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Cardiology 1 > ACS/MI/Angina > Flashcards

ACS/MI/Angina Flashcards

1
Q

Ischemia def

A

lack of O2 or blood flow

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2
Q

Infarction def

A

death of tissue, results from prolonged ischemia

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3
Q

Myocardial infarction

A

Heart attack

- cardiac myocyte death secondary to ischemia

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4
Q

Angina

A
  • chest pain due to ischemia

- usually result of atherosclerosis / coronary artery disease

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5
Q

Coronary Artery Disease (CAD)

-predominant cause

A

atherosclerotic plaque formation and subsequent rupture

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6
Q

Two types of thrombi

A
  • white: platelets and plaques

- red: platelets, fibrin, RBC

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7
Q

Occlusion type

  • unstable angina
  • NSTEMI
  • STEMI
A
  • Unstable angina: partial, white thrombus
  • NSTEMI: partial of large artery or total occlusion of small vessel
  • STEMI: total occlusion, red thrombus
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8
Q

Two general types of risk factor for CAD

A

modifiable

non-modifiable

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9
Q

Modifiable risk factors for CAD

A
  • diet
  • exercise
  • smoking
  • ETOH
  • dyslipidemia
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10
Q

Non-modifiable risk factors for CAD

A
  • age (men> 45 women>55)
  • gender
  • family hx
  • personality type (??? like type A?)
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11
Q

suspected ACS labs

  • general term
  • 4 examples
A

cardiac biomarkers

  1. Troponin
  2. CK
  3. CKMB
  4. Myoglobin

*not actually enzymes but often called cardiac enzymes

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12
Q

What are cardiac biomarkers

A

cardiac injury = cellular disruption, loss of intracellular components which are called biomarkers

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13
Q

What is the basis for dx of ACS in the ER

A

cardiac biomarkers

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14
Q

Troponin

A
  • important regulatory component in cardiac muscle
  • most specific and sensitive biomarker for cardiac tissue
  • if test is negative and within correct timing, very likely pt does not have disease (specific)
  • if test is positive, pt very likely to have dz (sensitive)
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15
Q

Two types of troponin tested and what is difference

A
  • Troponin T
  • Troponin I
  • typically only affect reference ranges
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16
Q

Sensitive troponin tests

A

higher threshold than ultra-sensitive tests for detection and time to detection

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17
Q

Ultrasensitive troponin tests

A

lower threshold for detection and early time to detection

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18
Q

Troponin

  • time to rise
  • time to peak
  • time to norm
A
  • 3-6 hours
  • 12 hours
  • 10 days
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19
Q

What should you monitor if mildly positive troponin

A

the change over time, 90-120 minutes in ER

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20
Q

if have sx suggestive of ACS for not long but no troponin yet does negative troponin mean no ACS?

A

NO - just might not be detectable yet

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21
Q

Why is troponin not a great option to monitor for re-infarctions

A

bc stays elevated for days

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22
Q

CK

A

Creatinine phosphokinase

  • skeletal muscle, heart, brain
  • lacks specificity due to multiple locations
  • multiple reasons for elevation
  • scott calls it a worthless test
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23
Q

CK timing

A
  • time to rise: 3-4 hrs
  • time to peak: 12 hours
  • time to normalization: 3-4 days

*almost the same as CKMB

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24
Q

CKMB

A
  • isoenzyme of CK
  • more specific to myocardium
  • multiple reasons for elevation
  • scott calls it a worthless test
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25
Q

CKMB timing

A

Time to rise: 3-4 hrs
Time to peak: 12-24 hrs
Time to normalization: 3-4 days

*almost the same as CK

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26
Q

Myoglobin

A
  • heme protein rapidly released from damaged m tissue
  • non-specific to heart
  • not used anymore in ER
  • might be more useful monitoring post MI patients bc of faster time to normalization
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27
Q

Myoglobin timing

A
  • Time to rise: 2-4 hours
  • Time to peak: 12-24 hrs
  • Time to normalization: 24-36 hrs
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28
Q

what is the gold standard in evaluation of chest pain

A
  • EKG

* always get EKG and CXR for pt with chest pain in ED

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29
Q

Standard of care timing EKG for pt with chest pain

A

within 10 minutes of arrival to ER

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30
Q

Definition of ST elevation/depression

A

> 1 mm above or below isoelectric line

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31
Q

what is T wave inversion a characteristic sign of

A

myocardial ischemia

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32
Q

Where is isolated T wave inversion a normal variant?

A

Flipped T in 3 is Free

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33
Q

What is a new onset of LBBB synonymous with?

A

acute MI until proven otherwise (would want to compare with old EKGs if possible)

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34
Q

Pathological Q waves

  • sign of what
  • due to what?
A
  • sign of previous myocardial infarction

- result of absent electrical activity bc there is scarring

35
Q

does absence of pathological Q wave = no infarction?

A

no

36
Q

What is the gold standard treatment of STEMI and NSTEMI

A

PCI - percutaneous coronary intervention

37
Q

3 PCI examples

A
  • angioplasty
  • balloon angioplast
  • arteriography
38
Q

uses for PCI

A
  1. evaluate presence of blockages

2. used to re-vascularize ischemic vessels

39
Q

Gold standard timing for PCI in ED for STEMI

A
  • 90 min door to needle

- from time pt checks in

40
Q

timing for PCI with NSTEMI

A
  • within 24 hours of presentation

- some critical its will qualify for fast intervention

41
Q

cardiac stress testing

- when used

A
  • diagnostic and prognostic tool

- evaluate its with known or suspected CAD/IHD (ischemic heart disease)

42
Q

Indications for cardiac stress testing

A
  • gender
  • age
  • sx: SOB, DOE, stable angina, etc.
43
Q

Two main types of stress testing

A
  1. exercise stress test

2. pharmacologic stress testing

44
Q

Exercise stress testing

A
  • run/bike with simultaneous EKG
  • look for EKG changes indicative of ischemia
  • limited if pt can’t move at moderate pace
45
Q

Pharmocologic stress testing

A
  • meds used to stress the heart

- adenosine, dobutamine, atropine, etc.

46
Q

Two scoring systems often used to evaluate ACS/MI

A
  • HEART score

- TIMI score

47
Q

HEART score category names

A 
History
EKG
Age
Risk Factors
Troponin
48
Q

History HEART score

A
  • highly suspicious
  • moderate suspicious
  • slightly suspicious
49
Q

EKG HEART score

A
  • significant ST depression
  • non specific
  • normal
50
Q

Age HEART score

A
  • > 65
  • 45-65
  • <45
51
Q

Risk factors HEART score

A
  • > 3 factors
  • 1 to 1 factors
  • No risk factors
52
Q

Troponin HEART score

A
  • > 3X normal limit
  • 1-3X normal
  • Normal
53
Q

HEART final score three categories

A
  • 0-3: early discharge and f/u
  • 4-6: admit for observation and serial enzymes
    7-10: aggressive tx and possible PCI
54
Q

TIMI scoring categories

A

one point for:

  • Age
  • ASA use
  • 2 episodes of angina
  • ST changes
  • elevated biomarkers
  • Known CAD
  • > RF
55
Q

UA

A

unstable angina

  • present at rest
  • no EKG changes or elevation in troponin
56
Q

NSTEMI

A
  • angina at rest

- does have ischemic EKG findings and/or elevation of troponin

57
Q

True/false: treatment of UA and NSTEMI is the same

A

true

58
Q

what percent of MIs occur >65 yo

A

60-65%

59
Q

Atypical sx of elderly and women

A

usually non-specific:

  • weakness
  • nausea
  • vomiting
  • dizzy
  • abd pain
  • HA
  • neck pain
60
Q

OPQ for NSTEMI/UA

A

O: gradual onset, can be sudden
P: pain worse with activity
Q: discomfort/pressure vs. pain. crushing, burning, tightness, squeezing

61
Q

RST for NSTEMI/UA

A

R: to epigastrium, shoulders, arms, neck, lower jaw
S: site is diffuse, typically not just one spot
T: brief 5-15 min

62
Q

Scott’s tx of NSTEMI/UA

A
  1. nitroglycerin
  2. Oxygen IF hypoxic (SpO2 <92%)
  3. Fentanyl/Dilaudid
  4. Antithrombotic
63
Q

When should avoid nitro

A

inferior right ventricular MI bc can cause hypotension/cardiogenic shock

64
Q

Why avoid morphine

A

CRUSADE study indicates 30% higher adjusted mortality (Dr. Letassy says the study’s results aren’t strong - observational retrograde etc.)

65
Q

Two main types of antithrombotic therapy

A

Antiplatelets

Anticoagulation

66
Q

What meds should be started within 24 hours of admission for UA/NSTEMI

A

beta-blockers

statins

67
Q

What is NOT indicated to tx NSTEMI/UA

A

fibronolytics (are indicated in STEMI if PCI is not available per Dr. Letassy)

68
Q

STEMI def

A

ST elevation MI

- MI leads to development of full thickness cardiac muscle death = ST elevation on EKG

69
Q

STEMI sx

A

same as UA/NSTEMI

70
Q

Labs for STEMI

A

Cardiac biomarkers

71
Q

when is PCI preferred tx of STEMI

A
  • older
  • high bleeding risk
  • fibrinolytic contraindications
72
Q

What is timing of fibrinolytics for STEMI

A

30 minutes from identification of STEMI

73
Q

What is complication of re-perfusion?

A

re-perfusion arrhythmia

  • looks like v-tach or wide-complex arrhythmias
  • unless pt is unstable, don’t shock/tx
74
Q

Prinzmetal

A

vasospastic angina

  • episodes of angina at rest
  • promptly resolve with nitrates
75
Q

dx criteria for Prinzmetal

A
  • nitrate responsive angina
  • transient EKG changes
  • angiographic evidence of coronary artery spasm
76
Q

Prinzmetal S&S

A

same as ischemic chest pain

- most events at rest/early am

77
Q

Prinzmetal EKG

A
  • transiet ST seg elevation
78
Q

Prinzmetal labs

A

cardiac biomarkers can be elevated, depends on length of episode

79
Q

Prinzmetal stress test

A

normal non-invastive stress test

80
Q

Prinzmetal tx

A
  • lifestyle modification (smoking cessation)
  • Calcium channel blockers
  • long acting nitrates
  • others (mg, statins, rho kinase inhibitors)
81
Q

Stable angina

A
  • ischemic chest pain occurs predictably and reproducible at certain level of exertion
  • resolved with nitroglycerin
82
Q

Stable angina S&S

A

same as all the other except resolves with rest

83
Q

Stable angina lab/radiographic testing

A
  • stress testing and coronary angiography will ID blocked arteries
84
Q

Stable angina tx

A
  • acute: nitro

- chronic: ASA, beta blocker, Calcium channel blocker, long acting nitrates

Cardiology 1 (11 decks)

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