STEP 2 CARDS: CAD, Chest pain, ACS

Question 1

A pt presenting to the ED with chest pain and suspected ACS should be given what first? ASAP?

Answer 1

Aspirin +P2Y12 Inhibitor

Question 2

What effect does cocaine have on the heart and what signs point to cocaine use?

Answer 2

Heart: tachy, htn, chest pain due to coronary vasoconstriction

Signs: sympathetic hyperactivity because its a stim, dialated pupils

Question 3

How do you approach cocaine associated chest pain?

Answer 3

Benzos for BP and anxiety
ASA for inhibition of cocaine induced plt aggregation
Nitro and CCBs for vasoconstrictive pain
Watch for stemi! you may have to cath

Question 4

This is given to decrease the risk of recurrent ischemic events and cardiovascular death following an MI and is recommended for 12 mo post MI regardless if stent was placed.

Answer 4

DAPT

Question 5

What are the pharmacologic pillars of post MI care?

Answer 5

DAPT, Bblockers, ACE/ARB, High intensity statin, and for those with LV systolic function/HF/comorbid DM spironolactone

Question 6

Used to reduce myocardial oxygen demand, decreases arrythmia risk, and inhibits adverse remondeling

Answer 6

Beta Blockers

Question 7

Use for both HTN management and inhibits post-MI remodeling

Answer 7

ACEs/ARBs

Question 8

Used to stabilize atherosclerotic plaque and reduce recurrent MI

Answer 8

high intensity statin

Question 9

Used in cases of reduced LVEF with symptoms or comorbid DM, inhibits post MI remondeling

Answer 9

mineralocorticoid antagonist

Question 10

What are our cardioselective beta blockers?

Answer 10

Meotprolol and atenolol

Question 11

In ACUTE management of ACS (STEMI, NSTEMI, UA), what are our pharmacologic interventions?

Answer 11

Nitrates, BBs, DAPT (think ASA and P2Y12), ANTICOAGULATION (unfrac heparin), statins, coronoary reperfusion if stemi, cornorary angiongraphy if Nstemi. Note that if the facility for PCI is 120 min away, initate fibrinolytics (alteplase)

Question 12

MI that presents with epigastric pain, nausea, and can have hypotension and bradycardia

Answer 12

RIGHT ventricular MI!

Question 13

Ischemic changes in anterior, lateral, or inferiror leads can be consistent with what side MI?

Answer 13

Left ventricular

Question 14

Pulmonary edema and an S3 and S4 are characerisitc of what sided MI?

Answer 14

Left vent

Question 15

How does an MI impact SVR?

Answer 15

It increases regardless of side of MI

Question 16

Which MI decreases LV preload?

Answer 16

Right sided

Question 17

Increased RV preload, decreased LV preload, reduced CO w/hypotension and compensatory increase in SVR is consistent with an MI where?

Answer 17

RIGHT ventricular infarction

Question 18

What are the left ventricular leads?

Answer 18

V1-4

Question 19

What are the right ventricular leads?

Answer 19

II, III, aVF

Question 20

What are the lateral leads?

Answer 20

I, V5 and V6

Question 21

What are disorders associated with S3?

Answer 21

HFrEF
high output states (eg thyrotoxicosis)
Mitral or aortic regurg

Question 22

What disorders are associated with an S4?

Answer 22

Cocnentric LV hypertrophy, restrictive cardiomyopathy, ACUTE MI

Question 23

This is a PE finding in an acute MI due to left ventricular stiffening and imparied relaxation by myocardial ischemia

Answer 23

s4

Question 24

Day 1 post MI: complication

Answer 24

Ventricular arrythmia caused by myocyte ectopy

Question 25

Day 3 post MI complication

Answer 25

acute pericarditis

Question 26

Day 5-7 post MI complication

Answer 26

ruptures; granulation tissue forms at about day 5 which is weaker than normal tissue and has a tendency to rupture.

Question 27

Day 28 post MI complication

Answer 27

Dresslar syndrome (autoimmune pericarditis)

Question 28

The primary anti-ischemic and antianginal effects of nitrates are due to what kind of dialation: systemic or coronary?

Answer 28

Systemic, the systemic dialation decreases preload and LVEDV reducing wall stress and oxygen demand

Question 29

Shockable not shockable: pulseless electrical activity/asystole

Answer 29

not shockable

Question 30

persistent ST elevation and deep q waves in the same leads is consistent with what?

Answer 30

LV aneurysm

Question 31

What artery is likely occluded and how can you tell?

Answer 31

Right Coronary Artery, STEMI in II III and aVF

Question 32

If someone has an MI and they have pulmonary congestion and seem to be having decompensated HF, what is your go to?

Answer 32

FUROSEMIDE

Question 33

What am I: asymptomatic plaque, stable angina, unstable angina, NSTEMI, STEMI: pain at rest, no elevation in troponin, no elevation in ST segment

Answer 33

Unstable angina

Question 34

What am I: asymptomatic plaque, stable angina, unstable angina, NSTEMI, STEMI: pain at rest, troponins elevated, no st elevations

Answer 34

NSTEMI

Question 35

What am I: asymptomatic plaque, stable angina, unstable angina, NSTEMI, STEMI: pain at rest, troponin elevation, st segment elevation

Answer 35

STEMI

Question 36

When are BBlockers contraindicated?

Answer 36

heart failure, cardiogenic shock, bronchoconstriction

Question 37

Chest pain, ECG with ST-depressions, and T wave inversions, dialated pupils, atrophic mucosa, and hypertension are consistent with....

Answer 37

acute myocardial ischemia in the setting of cocaine use

Question 38

How do you tell the difference between NSTEMI and UA?

Answer 38

Watch the troponins within 6-12 hours. Elevation = NSTEMI

Question 39

Exercise stress testing is used to evaluate what patients?

Answer 39

It is used to evaluate for CAD in pts with symptoms consistent with stable angina

Question 40

How does the presentation of inferior wall MI compared to anterior?

Answer 40

Pt's with inferior wall MIs tend to present with epigastric pain and nausea compared to the characterstic substernal chest pain of an anterior wall MI. Inferior wall MI's also dont have SOB because they dont cause pulm edema. Instead, inferior wall MIs usually supply blood to the SA and AV node leading to brady arrythmias.

Question 41

T-wave inversion in leads II, III, and aVF is concerning for what?

Answer 41

This finding is concerning for a right ventricular myocardial infarction, next steps would be doing right sided precordial ECG

Question 42

What are the hemodynamic findings in left ventricular MI?

Answer 42

Elevated LV and RV preload and elevated systemic vascular resistance

Question 43

What are the hemodynamic findings in right ventricular MI?

Answer 43

elevated RV preload and decreased LV preload, elevated SVR

Question 44

What leads to JVD in a right ventricular MI?

Answer 44

There is decreased RV contractility leading to increased preload that leads to JVD

Question 45

Presents with JVD, clear lungs, and profound hypotension caused by impaired delivery of blood to the left ventricle

Answer 45

inferior wall MI

Question 46

The anti-ischemic and antianginal effects of nitrates are primarily due to...

Answer 46

systemic vasodialation that lowers preload and left end-diastolic volume reducing wall stress and myocardial O2 demand

Question 47

STEMIs in V1, V2

Answer 47

LAD, septal myocardium involved

Question 48

STEMIS in V3, V4

Answer 48

LAD, anterior myocardium involved

Question 49

STEMIs in V5, V6, I, aVL

Answer 49

LAD or LCx, lateral myocardium involved

Question 50

STEMIs in II, III, avF

Answer 50

RCA or LCx, inferior myocardium involved

Question 51

V7-9 stemis

Answer 51

RCA or LCx, posterior MI

Question 52

V4R-V6R Stemis

Answer 52

RCA, Right ventricle invovled