STEMI/NONSTEMI

Question 1

cardinal symptoms of CV dx

Answer 1

Cardinal Symptoms of Cardiovascular Disease

• Chest pain or discomfort
• Dyspnea
• orthopnea
• paroxysmal nocturnal dyspnea
• wheezing Cough
• hemoptysis
• Fatigue
• weakness
• Pain in extremities with exertion (claudication)

Question 2

Epidemiology of the STEMI

Answer 2

1. Epidemiology:
   
   1. Coronary Heart Disease (CHD) Causes
      
      1. One (1) out of six (6) adults in the US (380,000 deaths/year)
      2. One(1)coronaryeventq30seconds
      3. STEMI accounts for 30% of all MI’s

Question 3

Clinical history of STEMI patient

Answer 3

1. Clinical Manifestations
2. History
   
   1. – Chest discomfort (more sever than angina)
   2. – Heavy, pressure, crushing, etc.
   3. – Retrosternal, left, across chest; neck, jaw,
   4. Left arm, epigastrium
   5. – Nausea, vomiting, diaphoresis, dyspnea,
   6. – Not reliability relieved by Nitro or rest
   7. – 20% AMI are painless (silent); diabetic elderly woman

Question 4

clinical manifestation of STEMI patient

Answer 4

1. Physical Exam
   
   1. Normal
   2. S4 Gallop
   3. BP Variable
   4. Sympathetic hyperactivity (↑ HR, ↑BP) seen in anterior MI
   5. Parasympathetic hyperactivity (Bradycardia, ↓BP) in inferior MI
   6. Heart Failure–S3, crackles, ↑JVD, new murmur

Question 5

ST Segment Elevation = X infarction?

Answer 5

transmural

Question 6

NSTEMI vs NSTE ACS

Answer 6

1. NSTEMI
   
   1. ST segment depression, T wave inversion
   2. Chest pain, elevated cardiac enzymes
2. NSTE ACS
   
   1. ST segment depression, T wave inversion, chest pain
   2. Normal cardiac enzymes

Question 7

ECG

Answer 7

ECG Evolution

1. Early Acute Phase
   
   1. T wave increase amplitude
   2. Hyper-acute pattern
   3. Convex upward ST pattern

Question 8

Other causes of ST elevation

Answer 8

1. Pericarditis
2. LVH with J point elevation
3. Normal variant early repolarization

Question 9

Evolved Acute Phase

Answer 9

Evolved Acute Phase

1. Chronic Phase
2. Resolution of ST elevation is variable (2 weeks inferior wall; later anterior wall)
3. Persistent ST elevation (after 2 weeks) think ventricular aneurysm

Question 10

QRS Complex normally

Answer 10

QRS Complex

• Ventricular depolarization
• .05-.10 sec duration
• Q waves shouldn’t be found more than. 03 sec in width
• Q waves, narrow/small, 1-2mm is normal in 1, AVL, AVF, V5,V6

Question 11

Normal ST Segment after QRS Complex

• Normally it is isoelectric; sometimes normally elevated not more than 1mm in standard leads and 2mm in chest leads; it is Never normally depressed more than 1/2 mm.

ST depression- sub endocardial/ST elevation – sub epicardial or transmural injury or ischemia.

Answer 11

observe the level (relative to baseline; elevated or depressed) and shape.

Normally it is isoelectric

Sometimes normally elevated not more than 1mm in standard leads and 2mm in chest leads

it is never normally depressed more than 1/2 mm.

ST depression- sub endocardial/ST elevation – sub epicardial or transmural injury or ischemia.

Question 12

V1-V7

Answer 12

Anterior Wall infarction

Question 13

II, III, aVF, V3R-V6R

Answer 13

RCA: inferior wall infarction (RV infarction)

Question 14

I, AvL, V5-V6

Answer 14

circumflex a–> Lateral wall

Question 16

V1-V3

Answer 16

Posterior descending a. –> posterior wall infarction

Question 17

Zone of ischemia

Zone of Injury

Zone of infarction

Answer 17

Zone of ischemia: T wave inversion due to altered repolarization

Zone of injury: ST segment elevation

Zone of infarction (muscle death): Q or QS waves

Question 18

Stages of a transmural infarct: subendocardial stage

Answer 18

1. infarct has not occured (no cell death yet)
2. R wave is more or less normal
3. ST elevation
4. T wave is peaked

Question 19

Transmural infarct: first day

Answer 19

R wave amplitude diminishing

ST elevation marked

Question 20

Transmural infarct: first and second day

Answer 20

R wave almost gone or gone

Significant Q wave

T wave inversion beginning

Question 22

Transmural infarct 2-3 days

Answer 22

No R wave, Marked Q wave, deep T wave inversion, ST may be at baseline

Question 23

transmural infarct After several weeks or months

Answer 23

1. Some R wave may return
2. significant Q wave persists
3. T wave often less inverted
4. ST elevation may persist if aneursym develops

Question 24

STEMI tx

Answer 24

E.D. Standard of Care - STEMI

• 12 lead ECG with continuous cardiac monitoring

• IV lines inserted
• Cardia cenzymes(cTnI),CBC,CMP,PT,PTT

Question 25

Reperfusion Strategy

Answer 25

Reperfusion Strategy - Choices * Primary Percutaneous Coronary Intervention (PCI) with angioplasty and stenting * Cath lab within 90 minutes (goal)

Question 26

STEMI tx 30 minutes and 90 minutes

Answer 26

_Fibrinolysis (clot busters)_ Fibrinolytic or Thrombolytic Begun in Emergency Dept. within **30 minutes (goal)** _Reperfusion Strategy - Choices_ * Primary Percutaneous Coronary Intervention (PCI) with angioplasty and stenting * Cath lab within 90 minutes (goal)

Question 27

failure of ST segment to normalize by 50-70% in the first hour

Answer 27

Reperfusion Therapy * Accelerates changes over minutes to hours * Failure of ST elevation to resolve by \> 50-70% within 1-2 hours suggests failure of fibrinolysis

Question 28

hospital does NOT have a cath lab and your patient has a STEMI: next step

Answer 28

If hospital does not have a catheter lab (non PCI capable) transfer within 120 min (goal)

Question 29

STEMI with symptoms up to but less than 12 hrs

Answer 29

Primary PCI–preferred for STEMI with symptoms \<12 hours • Lower mortality rate and ICH (intracerebral hemorrhage) If No

Question 30

Fibrinolytic Therapy: what two situations is it useful in?

Answer 30

Fibrinolytic Therapy: Useful in two situations STEMI or new left BBB within 12 hours of onset of symptoms • Major risk is ICH (.5 to 1.0%)

Question 31

Initial Medical Management - STEMI

Answer 31

ASA ## Footnote ASA (162–325mg) po–given on presentation /unless contraindicated

Question 32

apart from ASA, what other drugs would you give for a stemi initially?

Answer 32

IV Heparin or Enoxaparin * Adenosine diphosphate receptor (p2Y12) inhibitor * Antiplatelet agent (clopidogrel prasugrel ticagrelor) * Use for 1 year after PC1 for STEMI with stenting to prevent stent stenosis

Question 33

when do you use beta blockers? when DON'T you use beta blockers? when do you use an ACEI?

Answer 33

1. Nitroglycerin – relieve vasoconstriction; relieve pain, reduce pre and afterload 2. Morphine – persistent pain 3. Beta blocker – (esp. if ↑BP or ↑HR) Don’t use in decompensated HF ↓HR, ↓BP, MCO2 4. ACEI – helpful if EF↓, ↑BP; prevent remodeling statin

Question 34

AHA diet

Answer 34

Coronary ICU – AHA diet a variety of fruits and vegetables, whole grains, low-fat dairy products, skinless poultry and fish nuts and legumes non-tropical vegetable oils

Question 35

NSTEMI tx

Answer 35

1. Treatment for NSTEMI 2. • Assess for high risk patient/NSTEMI 3. • Age \> 65 y/o, \>3 CAD risk factors, prior stenosis, ST deviation, \>2 anginal event \< 24 hrs., elevated cardiac enzymes 4. • Highest risk – cardiac cath with 48 hrs. (consider PCI or CABG if indicated) 5. • Anti thrombotic therapy; ASA, Platelet P2Y12receptor antagonist, anticoagulant (UFH, LMWH-enoxaparin) 6. • Unstable-IVGP 11b/111a antagonist

Question 36

Subendocardial infarction

Answer 36

ST Depression

Question 37

ST depression

Answer 37

subendocardial infarction, digitalis toxicity, stress test

Question 38

significant Q waves

Answer 38

indicates necrosis