ACS, Stable Angina and Aortic Dissection

Question 1

Definition of acute coronary syndrome

Answer 1

Unstable angina, NSTEMI or STEMI

*NOT stable angina

Question 2

New onset angina at rest or minimal exertion
Angina accelerating in frequency or severity
Normal ECG or ST depression, T-wave inversion
Normal cardiac enzymes

Answer 2

Unstable angina

Question 3

ST depression and/or T-wave inversion

Abnormal cardiac enzymes

Answer 3

NSTEMI

Question 4

ST elevation
Abnormal cardiac enzymes
or
New LBBB or posterior MI

Answer 4

STEMI

Question 5

Most common cause of death in the united states

Answer 5

CAD

Question 6

Atherogenic risk factors

Answer 6

• Low HDL (<40 mg/dL)
• High LDL
• High VLDL

Question 7

Who are silent (painless) AMIs more common in?

Answer 7

Elderly, women, diabetics

Question 8

Classic components of angina pectoris (3)

*actually memorize

Answer 8

1. Substernal chest pain/discomfort
2. Provoked by exertion or emotional distress
3. Relieved by rest or nitroglycerin

Question 9

Typical angina presents with how many of the following components?

1. Substernal chest pain/discomfort
2. Provoked by exertion or emotional distress
3. Relieved by rest or nitroglycerin

Answer 9

3/3

Question 10

Atypical angina presents with how many of the following components?

1. Substernal chest pain/discomfort
2. Provoked by exertion or emotional distress
3. Relieved by rest or nitroglycerin

Answer 10

2/3

Question 11

Non-angina chest pain presents with how many of the following components?

1. Substernal chest pain/discomfort
2. Provoked by exertion or emotional distress
3. Relieved by rest or nitroglycerin

Answer 11

1-0/3

Question 12

Evaluates contractility of the heart

Assesses regional wall motion abnormalities (RWA) as hypokinesis, akinesis, dyskinesis, or normal

Answer 12

Dobutamine Stress ECHO

Question 13

Test used to asses for how much of a coronary artery is occluded

Answer 13

Coronary angiography

*>70% = significant stenosis

Question 14

STEMI ECG criteria

Answer 14

ST elevation > 2mm in continuous leads or new LBBB

*Can not diagnose STEMI when there is known/old LBBB

Question 15

Differences in blood flow in STEMI vs NSTEMI

Answer 15

STEMI = complete occlusion of blood flow

NSTEMI = partial occlusion of blood flow, or complete occlusion in presence of collateral circulation

Question 16

Initial treatment and management of stable angina

Answer 16

Aspirin, B blocker, nitroglycerin, statin

Question 17

If stable angina is no relieved by initial treatment (Aspirin, B blocker, nitroglycerin, statin) then what?

Answer 17

add Ca channel blocker or long acting nitrate

Question 18

If stable angina is not relieved by Aspirin, B blocker, nitroglycerin, statin; and the addition of a Ca blocker or long acting nitrate, then what?

Answer 18

Consider ranolazine, refer for coronary angiography

Question 19

Coronary artery bypass graft (CABG) indications

Answer 19

• 3 vessel disease >70% stenosis
• Left sided (primarily)
• LV dysfunction

Question 20

Initial management for all patients presenting with ACS

Answer 20

MONA (morphine, oxygen, nitrates, aspirin)

Question 21

In a patient presenting with ACS, what else can be done in addition to MONA?

Answer 21

Dual anti-platelet therapy (DAPT)

ASA and P2Y12 inhibitor (clopidogrel, ticagrelor)

Question 22

Drugs shown to improve mortality in MI (3)

Answer 22

ASA, B blockers, ACEi

Question 23

Treatment and management of STEMI

Answer 23

PCI (percutaneous coronary intervention aka stent) <90 min

• or transfer to PCI capable hospital in <120 min
• or administer thrombolytics <30 min then transfer to PCI capable hospital

Question 24

In the event of unstable angina or NSTEMI,

This score system predicts risk of 14 day death, recurrent MI, or urgent revascularization

Answer 24

TIMI score

Question 25

ECG leads showing ST elevations Coronary artery involved Inferior MI

Answer 25

II, III, aVF | RCA

Question 26

ECG leads showing ST elevations Coronary artery involved Septal MI

Answer 26

V1-V2 | LAD

Question 27

ECG leads showing ST elevations Coronary artery involved Anterior MI

Answer 27

V2, V3, V4 | LAD

Question 28

ECG leads showing ST elevations Coronary artery involved Lateral MI

Answer 28

V5, V6 or I, aVL | LCX

Question 29

ECG leads showing ST elevations Coronary artery involved Posterior MI

Answer 29

Tall R waves and ST depression in V1, V2, V3 RCA in right dominant LCX in left dominant

Question 30

Complication of MI that presents as pericarditis

Answer 30

Dressler syndrome * weeks to months later * autoimmune

Question 31

Classification systems for aortic dissection (2)

Answer 31

Debakey, Stanford

Question 32

The following are risk factors for what diagnosis? ``` Long term HTN Smoking Dyslipidemia Marfan Bicuspid aortic valve Giant cell arteritis Takayasu arteritis Syphilis Deceleration trauma ```

Answer 32

Aortic dissection

Question 33

Pathogenesis of aortic dissection

Answer 33

Intimal tear allows blood to penetrate the vessel wall and dissect the intima away, creating an intimal flap *creates a false lumen within the tunica media for blood to flow into

Question 34

Imaging study used to diagnose aortic dissection

Answer 34

CT angiography

Question 35

Treatment and management for aortic dissection

Answer 35

- Anti-impulse therapy: B blockers and vasodilators to lower BP and HR - Opiates for pain control - Refer to surgery

Question 36

Type A aortic dissection mortality vs management type (medical intervention vs surgery)

Answer 36

Surgical management = higher survivability in type A *Type A for Ascending aorta

Question 37

Type B aortic dissection mortality vs management type (medical intervention vs surgery)

Answer 37

Medical management = higher survivability in type B * Type B for descending aorta * Type B also has higher survival rate overall