Acute Coronary Syndrome

Question 1

What are the initial treatments for an individual with chest pain in the ED?

Answer 1

1. STAT EKG
2. Oxygen
   3.ASA- 75-325 chewed or suppository
3. NTG- sublingual 0.4mg x3 doses or gtt (ensure not right sided because of decreased preload)
4. Morphine 2-4mg Q5-15
   6 labs- CBC, CMP, Cardiac enzymes, coags

Question 2

Name the cardiac bio markers from most to least specific-

Answer 2

Triponin
CK-MB
Myoglobin

Question 3

What are the elevation times for the cardiac enzymes

Answer 3

Myoglobin- 1-4hrs

CK-MB - 3-12hrs

Troponin - 3-12 hours, elevated for 7-10 days

Question 4

What are some other causes for an elevated troponin?

Answer 4

Sepsis
PE
Rhabdo
Renal failure
Burns
Aortic dissection

Question 5

An elevation in leads V5, V6, AVL, and 1 are caused by what?

Answer 5

A lateral infarction. Usually the circumflex artery

Question 6

An elevation in leads 2,3 and AVF are caused by what?

Answer 6

An inferior MI usually the RCA

Question 7

An elevation in leads V2 and V3 is indicative of what?

Answer 7

A septal MI, often the LAD

Question 8

An elevation in leads V2, V3, V4 is indicative of what?

Answer 8

An anterior MI, often the LAD

Question 9

T inversions are indicative of what?

Answer 9

Ishemia

Question 10

ST elevations are indicative of what?

Answer 10

Cardiac injury

Question 11

Q waves are indicative of what?

Answer 11

Infarct

Question 12

If a patient has a highly TIMI score (4-7). This is indicative that why intervention needs to be done

Answer 12

The patient would benefit from PCI

Start them on a IIb/IIIa inhibitor (Integrilin)

Question 13

Integrilin should be given when?

Answer 13

Pre and post PCI patients

Question 14

STEMI criteria includes:

Answer 14

1. ST elevations in 2 continuous leads
2. New LBBB
3. ST depression in 2 or more precordial leads
4. ST depression w/ ST elevation in AVR- may indicate LAD or LM occlusion

Question 15

Treatments for patients after MI

Answer 15

Beta blocker ( decreased cardiac events)
ACEI (helps with remodeling)

Plavix
ASA
Statin

Question 16

Fibrinolytic therapy relative contraindications include:

Answer 16

Severe HTN >180/110
Current Anticoagulant use w/ INR > 2.5
Known bleeding
No compressible vascular puncture
Major sx or trauma (to include cpr)
Pregnancy

Question 17

What makes angina stable?

Answer 17

Follows a predictable pattern; like pain on exertion

Question 18

What makes angina unstable?

Answer 18

Intermittent; occurs more, at rest, varies from its usual pattern

Question 19

Prinzmetals angina is what?

Answer 19

Epicardial coronary vasospasms

Question 20

Post-infarct angina is what?

Answer 20

Angina that occurs 24hours to 30 days after an Mi

Question 21

What classifies a NSTEMI or Unstable angina?

Answer 21

T inversions
ST depressions
ST wave changes w/ out pain

Question 22

What is the treatment of a NSTEMI?

Answer 22

Aspirin
Nitroglycerin 
Plavix
Beta blockers
ACEI- if BP still elevated after BB and nitro
Statin
Echo 
IIb/IIIa of going to PCI

Question 23

At what point would you send an NSTEMI patient to the catch lab?

Answer 23

Worsening or persistent symptoms or recurrent ischemia

Widespread EKG abnormalities

CHF

VTach

Prior CABG or PCI (within the last 6 months)

Depressed LV function

+cardiac markers

Hemodynamics instability

Question 24

What should you expect post MI if patient has experienced acute deterioration and new mitral regurgitation with s/s of HF

Answer 24

Papillary muscle rupture

Question 25

What are S/S of cardiogenic shock?

Answer 25

``` Hypotension Tachycardia Oliguria Pulmonary congestion Crackles Cool extremities ```

Question 26

What is the treatment for cardio genic shock?

Answer 26

``` Ventilation IVF Sodium bicarbonate gtt for metabolic acidosis ASA IV heparin IIb/IIIa inhibitor PA catheter Inotropes Levophed ```

Question 27

What are signs of right ventricular failure?

Answer 27

``` JVD Hypotension Lungs CTA Peripheral edema Hepatomegally ```

Question 28

What is the treatment for right heart failure?

Answer 28

``` IVF Meds to decrease afterload: Milronone, dobutamine Oxygen Coronary reperfusion Transcutaneous pacing ```

Question 29

Dressler's syndrome is what?

Answer 29

Pericarditis post MI

Question 30

What do you not give/do for right heart failure

Answer 30

No decreasing preload-- No nitrates or diuretics

Question 31

What are symptoms of pericarditis?

Answer 31

Progressively worsening chest pain especially when supine Friction rub Global ST elevations

Question 32

What is the treatment for pericarditis?

Answer 32

ASA, colchicine and steroids

Question 33

At discharge all ACS/MI patients should get what 5 things?

Answer 33

ASA BB Statin ACEI (if LV dysfunction) Smoking cessation