NSTEMI, STEMI, Cardiac Shock

Question 1

Initial steps in management of CP include:

Answer 1

M, O, N, A

ECG
Labs

Question 2

P2Y12 inhibitors to know (2)

Answer 2

Clopidogrel

Ticagrelor

Question 3

When should GpIIB/IIIA inhibitors be given?

What are some? (3)

Answer 3

In high risk NSTE-ACS

Tirofiban
Eptifibatide
Abciximab

Question 4

2 common drugs used in anti-coagulation therapy

Answer 4

IV heparin

Enoxaparin

Question 5

Patients who are risk for MI should receive:

Patients who are low risk:

Answer 5

PCI

Stress test

Question 6

In what cardiac event should a fibrinolytic/thrombolytic absolutely NOT be given?

When is it OK?

Answer 6

ACS w/o ST elevation

Beneficial in STEMI

Question 7

3 pieces of the “mainstays” of treatment of NSTE-ACS:

Answer 7

Anti-platelet therapy
Anti-coagulation therapy
Coronary intervention

Question 8

4 ECG changes w/ STEMI

Answer 8

ST elevation
Peaked T waves
Q waves
T wave inversion

Question 9

What are lab findings in a STEMI?

Answer 9

Cardiac enzymes might be OK if presenting early enough. They can become positive by 4-6 hrs.
Troponin can be elevated for 5-7 days.

Question 10

Management of a patient with a STEMI (3)

Answer 10

Aspirin
P2Y12 inhibitors
Reperfusion therapy (PCI or thrombolytics)

Question 11

What must be the door to balloon time for PCI?

Answer 11

90 min or less

Question 12

If the patient presents to a hospital without PCI abilities, how long do they have to transfer them?

Answer 12

120 min, PCI is still preferred to thrombolytics

Question 13

When would you use thrombolytics in a patient with STEMI?

Answer 13

If there is not PCI abilities within 120 min away

Question 14

Absolute C/I for thrombolytic therapy (6)

Answer 14

Previous hemorrhagic stroke
Other strokes within 1 year
Intracranial neoplasm
Head traume
Active internal bleed
Aortic dissection

Question 15

Patients being discharged post STEMI should be given which meds?

Answer 15

BB

ACE-I/ARB

Question 16

Post MI complications (5)

Answer 16

Post infarct ischemia
Arrhythmias
RV infarct
Mechanical complications
Myocardial dysfunction

Question 17

When is post infarct ischemia seen? (2)

Answer 17

After thrombolytic therapy for STEMI

After NSTEMI treated medically

Question 18

Treatment for post infarct ischemia

Answer 18

Vigarous medical therapy

If refractory, should undergo early coronary angiography and revascularization

Question 19

Kinds of arrhythmias seen post MI (4)

Answer 19

Sinus bradycardia
SVT including AFib
Conduction problems
Ventricular arrhythmias

Question 20

When is sinus bradycardia seen mostly?

Answer 20

After an inferior MI or w/ meds

Question 21

SVT and AFib should be treated with:

Answer 21

Metoprolol or CCBs
Can do a cardioversion if pt. is hemodynamically unstable
Amiodarone if the patient is in HF

Question 22

1st degree AV block

Answer 22

Most common, no Tx

Question 23

2nd degree AV block (Mobitz type 2) - Wenckebach

Answer 23

Transient and usually no Tx unless symptomatic

Question 24

Complete AV block

Answer 24

More common in inferior MI which may be transient

Prognosis with anterior MI is worse, as it is a sign of significant infarct and needs permanent pacing

Question 25

Hemodynamically significant ventricular arrhythmias (VT/VF) should be treated with: What about hemodynamically stable ventricular tachy?

Answer 25

Prompt defibrillation Anti-arrhythmic (Amiodarone)

Question 26

Rv infarct occurs in a 1/3 of... What does it present with? What should be avoided? What suggests Dx? Treat with:

Answer 26

Inferior MIs Hypotension with normal Lv function, elevated JVP and clear lungs Avoid VDs including NTG ST elevation in right anterior leads IV fluids

Question 27

Lv aneurysms occurs in...

Answer 27

Completed infarctions

Question 28

Pericarditis is treated with...

Answer 28

High dose aspirin

Question 29

Mural thrombus occurs most in... What is the Tx?

Answer 29

Large anterior infarctions Anti-coagulation therapy

Question 30

Myocardial dysfunction presents with... What should you do? Acute LV failure presents with:

Answer 30

Hypotension not responsive to fluid resuscitation, refractory HF or cardiogenic shock Urgent echo: RV, LV and r/o mechanical complications Pulm edema

Question 31

Cardiogenic shock is defined as: Does it respond to fluids? What should be done if that is the Dx? How is LV function usually?

Answer 31

Systolic Bp < 90 mmHg and signs of diminished perfusion Does not respond to fluids Urgent coronary angio, revascularization and possible placement of intra-aortic balloon pump LV function is usually moderately to severely reduced

Question 32

What is the treatment for cardiogenic shock? What is the prognosis?

Answer 32

If not as sick, give IV diuretics Give inotropic support with dobutamine, NE or dopamine Poor, 30 day mortality is 40-80%

Question 33

Hypovolemic shock How does it occur? Tx?

Answer 33

Decreased intravascular volume secondary to loss of blood/fluids Blood loss or dehydration Replete intravascular vol

Question 34

Obstructive shock causes

Answer 34

Cardiac tampanade Tension PTX Massive PE Underlying cause should be treated

Question 35

Most common type of shock is....

Answer 35

Distributive shock

Question 36

Septic shock requirements What causes it?

Answer 36

Fluid-unresponsive hypotension (SBP < 100 mmHg) Serum lactate > 2 mmol/L Need for vasopressors to keep MAP above 65 mmHg G+ or G- orgs

Question 37

Tx for septic shock

Answer 37

Initial resuscitation Ventilation Cardiac monitoring IV access and fluid restriction

Question 38

Hemodynamic measurements in cardiogenic shock (5)

Answer 38

Reduced CO, CI | Elevated SVR, CVP and PCWP

Question 39

Hemodynamic measurements in septic shock (5)

Answer 39

CO and CI increase first, but in severe cases they can be lowered due to myocardial depression Low SVR, CVP and PCWP.

Question 40

Mainstay of therapy in septic and hypovolemic shock: What else should be done?

Answer 40

Vol replacement Vasoactive therapy w/ NE or dopamine, vasopressin. Early treatment with empiric broad IV abx.

Question 41

What areas of the heart are supplied by which vessels?

Answer 41

LAD - apex, LV anterior wall, anterior 2/3 of septum RCA - RV free wall, LV posterior wall, posterior 1/3 of septum LCX - LV lateral wall