Acute Coronary Syndrome

Question 1

Risk factors:

Answer 1

1. Age: M>45, W>55

2. FHx: M60

Question 2

DDx of chest pain:

Answer 2

1. Cardio: angina, unstable angina, MI, coronary vasospasm, valvular dz, thoracic aortic aneurysm, pericarditis
2. Pulm: PE, pneumothorax, cough
3. GI: GERD, esophageal spasm, esophageal rupture, esphagitis, esophageal ulcer, peptic ulcer, hiatal hernia
4. Musculoskeletal: costochondritis, herpes zoster, trauma, vomiting
5. Other: cocaine, anxiety

Question 3

Acute coronary syndrome history:

Answer 3

1: Pain: dull, aching, pressure, squeezing, heaviness

2. Diaphoresis, palpitations, pallor, impending doom

Question 4

Acute coronary syndrome Physical exam:

Answer 4

1. S4, or S3
2. New systolic mitral murmur (papillary)
3. Hypotension
4. Pulmonary edema
5. Oliguria

Question 5

Acute coronary syndrome tests:

Answer 5

1. Troponins

2. ECG

Question 6

Pericarditis history:

Answer 6

1. Pain - worse with lying down, coughing, deep inspiration

2. Pain - better when sitting, leaning forward

Question 7

Pericarditis physical exam:

Answer 7

Pericardial rub

Question 8

Pericarditis tests:

Answer 8

ECG

Question 9

Aortic Dissection history

Answer 9

Pain - tearing, cutting, to mid-back or posterior chest

Question 10

Aortic Dissection physical exam:

Answer 10

1. Unequal BPs in arms

2. Loss of radial/carotid pulses

Question 11

Aortic Dissection Tests:

Answer 11

1. CXR - mediastinal widening
2. angiography
3. Transesophageal echo
4. Helical CT/MRI

Question 12

PE history:

Answer 12

1. Pain - sharp, pleuritic
2. Tachycardia, tachypnea, hypoxia
3. Cough, hemoptysis, dyspnea
4. Syncope - large thrombus

Question 13

PE physical exam:

Answer 13

DVT - erythema, tenderness, unilateral edema, Homan’s sign, palpable cord

Question 14

PE tests:

Answer 14

1. CXR
2. DDimer
3. V/Q perfusion
4. Helical CT

Question 15

Pneumothorax history

Answer 15

Pain - sharp pleuritic

Question 16

Pneumothorax tests:

Answer 16

CXR

Question 17

Panic Attack history:

Answer 17

1. younger age groups included

2. parasthesias, palpitations, fear of going crazy, depersonalization…

Question 18

Cocaine abuse physical exam:

Answer 18

arrythmia

Question 19

Typical Angina definition:

Answer 19

1. Substernal chest discomfort/pressure
2. Provoked by exertion/stress
3. Relieved by rest

Question 20

Atypical Angina definition:

Answer 20

Only 2/3 of:

1. Substernal chest discomfort/pressure
2. Provoked by exertion/stress
3. Relieved by rest

Question 21

Unstable angina Etiology and Features and Duration:

Answer 21

1. Etiology: partial occlusion.
2. Features: New onset, progressive, at rest, in sleep, prolonged
3. Duration: 20-30min

Question 22

EKG changes in unstable angina

Answer 22

ST depression

Question 23

NSTEMI Etiology, EKG changes , and durati onfor Type 1 and 2

Answer 23

Type 1: partial occlusion,
Type 2: demand ischemia

EKG for both: ST depression,
Positive troponins
Duration: 30min- hrs

Question 24

STEMI etiology, EKG changes, duration:

Answer 24

Etiology: Complete occlusion
Positive troponins
EKG: ST elevation AND Q wave.
Duration: 30min- hrs

Question 25

Prinzmental Variant definition, features, EKG changes, duration:

Answer 25

Coronary vasospasm, NOT acute coronary syndrome, typically not caused by atherosclerosis. Occurs at rest EKG: ST elevation Duration: minutes

Question 26

EKG signs: 1. T-wave inversions: 2. T-wave peaking: 3. ST depressions 4. ST elevations 5. Q waves:

Answer 26

1. T-wave inversions: sensitive but not specific for ischemia/infarction 2. T-wave peaking: early sign of ischemia/infarction 3. ST depressions: ischemia 4. ST elevations: injury 5. Q waves: necrotic tissue, may not present until 24-36hrs after

Question 27

First marker for cardiac injury

Answer 27

CK/myoglobin

Question 28

Troponin - sens/spec, abnormal and normal timeframe:

Answer 28

>95%/90 sens/spec >99% MI diagnosis Abnorm 1-8hrs, peak at 24hrs Normal 7-10 days after MI

Question 29

CK-MB - sens/spec, abnormal and normal timeframe:

Answer 29

Lower sens/spec Good for recurrent MI Abnormal 3-8hrs, peak at 24hrs, Normal 2-3 days after MI

Question 30

DDx of high troponin:

Answer 30

ACS/ CAD, demand ischemia, nonischmic injury like myocarditis, toxins, trauma, CKD, PE, HF.

Question 31

CT angiography rules out

Answer 31

ACS, dissection, PE

Question 32

Stress test for

Answer 32

rule out ACS

Question 33

CXR for:

Answer 33

cardiomegaly, CHF, other chest pain cause

Question 34

Echo for:

Answer 34

wall motion abnormalities, valvular abnormalities

Question 35

Medical Treatment for ACS:

Answer 35

1. Anti-coag: LMWH, Heparin 2. Anti-platlet: ASA, clopidogrel (GDP inhibs) 3. Anti-ischemia: Beta-Blocker, Nitroglycerine, Morphine, O2 4. ACE-I/ARB - if MI to decrease cardiac remodeling 5. GP IIB/IIIa inhib (abciximab, eptifibatide, tirofiban) - peri or post percutanous coronary intervention 6. Statin - staring in hospital and continue outpatient

Question 36

Reperfusion Therapy - only for STEMI:

Answer 36

1st line: percutanous coronary intervention (PCI) - door to balloon 90min! 2nd line: tPA withing 30 min! If need to transfer from OSH for : transfer should be

Question 37

MI complications:

Answer 37

0-24hrs: arrythmia, cardiogenic shock, HF, acute valve dysfunction 1-4days: pericarditis 3-14days: Rupture: free wall- tamponade, septum -VSD, papillary - murmur. Pseudoaneuryms - mural thrombus 2-10weeks: Dressler syndrome - immune mediated pericarditis, True aneurysm

Question 38

TIMI Score is:

Answer 38

risk of unstable angina/NSTEMI: chance of death/MI/urgent revasc in 2weeks

Question 39

Factors in TIMI score:

Answer 39

AMERICA: Age>65 - 2pts, >25- 3pts, Markers - positive, EKG - ST changes or LBBB, Risk factors >=3, Ichemia, CAD - known, ASA use in last week. Low risk - 0-2: meds, stress test, coronary angio if +stress test. High risk 3+: meds, coronary angio

Question 40

Patients with sustained Vtach or Vfib need this treatment:

Answer 40

ICD = implantable cardioverter-defibrillator

Question 41

Discharge and followup tests:

Answer 41

Stress test and echo- assess EF for baseline

Question 42

EKG - U waves mean:

Answer 42

hypokalemia

Question 43

Hyperkalemia EKG findings progressively:

Answer 43

peaked T waves -> PR prolongation -> P wave flattening --> QT prolongation --> sine wave

Question 44

EKG findings for hypocalcemia and hypercalcemia:

Answer 44

Hypocalcemia: QT prolongation Hypercalcemia: QT shortening