Chest Pain and ACS Flashcards
(149 cards)
1
Q
Myocardial necrosis + elevated cardiac enzymes
A
AMI
2
Q
Twp types of AMI
A
STEMI
NSTEMI
3
Q
phrase for either acute myocardial infarction or acute ischemia (unstable angina)
A
acute coronary syndrome
4
Q
chest pain for inadequate myocardial perfusion → angina that is occurring more frequently and non-exertional → no STE or elevated biomarkers
A
Unstable Angina
5
Q
sign often seen in ACS
A
Levine Sign
6
Q
risk factors for CAD
A
SADCHF
smoking, age, DM, cholesterol, HTN, family hx
7
Q
“ABC’s”…
A
immediate needs → airway, breathing, circulation
8
Q
retrosternal, left chest, epigastric pain
A
acute coronary syndrome
9
Q
character of pain associated with ACS
A
crushing, tightness, squeezing, pressure
10
Q
Other symptoms associated with ACS
A
dyspnea
diaphoresis
nausea
11
Q
physical exam findings associatedwith AMI
A
hypotension
diaphoresis
S3 Gallop
12
Q
retrosternal, Left anterior chest pain crush, squeeze, tight, pressure like worse with exertion & better with rest diaphoresis, SOB, nausea lasts 2 - 30 minutes
A
classic chest pain
13
Q
stabbing and well localized
pain that lasts 12 - 24 hours and is constant
positional or worsens with movement
A
Non-classic chest pain
14
Q
Patient with AMI and this particular symptom have 2-4x higher risk of sudden cardiac death
A
dyspnea at rest
15
Q
absence of chest pain despite ischemia → common in diabetics and elderly → atypical or less impressive symptoms
A
silent ischemia “silent MI”
16
Q
Why do diabetics have worse prognosis in relation to MI?
A
2 - 4x greater risk of CAD → diabetes related atherosclerosis affects many systems
17
Q
Other things beside ACS that can cause STE on EKG
A
pericarditis, myocarditis, BER, LVH, ventricular aneurysm
18
Q
Cardiac Biomarker with high sensitivity and specificity
A
Troponin
19
Q
Troponin is specific for ___ but not the ____
A
myocardial necrosis
mechanism
20
Q
what do you want to look at when measuring troponin?
A
trend
21
Q
When is troponin detectable?
When is it most reliable?
A
within 2 - 3 hours
at 6 hours
22
Q
when do troponin levels peak?
A
48 hours
23
Q
How long do Troponin levels remain elevated?
A
up to 10 days
24
Q
small protein in skeletal and cardiac muscle
A
myoglobin
25
how long does it take myoglobin to rise?
3 hours
26
when will myoglobin peak?
4-9 hours
27
when will myoglobin return to baseline?
24 hors
28
When will Creatinin Kinase MC be elevated?
4 - 8 hours
29
When will Creatine Kinase MB peak?
12 -24 hours
30
when will creatine kinase MC return to normal?
36 - 72 hours
31
this scoring system is used to estimate 14 - 30 days mortality of patients
TIMI (Thrombosis in Myocardial Infarction) Score
32
chest pain from inadequate myocardial perfusion → no classic ST changes or elevated biomarkers
unstable angina
33
this occurs at rest, is prolonged lasting usually > 20 minutes
rest angina
34
new chest pain that limits physical acitivty (walking 1-2 blocks or 1 flight of stairs)
New-onset angina
35
Chest pain that has been previously diagnosed, has longer duration and is more frequent
increasing angina
36
How long does angina last and how long does it take to resolve?
< 10 -20 minutes
| resolves within 2 - 5 minutes of rest/nitro
37
EKG findings in the setting of MI symptoms
STEMI
38
No EKG changes + elevated biomarkers
NSTEMI
39
How is unstable angina diagnosed?
based on history → nondiagnostic biomarkers and EKG
40
ST Depression on EKG indicates
ischemia
41
ST Elevation on EKG suggests
transmural injury
42
Leads V1, V2, V3
anteroseptal
43
Leads V1 - V4
anterior
44
Leads V1 - V, I and aVL
anterolateral
45
Leads I and aVL
lateral
46
Leads II, III, aVF
inferior
47
Leads II, III, aVF, V5 , V6
inferolateral
48
depressions and tall R wave in V1 and V2
posterior
49
New LBBB =
STEMI equivalent
50
what are you looking for on EKG?
1 mm STE in 2 + contiguous leads
reciprocal changes
Q waves
51
Wide QRS in V5 - V6
| Deep S in V1 - V2
LBBB
52
rsR' in V1 - V2
| Deep S in V5 - V6
RBBB
53
Things that can interfere with diagnosing a STEMI
```
pre-exisitng LBBB
peri/myocarditis
paced rhythms
hypokalemia
digoxin effect
LVH
```
54
Inverted T waves in V2 and V3
Wellens' Sign
55
T or F: STEMI needs elevated biomarkers to "make the call"
False → STEMI doesn't need elevated markers to diagnose
56
Diagnosis for 2 negative troponins + 2 hours apart + TIMI < 2
exclused MI as diagnosis
57
T or F: elevation of tropin correlates with prognosis
true → more elevated troponin elevation is always worse than less troponin elevation with respect to prognosis
58
Treatment for Chest pain
Aspirin
nitroglycerin
oxygen (if hypoxic)
Morphine
59
Treatment goal for STEMI if your hospital has catheter lab
< 90 minutes
60
mechanical reperfusion for MI
PCI +/- stent
61
pharmacologic reperfusion for MI
fibrinolytic
antiplatelet
antithrombin
62
Treatment goal for STEMI if your facility lacks cath lab
< 120 minutes
63
If you can't meet the 90 and 120 minute timeframes for MI, what do you do?
fibrinolysis within 30 minutes
64
Three agents most STEMI patients receive in the ED
antiplatelet
antithrombin
nitrate
65
Antiplatelet agents commonly used
ASA
clopidogrel
prasugrel
ticagrelor
66
antithrombin agents commonly used
unfractionated heparin
enoxaparin
fondaparinux
67
contraindications to nitrates in STEMI patient
hypotension
inferior STEMI
viagra
68
Treatment for unstable angina/NSTEMI
antiplatelet (ASA, clopidogrel, prasugrel, ticagrelor)
antithrombin (UFH, enoxaparin, fondaparinux)
nitrates (nitroglycerin SL or IV)
69
When would NSTEMI get PCI?
within 24 - 48 hours
70
Preferred reperfusion therapy if less than 90 - 120 minute timeframe
Percutaneous Coronary Intervention (PCI)
71
Indicated for STEMI if time to treatment is < 6 - 12 hours from symptom onset and patient has STE on EKG
TPA [fibrinolytic]
72
When does TPA work best?
early
large infarction
anterior infarction
73
```
prior intracranial hemorrhage
AVM
intracranial neoplasm
ischemic stroke in last 3 months
active bleed
suspected aortic disease or pericarditis
```
absolute CI for fibrinolytics
74
STEMI patient who gets fibrinolytic needs what for at least 48 hours?
full dose anticoagulant (UFH, enoxaparin, fondaparinux)
75
WHAT DO YOU WANT TO GIVE YOUR STEMI PATIENTS ??
aspirin 325 mg ASAP (reduces mortality by 23%)
76
When would you ever hold aspirin in a patient?
severe allergy or active PUD
| give clipidogrel if true allergy
77
this is indicated in patients with ACS → reduces the risk of AMI in unstable angina
Heparin + ASA
78
how should you titrate your nitrate?
titrate to BP not pain reduction
79
How can nitrate worsen infarct in certain instances?
inferior infarct that is volume dependent → hypotension exacerbation
80
This agent is antiarrhythmic + anti-ischemic + antihypertensive
Beta Blocker
81
How is BB helpful?
decreases O2 demand
decreases HR
decreases arterial pressure
decreases myocardial contractility
82
when would you administer BB in STEMI or NSTEMI?
PO metoprolo within 24 hours
83
Contraindications for BB in STEMI/NSTEMI
```
CHF
decrease CO
> 70
BP < 120
HR > 110 or < 60
block
asthma
```
84
this agent reduces left ventricular dysfunction/dilation → slows development of CHF
ACE inhibitor
85
NSTEMI or unstable angina with EF < 40% - give?
ACE inhibitor
86
When would you give ACE for STEMI or HF?
within first 24 hours
87
what do you usually avoid giving a patient after MI?
CCB
88
Coronary vasodilator that suppresses automaticity and protects myocytes → data conflicts on mortality benefit
magnesium
89
what will most patients (72-100%) in CCU have after AMI?
dysrhythmias → A-fib, AV blocks, PVC, V-tach, CHF, pericarditis, papillary muscle rupture, ventricular wall rupture
90
treatment for A-fib in post MI
BB → atenolol or metorpolol
| anticoagulate
91
3rd degree complete heart block usually presents after which two AMI?
anterior
| inferior
92
recommended treatment for 3rd degree heart block
pacing (won't reduce mortality though)
93
this rhythm presents commonly shortly after AMI and is usually transient
ventricular tachycardia
94
which rhythm do you want to avoid delayed treatment?
V-fib
95
HF congestion is commonly caused by
post MI LV diastolic function
96
when will ventricular free wall rupture occur?
1 - 5 days post infarct
97
signs of ventricular free wall rupture
hypotension
tachycardia
confusion
agitation
98
Patient who had MI 2 - 8 days prior now has CP + dyspnea + NEW HOLOSYSTOLIC MURMUR (@ LLSB)
rupture of intraventricular septum
99
Patient had inferior MI 3 - 5 days prior and now has dyspnea + new HF + pulmonary edema + new holosystolic murmur
papillary muscle rupture
100
Patient had AMI 2 - 4 days prior and now has positional CP worse with inspiration and better sitting forward
pericarditis
101
Symptomatic treatment for pericarditis
ASA or cochicine
102
CP + Fever + pleuropericarditis on EKG → last post MI syndrome presenting 2 - 10 weeks after
Dressler Syndrome
103
Treatment for Cocaine or Amphetamine Induced ACS
ASA
nitrates
Benzo
104
what do you avoid with cocaine/amphetamine induced ACS?
BB for 24 hours
105
when would you need emergent treatment for bradycardia?
hypoperfusion/hypotension
106
what is the MC cause of bradycardia?
factors outside the cardiac system (ACS, drugs, hypoxia, etc)
107
this drug enhances the automaticity of the heart and is vagolytic
Atropine
108
SA node fires at < 60 bpm and AV conduction remains intact
sinus bradycardia
109
Prolonged PR (> 200 or 0.2 sec)
first degree block
110
progressive prolongation of PRI then dropped beat → often due to blocked AV node
second degree type I (wenckebach)
111
NO lengthening of PRI → non-conducted beats with P-wave that "march out" → wide QRS
second degree type II (Mobitz II)
112
ventricular reate of 30 - 45 bpm + atria firing at 60 - 100
third degree (complete) block
113
Treatment for tachycardia in stable patients?
| Treatment in unstable patients?
stable → IV meds
| unstable → electrical therapy
114
first step in resolving tachycardia
vagal maneuvers
115
treats tachycardia by blocking AV conduction
adenosine
116
If patient with tachycardia was unstable or fefractory to meds, what do you do?
syncronized cardioversion
117
what should you give patient presenting with A-fib who needs cardioversion - urgent or stable instance?
urgent → heparin before or right after
| stable → anticoag for 3 - 4 weeks then cardiversion
118
first line in rate control for a-fib or flutter
BB or CCV
119
what do you give patients with recurrent paroxysmal atrial fib
flecainide or propafenone
120
which arrhythmia is very responsive to electrical cardioversion ?
atrial flutter
121
when discharging a patient with a fib or flutter what do you want to bridge their anticoag with?
enoxaparin
122
Preferred med for rapid treatment of wide complex tachycardia or new a-fib
amiodarone
123
preferred pharmacologic agent for V-tach if stable and have good LV function
procainamide
124
disorganized depolarizations with no cardiac output → usually ischemic disease +/- AMI
ventricular fibrillation
125
acute elevated BP > 180/120 + end organ damage (brain, aorta, kidneys, eye)
hypertensive emergency
126
Profoundly elevated BP WITHOUT end organ damage
hypertensive urgency
127
Oral therapy for severely elevated BP
labetalol, captopril, losartan, nifedipine, clonidine
128
oral therapy for elevated BP
HCTZ, lisinopril, amlodipine
129
goal of treating high blood pressure
minimize end-organ damage while avoiding hypoperfusion
130
Umbrella term for DVT and PE
venous thromboembolism (VTE)
131
when does thromboembolism occur?
when coagulation exceeds removal by fibrinolysis
132
when will you see PE symptoms?
when 20% of vasculature is occluded
133
dyspnea unexplained by auscultation + pleuritic chest pain + abnormal CXR and EKG + tachycardia + clear lungs + S3 or split S2
PE
134
EKG with sinus tachycardia + S1Q3T3 + RBBB
PE
135
calf pain elicited by passive foot dorsiflexion
Homan's sign
136
pale or white limb as the result of proximal DVT that causes complete obstruction + increased swelling + increased comparement pressure + extreme pain
phlegmasia alba dolens
137
If the leg turns dusky or blue color?
phlegmasia cerulean dolens
138
wedge shape lung oligemia on CXR for PE
Westermark sign
139
peripheral dome shaped dense opacity on CXR
Hampton Hump
140
Treatment for VTE
systemic anticoagulation (UFH, LMWH)
141
isolated calf DVT
LMWH + warfarin
142
only approved fibrinolytic for PE
Alteplace (TPA)
143
two greatest risk factors for occlusive arterial disease
smoking and DM
144
MC location for occlusive arterial disease
femoropopliteal
145
MC cause of 2/3 of all peripheral emboli
A-fib
146
Six Ps of arterial occlusion
Pain, Pallor, Paralysis, Pulselessness, Paresthesia, Polar
147
How is arterial occlusive pain relieved?
hanging feet over the edge of the bed
148
How do you differentiate claudication from occlusion?
acute limb ischemia in claudication is NOT relieved by rest or gravity
149
initial therapy for arterial occlusion
heparin + ASA
