All about the heart

Question 1

ACS definition

Answer 1

Unstable angina through AMI

Question 2

Three principals of UA

Answer 2

At rest, <20 minutes usually
New-onset which limits walking 1-2 blocks or 1 flight of stairs
Diagnosed increasing in frequency or duration or threshold is lower

Question 3

Angina precipitators

Answer 3

Exercise, stress, cold

Question 4

Angina typically lasts

Answer 4

<10 mins, up to 20, improves within 2-5 minutes or after nitro

Question 5

Atypical AMI symptoms

Answer 5

Fat beeties woman

Question 6

S3

Answer 6

Present in 15-20% of AMI, may indicate a failing myocardium

Question 7

TIMI - Thrombosis in Myocardial Infarction

Answer 7

0-2 have 2-9% 30 day risk of death, MI, or revascularization
Age 65+
3 or more traditional risk factors
Prior stenosis of >50%
ST segment deviation
2 or more anginal events in 24 hour prior
Aspirin use within 7 days prior to presentation
Elevated cardiac markers

Question 8

isobar

Answer 8

Introduce
Situation/status
Observations
Background
Actions/assessment
Responsibility

Question 9

AHS inclusion criteria

Answer 9

2mm in at least 2 of V1-V6
1mm in 2 of inferior or V4R
1mm in 2 of V5,V6 aVL
1mm depression V1-V2 and 1mm elevation V8, V9

Question 10

Exclusion criteria (SIBBS)

Answer 10

Structural anomaly of brain vessels
Ischemic stroke within 3 months (except within last 3 hours)
Brain tumor
Brain bleed
Significant closed head or face trauma in 3 months

Question 11

Relative contras ask about

Answer 11

BP, strokes, CPR, surgery in 3 weeks, internal bleeding, non-compressible bleeding from IV attempts
Preggo, active ulcers, pts on coumadin

Question 12

Where da clot?

Elevation III > II plus depression of >1mm in I and or aVL

Answer 12

RCA PPV 94%

Question 13

Where da clot?Elevation III > II plus depression of >1mm in I and or aVL PLUS V1 and or V4R elevation

Answer 13

Proximal RCA PPV 100%

Question 14

Where da clot?

ST elevation in L, aVL, V5 V6 and depression in V1, V2, V3

Answer 14

LCA PPV 91%

Question 15

Where da clot?
Elevation V1, V2, V3 +
>2.5mm V1 and/or RBBB with q wave

Answer 15

Proximal LAD PPV 100%

Question 16

Where da clot?
Elevation V1, V2, V3 +
St depression >1mm in II, III and aVF

Answer 16

Proximal LAD PPV 93%

Question 17

Where da clot?
Elevation V1, V2, V3 +
<1mm depression / elevation in inferior leads

Answer 17

Distal LAD PPV 78%

Question 18

Reciprocal changes

Answer 18

From subendocardial ischemia, means larger area of injury risk, worse underlying CAD, more severe pump failure, increased mortality

Question 19

One of V5, V6, aVL with isoelectric or elevated ST in I

Answer 19

strongly suggestive of left circumflex lesion

Question 20

Tins nitro

Answer 20

WILL dilate atherosclerotic vessels if they have intact vascular smooth muscle
Inhibits platelet aggregation
If not treated with thrombolytics, it will reduce infarct size and improve regional function
Mortality rate is lowered by 35% with nitrates.
SHOULD be titrated to 10% reduction in MAP, or 30% if baseline is hypertensive NOT symptom resolution

Question 21

B blockers in AMI

Answer 21

Antidysrhythmic, anti-ischemic and anti hypertensive properties. Diminish MVO2 from decrease in hrt rate, arterial BP and myocardial contractility. Prolongs diastole for better perfusion

Question 22

When to use B-blockers

Answer 22

Increases risk of cardiogenic shock
Don't give if:
Signs of heart failure
Evidence of low CO
Age over 70, SBP<120, tachy >110 or brady <60

Question 23

Atrial kick in AMI

Answer 23

Normally lose 10-20% CO when kick is eliminated, lose up to 35% with reduced LV compliance when kick is eliminated

Question 24

Sinus tach in AMI

Answer 24

Poor prognosis, common in anterior. Treat anxiety, pain, pump failure etc

Question 25

Complete heart block

Answer 25

Anterior/inferior AMI as RCA and septal perforating branch of LAD supply AV conduction system
15% mortality without RV involvement, 30% with
Poor prognosis is due to how much is involved, not the block itself. Still pace though yo

Question 26

Mortality rates from CO in AMI

Answer 26

10% no heart failure
15-20% mild failure
40% frank pulmonary edema
50-80% cardiogenic shock

Question 27

Ventricular free wall rupture

Answer 27

Pericardial tamponade (90% death rate) 
Severe acute tearing pain. Hypotensive, tachy, possibly confusion and agitation, Becks triad

Question 28

RV infarcation

Answer 28

Usually not isolated to RV
From RCA or if left dominant LCX
Use V4R if inferior 
Right ventricle becomes kinda useless, left ventricle bulges into RV and moves blood that way, so if LV is involved thats pretty fucked up I guess
Tins says 1-2L of fluid

Question 29

Post PCI

Answer 29

Assume chest pain is abrupt vessel closure until proven otherwise, occurs in 4% of pts 2-14 days postprocedure

Question 30

Cardiogenic shock

Answer 30

A combo of damage to myocardium, and inflammatory response which depresses pump function and dilates peripheral vasculature

Question 31

Average ejection fraction

Answer 31

Above 50-55%

Question 32

Virchow’s triad

Answer 32

Hypercoaguability
Hemodynamic changes - stasis/turbulence
Endothelial injury/dysfunction

Question 33

Cardiogenic shock physical presentation

Answer 33

Usually <90SBP (higher if baseline is htn
PP <20
Sinus tach (check if pt is on BB) 
Tachypnea
Rales (unless isolated RV)
JVD
Hepatojugular reflex
Murmur