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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
Note 
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