w/ thrill RV failure

Question 42

2 risk factors for acute VSD

Answer 42

transmural MI | HTN

Question 43

swan finding in acute VSD

Answer 43

step up in O2

Question 44

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

Answer 44

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

Question 45

Rx for post-MI VSD

Answer 45

IABP and Sx

Question 46

when does post-MI MR occur?

Answer 46

within 1 week

Question 47

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

Answer 47

can be small

Question 48

does loudness of MR murmur correlate with severity?

Answer 48

no

Question 49

how often are thrills present in post-MI MR?

Answer 49

rarely

Question 50

clinical hallmark of post-MI papillary m rupture

Answer 50

sudden pulmonary edema

Question 51

causes of acute MR post-MI

Answer 51

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

Question 52

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

Answer 52

Posteromedial | PDA

Question 53

why is rupture of the posteromedial pap m survivable?

Answer 53

multiple heads

Question 54

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

Answer 54

anterolateral | LAD and LCX

Question 55

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

Answer 55

O2 step up if the MR is transmitted to PA

Question 56

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

Answer 56

40-90%

Question 57

what is surgical mortality for post MI VSD?

Answer 57

50%

Question 58

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

Answer 58

90%

Question 59

4 class I indications for IABP

Answer 59

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

Question 60

75-75 rule

Answer 60

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

Question 61

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

Answer 61

300mg

Question 62

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

Answer 62

600mg

Question 63

Bivalirudin dosing

Answer 63

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

Question 64

Lovenox dosing after fibrinolytic therapy

Answer 64

If age >75 : no bolus, .75mg Q12 If age < 75: 30mg IV Bolus, then 1mg/kg Q12 (If CrCl< 30 : 1mg/kg qd)

Question 65

Class I indication for giving eplerenone in STEMI

Answer 65

If EF<40% AND HF sxs or DM

Question 66

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

Answer 66

Within 7 days

Question 67

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

Answer 67

Atorvastatin 40-80mg Rosuvastatin 20-40mg > 50%

Question 68

Are Zocor and Pravachol high dose statins?

Answer 68

No

Question 69

Is cardiogenic shock increasing or decreasing in incidence?

Answer 69

Decreasing

Question 70

What class rec is IABP in shock post STEMI?

Answer 70

IIa

Question 71

Most sensitive ECG findings in RV infarction?

Answer 71

>1mm ST Elev in V1, V4R

Question 72

DDx of RV Infarction

Answer 72

PE constrictive pericarditis Tamponade

Question 73

Telemetry finding with free wall LV rupture

Answer 73

PEA

Question 74

Time frame for post STEMI VSD

Answer 74

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

Question 75

Should all post-MI VSDs be closed?

Answer 75

Yes

Question 76

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

Answer 76

Inferior wall