ACS lecture

Question 1

Define ACS STE

Answer 1

STEMI – myocardium damaged confirmed by elevated troponins and STE on EKG

Question 2

What are the 2 kinds of ACS NSTE? Define each

Answer 2

Unstable angina – chest pain at rest with possible EKG changes at rest BUT no elevated troponins
NSTEMI – myocardial damaged confirmed by elevated troponins and EKG changes w/out STE

Question 3

Describe the burden of disease of ACS

Answer 3

1) > 7 million globally / year
2) All cardiovascular disease is still leading cause of morbidity and mortality in USA
-STEMI responsible 30% of cases
-NSTE ACS remaining 70 %

Question 4

List the common risk factors of ACS

Answer 4

1) Age 65 +
2) Current smoker
3) HTN, DM, hyperlipidemia
4) Elevated BMI
5) Significant + FHx of CAD
-Male < 55 y/o
-Female < 65 y/o

Question 5

What are the most common symptoms of ACS?

Answer 5

1) Acute chest pain – 1% of OP visits, 5% of ER visits/year
-incl. pressure
2) Referred pain - radiation to jaw or arms
3) Visceral afferent – GI
4) Sympathetic discharge – diaphoresis, tachycardia

Question 6

What are some symptoms less likely to be ACS?

Answer 6

CP induced with palpation, varies with breathing or position

Question 7

What is the pathophys of ACS?

Answer 7

Myocardial ischemia
Other – coronary artery spasm and/or dissection

Question 8

Define the layers of the heart

Answer 8

1) Epicardium = Visceral pericardium = where coronary arteries course
2) Myocardium
3) Endocardium & subendocardium

Question 9

Give the OLDCARTS for ACS

Answer 9

CC: chest discomfort
-Onset: acute
-Location: substernal
-Duration: persistent, progressive
-Character: Crushing, pressure, need to belch
-Aggravated: exertion
-Alleviate: rest
-Radiate: 1 or both jaws, shoulders, upper arms
-Timing: often in the morning or during activity (snow shoveling), symptoms usually constant
-Associated symptoms: nausea, emesis, diaphoresis, belching, palpitations
-Severity: varies

Question 10

With ACS, _____________ are more likely to experience accompanying nausea, radiation to shoulders, and dyspnea or just fatigue

Answer 10

women

Question 11

65 + and patients with _______ are more likely to report dyspnea rather than CP as initial symptom as well as vague abdominal pain

Answer 11

DM

Question 12

ACS: ______ is most common for both men and women

Answer 12

CP

Question 13

List some life threatening causes of CP

Answer 13

Dissection of Aortic Aneurysm
Emboli - PE
ACS
Tension Pneumothorax
Hole in GI tract
Esophageal rupture
Perf PUD

Question 14

Give some cardiovasc DDxs for chest pain

Answer 14

CAD – ischemia
Non-CAD
Aortic dissection
Myocarditis
Pericarditis

Question 15

Give some pulmonary DDxs for chest pain

Answer 15

PE
Tension pneumothorax
PNA
Pleuritis

Question 16

Give some psych DDxs for chest pain

Answer 16

Depression, anxiety, etc.

Question 17

Give some MSK DDxs for chest pain

Answer 17

Cervical disc
Costochondritis
Fibromyalgia
Herpes Zoster (prior to rash)
Neuropathic pain
Rib injury/fracture
Sternoclavicular arthritis

Question 18

Give some GI DDXs for chest pain

Answer 18

1) Biliary
Cholangitis
Cholecystitis
Choledocholithiasis
Biliary colic
2) PUD
Non-perforated
perforated
3) Esophageal
Esophagitis
Spasm
Reflux
Rupture
4) Pancreatitis

Question 19

Describe EKGs (for all pts with potential cardiac chest pain)

Answer 19

1) Clinically, if ACS suspected – STAT transfer over performing EKG
2) 12 lead EKG
3) Evidence of ischemia:
-Hyperacute T waves - first few minutes
-ST segment & T wave changes
-Q wave
4) EKG findings that may obscure ischemic EKG changes – LBBB, delta wave, ventricular pacing

Question 20

What are the diagnostic studies for ACS

Answer 20

1) High sensitivity cardiac troponins
-Organ specific, NOT disease specific biomarker
-ER - serial measurements as levels may take several hours to elevated
2) Imaging: CXR, CT chest, POCUS – mainly to consider alternative Dx

Question 21

______________ injury = elevated troponin

Answer 21

Myocardial

Question 22

Give some examples of non-ischemic causes of elevated cardiac enzymes

Answer 22

UA
HF
Myocarditis
Rapid A. Fib or any tachycardia (SVT, WPW)
PE
Proximal Aortic Dissection
Chronic and Acute renal disease
Sepsis

Question 23

When should you suspect/ Dx ACS?

Answer 23

History/Exam
EKG changes
Troponin elevation

Question 24

Describe coronary angiography for ACS mgmt

Answer 24

1) View the anatomy of the coronary arteries
-PCI = percutaneous coronary intervention
-coronary ballon angioplasty
-coronary stent placement
-DES = drug eluting stent

Question 25

Describe the initial mgmt of ACS outside hospital setting or enroute to ER

Answer 25

162-325 mg ASA PO Supplemental oxygen if pulse ox < 90% SL NTG, 0.4mg PRN chest pain if no contraindications Contraindications: hypotension, inferior or posterior MI (right ventricle involvement)

Question 26

What was the old mnemonic for ACS mgmt?

Answer 26

MONA Morphine for pain, dyspnea, anxiety, pulmonary congestion Oxygen Nitroglycerin Aspirin

Question 27

Describe pharmacologic mgmt of ACS

Answer 27

1) Usually a DES placed if balloon angioplasty performed followed by DAPT Rx 2) Parental anticoagulant prior to and after PCI -Unfractionated heparin, LMW heparin 3) On D/C from hospital = DAPT continued usually for ~ 1 year

Question 28

~ 10% patients with ACS have concomitant ____________

Answer 28

atrial fibrillation

Question 29

How do you Tx ACS with AFIB?

Answer 29

Long term oral anticoagulation (OAC) typically needed + DAPT Increased risk of bleeding Recommendations changing/vary

Question 30

Describe Dual antiplatelet therapy for stents

Answer 30

1) ASA 81 mg daily 2) DES -Clopidogrel (Plavix) 75 mg qd -Ticagrelor (Ticlid) 90 mg bid -Prasugrel 10 mg qd (not if h/o CVA or increased bleed risk)

Question 31

Describe which patients with ACS should get which parts of the pharmacologic mgmt

Answer 31

1)Statin therapy: all patients, high intensity 2) Cardioprotective B-blockers: all patients 3) SGLT-2 inhibitors: all patients 4) SL NTG PRN -- 5) ACEi: most patients -- 6) GLP-1 agonist: if patient has DM 7) GDMT: for HTN, DM, HFrEF

Question 32

Describe non pharmacologic mgmt for ACS

Answer 32

Smoking cessation Immunization encouraged Cardiac rehabilitation – PT directed initially

Question 33

Describe the long term effects of ACS

Answer 33

10% experience depression – SNRI, SSRI Up to 20% experience future ACS events within 4 years

Question 34

All NSAIDs, incl. Cox 1 & Cox 2 inhibitors, have an increased risk of ______ events in at risk patients

Answer 34

CVD

Question 35

Cox-2 inhibitors: ____________________was taken off the market in 2004 because of post marketing evidence of increased cardiovascular adverse events

Answer 35

Rofecoxib (commonly known as Vioxx)

Question 36

Describe Echo to evaluate LV function after ACS

Answer 36

HFrEF = increased mortality Wait ~ 14 days to allow for myocardium recovery (stunned myocardium) Detects complications – VSD, LV thrombus, LV aneurysm, acute MR

Question 37

Describe when to do stress tests post-ACS

Answer 37

1) No revascularization – prior to d/c if no angina or HF 2) Revascularization – wait ~ 4-6 weeks post d/c