IHD ***

Question 1

Criteria for STEMI

Answer 1

ST-elevation in 2 contiguous leads that is:
Men < 40: 2.5 mm ST-elevation in V2 or V3, 1 mm in any other lead
Men > 40: 2.0 mm ST-elevation in V2 or V3, 1 mm in any other lead
Women: >1.5 mm ST-elevation in V2 or V3, 1 mm in any other lead

Question 2

Which ECG leads relate to which part of the heart?

Answer 2

Septal = V1 + V2
Anterior = V3 + V4
Lateral = v5 + v6
Anteroseptal = V1-V4
Anterolateral = V3-V6
Inferior = II, III, aVF

Question 3

RF

Answer 3

Smoking
DM
Obesity
HTN
Lipids
CKD
Inactivity
Age
Fam history

Question 4

Sx + signs

Answer 4

Substernal chest discomfort
Provoked by exertion or emotion
Relieved within 5 mins of rest of GTN spray
SOB, diaphoresis, pre-syncope
Atypical presentation: women, diabetes, elderly
Epigastric pain
Pleuritic CP
SOB
N/V/ belching
Signs: normal exam, hypotension, new S3 gallop, new JVP distension

Question 5

Complications

Answer 5

Cardiac rupture
Arrhythmia
Shock
HTN
HF
Pericarditis
Aneurysm
DVT

Question 6

Ix

Answer 6

ECG (ST elevation or depression, new LBBB, new Q wave)
Labs: trop, CK-MB if <6hrs, CBC, INR, lipids, a1c, LFTs, Cr, lytes
CXR
Stress test
Coronary CT angiography

Question 7

Other causes of high trop

Answer 7

HF, malignancy, pericarditis, PE, renal failure, sepsis, stroke, SAH

Question 8

Reducing risk

Answer 8

Smoking cessation
Diabetes control
Wt loss
Exercise

Question 9

What clinical decision tools are there?

Answer 9

TIMI (thrombolysis in MI)
HEART score (predicts cardiac event)

Question 10

Acute medical mangement

Answer 10

ABCs
- oxygen if sats <92%
ASA 300mg chewable
Nitroglycerin SL 0.4mg 1-2 sprays q5 mins
IV Morphine 3-5mg for pain

PCI within 120 mins:
Ticagrelor 180mg x1 then 90mg BID for 1 yr
Anticoagulant (UFH, enoxaparin) for 48 hrs/ until PCI performed

PCI unavailable, use fibrinolytics:
fibrinolytics - tpa (alteplase)
- clopidogrel PO
- transfer to PCI hospital

BB - start within 24hrs if no HF
ACEi - start within 24hrs if HTN, DM, CKD, STEMI or LVEF <40%

Question 11

Indications for CABG/ PCI in STEMI vs NSTEMI

Answer 11

NSTEMI: in refractory angina, S+S HF, unstable, DM, TIMI >2
STEMI: if onset sx <2 hrs, fibrinolytics 30 mins

Question 12

Longterm medications

Answer 12

GTN spray PRN
BB, CCB 2nd line
Statin (rosuvastatin 20-40mg)
ASA 81mg
ACEi if HF, HTN, DM, CKD, STEMI in anterior location
P2Y12 inhibitor (Ticagrelor) in NSTEMI for 1 yr, stent w/ ACS for 1 yr

Question 13

What monitoring should happen in family office longterm?

Answer 13

Sx control
Med adherence
Impact on ADLs
Lifestyle modifications
Pneumococcal + flu vaccine
Screen for complications
A1c, BP, lipids

Question 14

Criteria for NSTEMI

Answer 14

NSTEMI: + trop, ST depression, new Q wave

Question 15

criteria for unstable angina

Answer 15

Unstable angina: myocardial damage, no ECG or BW changes

Question 16

What are the indications for a 15 lead ECG?

Answer 16

change in ST in V1,V2 or V3
ST elevation in II, III, aVF or I + aVL
MI w/ hypotension