Cardio E2: ACS

What is the #1 cause of death in the U.S.?

Coronary artery disease

What is the #1 cause of ACS?

Atherosclerosis

What are the 3 "killers" you should r/o with chest pain?

MI, PE, Aortic dissection

Which populations commonly present with atypical angina?

DM, Elderly, Females

What symptoms may be present in women with atypical angina?

Abdominal pain, Unusual fatigue, Sleep disturbances, SOB, "Indigestion", Anxiety, Chest discomfort

What symptoms may be present in the elderly with atypical angina?

Syncope, Weakness, Confusion

Variant angina is often seen in what population?

Young females w/ few RFs

What is coronary artery vasospasm WITHOUT high grade stenosis?

Variant angina

What EKG findings may be seen with variant angina?

ST elevation when spasming, otherwise normal

How do you manage variant angina?

Cath (due to ST elevation/CP), Nitrates for CP

Which class of medications should be used for long-term prevention of variant angina?

CCBs

What type of angina is not responsive to sublingual nitroglycerin?

Unstable

What are the 3 criteria for diagnosing an MI?
(2/3 are needed for diagnosis)

- Chest pain consistent w/ ACS
- ECG changes consistent w/ injury
- Elevated cardiac enzymes

Angina, NSTEMI, or STEMI:
Negative troponin

Angina

Angina, NSTEMI, or STEMI:
Low positive troponin

NSTEMI

Angina, NSTEMI, or STEMI:
High positive troponin

STEMI

NSTEMI or STEMI:

Pain generally lasts <30 minutes

NSTEMI

What EKG findings may be seen with NSTEMI?

ST depression, T wave inversion

NSTEMI or STEMI:

Pain generally lasts >30 minutes

STEMI

What EKG findings may be seen with STEMI?

ST elevation at least >1mm in 2 contiguous leads, OR new LBBB

NSTEMI or STEMI:
Full thickness/transmural

STEMI

In treatment of STEMI, fibrinolytics (tPA) should be administered within ____ minutes

30

In treatment of STEMI, PCI should be done within ____ minutes

90

Why should BBs not be used for treatment of an MI that was induced by cocaine?

they will further induce vasospasm

Which class of medications should NOT be used in treatment of a cocaine-induced MI?

Beta blockers

What is the mechanism for a drug-induced MI?

Vasospasm

What are the lateral reciprocal leads?

II, III, aVF

What are the inferior reciprocal leads?

I, aVL

What are the posterior reciprocal leads?

V1-V4

What are the anterior reciprocal leads?

None

What EKG finding represents infarction?

Q waves

What are the criteria for abnormal Q waves?

- 1 small square wide
- Depth greater than 1/3 of QRS height

In order to show evolution on ECG, serial ECGs should be ordered at ____ minute intervals

10

What is the primary ECG sign of subendocardial ischemia?

ST depression and inverted T waves

If a patient presents with CP and risk factors but their EKG is normal, what should be ordered?

Serial EKGs

Which leads represent LAD?

V1-V4

Which leads represent LCx?

V5, V6, I, aVL

Which leads represent RCA?

II, III, aVF

Which leads represent the posterior heart (LCx/RCA)?

V1, V2 (depression)

What do Q waves on EKG suggest?

Irreversible myocardial cell death

Which Killip Classification:
No evidence of heart failure

Class I

Which Killip Classification:
Mild-moderate heart failure

Class II

Which Killip Classification:
S3 gallop & elevated JVP

Class II

Which Killip Classification:
Rales < half way up lung fields

Class II

Which Killip Classification:
Pulmonary edema (seen on CXR)

Class III

Which Killip Classification:
Cardiogenic shock

Class IV

Which Killip Classification:
Systolic BP <90 and signs of hypoperfusion

Class IV

What is TIMI score used for?

Helps determine therapeutic decision making and categorizes death/ischemic events risk in patients w/ STEMI or UA/NSTEMI

Higher TIMI store = _______________ mortality

higher

How often should serial cardiac enzymes should be ordered?

3-6 hours

What is the most sensitive and most specific cardiac enzyme?

Troponin I

Which cardiac enzyme is elevated first?

Myoglobin

T/F: a normal EKG can automatically r/o ACS

False

T/F: Q waves are indeterminant of when an ACS occured

True

New _________ + cardiac equivalent chest pain is considered an acute MI until proven otherwise

LBBB

Which patients should NEVER undergo an exercise stress test?

Acute MI (wait until d/c), Unstable angina, Severe aortic stenosis

What is the only medicine that is definitely used in ALL ACS patients?

ASA

What is the goal for Supplemental O2 levels?

94-98%

MONA

M- morphine (or fentanyl)
O- oxygen
N- nitrates
A- aspirin

BASH

B- beta blockers
A- ACE inhibitors
S- statin
H- heparin

Which drug shows evidence of increased mortality in NSTEMIs?

Morphine

When should oxygen be given?

When O2 sat is <90%

What should be given to patients with an ASA allergy/contraindication?

Clopidogrel (Plavix)

Oxygen dose:

2 LPM via nasal cannula

Nitrate dose:

Sublingual, 0.4 mg every 5 min x3

ASA dose:

325 mg chewable

Nitrates should be avoided in which patients?

Hypotensive, RV infarctions

T/F: Nitrates improve mortality

False

T/F: BBs decrease mortality

True

What is the only positive effect of morphine in ACS?

Analgesia

Fibrinolytics disrupt formed clots if given within _______ of pain onset

12 hours

What is used to reverse Fibrinolytics?

FFP + cryoprecipitate

What is the preferred anticoagulant for patients with STEMI?

IV Heparin

What is the reversal agent for Heparin?

Protamine sulfate

What should patients taking Heparin should be monitored for?

HIT

What is the preferred anticoagulant for patients with angina & NSTEMI?

Lovenox (Enoxaparin)

For outpatient management following acute event, if a stent was placed, what meds should the patient be started on?

Dual anti-platelet therapy --> ASA + P2Y12 inhibitor

Patients with a drug-eluting stent (coated) should be on dual anti-platelet therapy for how long?

1 year minimum

Patients with a bare metal stent (not coated) should be on dual anti-platelet therapy for how long?

30 days minimum

What are some P2Y12 inhibitors?

Plavix (Clopidogrel), Brilinta (Ticagrelor)

What is the mainstay treatment for outpatient management after an acute event?

Beta-blockers (at least 6 mos)

What should patients taking nitrates avoid?

Sudden discontinuation, ED medications

What is Dressler's syndrome?

Post-MI pericarditis

What is a triphasic pericardial friction rub that does not go away when the patient holds their breath?

Pericarditis/Dressler's syndrome

What improves pain for pts w/ Dressler's syndrome?

Sitting upright

What worsens the pain for pts w/ Dressler's syndrome?

Lying flat

Diffuse ST changes in all leads may be indicative of what?

Pericarditis/Dressler's syndrome

What is the tx for Dressler's syndrome?

NSAIDs + Colchicine

What are the absolute contraindications to Thrombolytics?

prior intracranial hemorrhage, known cerebral vascular lesion, known malignant intracranial neoplasm, ischemic stroke w/in 3 mo, suspected Aortic dissection, active bleeding/bleeding diathesis, significant closed head / facial injury w/in 3 mo