Acute coronary syndrome

Question 1

What is myocardial infarction

Answer 1

Cell death of myocytes

Question 2

What are the three main spectrums of Acute coronary Syndromes

Answer 2

Unstable Angina, Non-ST-Elevation Myocardial Infarction, ST-Elevation Myocardial Infarction

Question 3

Why does Nitroglycerin and rest not relieve a person’s symptoms in some ACS cases

Answer 3

There could be complete occlusion of an artery leading to a need of more intense therapy

Question 4

T/F: When a patient enters an emergency department with clinical suspicion of ACS with ischemic symptoms and ECG should be within 10 minutes

Answer 4

True

Question 5

What are the two types of ACSs that can be shown from an ECG

Answer 5

Non-ST-Elevation Myocardial Infarction, ST-Elevation Myocardial Infarction

Question 6

T/F: Non-ST-Elevation Myocardial infarction is highly specific for a hear attack

Answer 6

False: ST-Elevation Myocardial Infarction is high specific for a heart attack. In Non-ST-Elevation Myocardial infarction ischemia is a concern

Question 7

What is the cardiac enzyme that is sensitive to having a heart attack (confirms), how long does it take for the enzymes to show up, how long to peak

Answer 7

Troponin, 4 hours, 1 day

Question 8

What is a spontaneous MI (type 1)

Answer 8

Spontaneous MI due to plaque rupture, thrombus formation, and low blood flow

Question 9

What is a risk calculator used in patients with ACS, what does it asses

Answer 9

TIMI, Death or myocardial infarction within the next 14 days

Question 10

On the TIMI score what events are one point each in the variable “HISTORY”

Answer 10

Greater than or equal to 2 events in the past 24 hours, Known cardiovascular disease, Aspirin use within 7 days

Question 11

On the TIMI score what causes a point to be added in the variable “ECG”

Answer 11

Changes in ST

Question 12

On the TIMI score what causes a point to be added in the variable “Troponin”

Answer 12

Elevated Troponin

Question 13

On the TIMI score what causes a point to be added in the variable “Age”

Answer 13

Age greater than 65 years

Question 14

On the TIMI score what causes a point to be added in the variable “Risk factors”

Answer 14

Having 3 or more risk factors

Question 15

When all the points are compiled for the TIMI score what indicates low risk, intermediate risk, High risk

Answer 15

0-2, 3-4, 5-7

Question 16

T/F: A clinical assessment that includes a physical exam gives evidence on whether a patient has heart failure

Answer 16

True

Question 17

When getting labs what is needed for coagulation profile

Answer 17

INR, PTT

Question 18

When getting labs what is needed for CBC

Answer 18

HgB, Hct, platelets

Question 19

What Chem 7 labs are good for treating a patient

Answer 19

Electrolytes, BUN, Cr

Question 20

What are the treatment goal for ACS

Answer 20

Restore blood flow to limit infarct size if having an MI, prevent/minimize complications, prevent reocculusion, relieve symptoms, resolve ECG changes

Question 21

For patients who are having an acute coronary syndrome what are the treatment considerations (hint:thrombinss)

Answer 21

T: Thinopyridine (P2Y12 inhibitor)
H: Heparin (parental anticoagulant)
R: Renin-angiotensin-aldosterone system inhibitor
O: Oxygen
M: Morphine
B: Beta-blocker
I: intervention (PCI)
N: Nitroglycerin 
S: Salicylate
S: Statin

Question 22

What is the acute supportive care that should be done regardless of whether the patient has a NSTEMI or STEMI

Answer 22

Aspirin: 162 mg - 325 mg IR, Nitroglycerin: 0.3 - 0.4 mg sublingual every 5 minutes as need but up to 3 doses
Oxygen: if O2 saturation is less than 90%

Question 23

What drugs should all patients with ACS have, what is the preferred maintenance dose

Answer 23

Aspirin, 81 mg

Question 24

T/F: Aspirin is contraindicated in patiens using ticagrelor

Answer 24

False: Patients treated with ticagrelor should not use aspirin doses greater than 100 mg daily

Question 25

Why should aspirin tablets be crushed or chewed before eating them for ACS

Answer 25

The patient needs to bypass the enteric coating in order to get immediate release

Question 26

T/F: There is no safety and efficacy data for the use of morphine and oxygen in ACS that has been established

Answer 26

True

Question 27

What is the rationale behind using morphine, when should oxygen be administered in support

Answer 27

Decreases anxiety and calms the patient lowering BP, NTG is not working, IV acts as vasodilator/ When arterial oxygen saturation is less than 90%

Question 28

When nitroglycerin is given IV what determines the titration, how often can this titration occur

Answer 28

Pain relief and BP, every 3-5 minutes

Question 29

How does NTG cause headache

Answer 29

Vasodilation causes pain in the head

Question 30

When should NTG be avoided

Answer 30

The patient has a right ventricular infarct, use of phosphodiesterase inhibitors

Question 31

What phosphodiesterase inhibitors should be avoided with NTG use, how long

Answer 31

Sildenafil (Viagra) and Vardenafil (Levitra) within 24 hours, Tadalafil (Cialis) within 48 hours

Question 32

When should oral beta-blockers be started if a patient is having a ACS event

Answer 32

Within the first 24 hours

Question 33

When should IV beta-blockers be considered

Answer 33

A high blood pressure and high heart rate

Question 34

When should beta blockers be avoided

Answer 34

Acute or Congestive heart failure, older than 70, Systolic BP less than 120 mmHg, Heart rate greater than 110 or less than 60, prolonged time since symptom onset

Question 35

If a patient comes in with STEMI what should be done after the patient has had acute supportive care, how

Answer 35

Initiate reperfusion therapy: Primary PCI preferred, fibrinolysis if the door to balloon time is greater than 120 mins

Question 36

What is the goal for reperfusion in a patient who has a STEMI, why

Answer 36

From door to drug 30 mins (thrombolytics), from door to balloon 90 mins (primary PCI)/ the more time wasted the more heart muscle tissue dies

Question 37

What are two main characteristics a patient must have in order to be an adequate patient for fibronyltics

Answer 37

History of acute coronary syndrome presenting with symptoms within 12 hours of the symptom onset, EKG shows there is an ST elevation

Question 38

T/F: Only consider fibronolytics if the patient has the two main indications and cannot recieve a PCI within one hour

Answer 38

False: Only consider fibronolytics if the patient has the two main characteristics and cannot recieve a PCI within two hours