MI

HEART ATTACK TIME BABY

NSTEMI

NSTEMI

What is a considered to be present in patients having the same manifestations as those in unstable angina, but who have elevated troponins (no ECG changes)?

MI (myocardial infarction)

evidence of myocardial necrosis in a patient with evidence of decreased perfusion from coronary arteries

complete/partial of a coronary artery due to ruptured plaque or imbalance of oxygen supply and demand

What are some of the causes of acute MI?

Chest pain (crushing, elephant) longer than 20 min, radiates to jaw/neck/shoulders/arms

What are the classic symptoms of a MI

radiation to both arms, radiation to the left arm or right shoulders, S3

What are some symptoms that strongly rule in an MI

pleurititc chest pain, sharp/stabbing chest pain, positional chest pain, pain reproduced by palpation

Symptoms that rule out an MI

JVD (especially with Right-sided HF), S3 gallop with ischemia, S4 gallop with heart failure, rales/pedal edema (w/HF), holosystolic murmur, cardiogenic shock

What are some red flags for AMI during a physical exam?

blood hitting a compliant LV (occurs after S2)

What causes an S3?

LV is noncompliant so the atria have to work harder (just before S1)

What causes an S4?

hypotension, clear lungs, elevated JVP, Kussmaul’s sign

A 57 y/o male presents to the ER with chest pain. EKG show STEMI on the inferior and right sided leads. What other stuff might you expect on a physical exams?

hypotension, new holosystolic murmur at the LLSB with a thrill

What are some signs that your patient has a rupture of the interventricular septum?

PE, spontaneous pneumo, AMI, aortic dissection, pericardial tamponade

What are the quick killers associated with chest pain?

Aortic Dissection

A 67 y/o male presents to the ER with Chest pain. He describes the pain as tearing, ripping and says it radiates to in between his shoulder blades. He states the pain is felt above and below the diaphragm? This is a red flag for

Acute pericarditis

A 67 y/o male presents to the ER with chest pain that he describes as acute, sharp, severe and constant. He says that it radiates to his back, neck, and shoulders and gets worse when he breathes or lies down, but gets better when leaning forward. This a red flag..

mitral valve prolapse

A 67 y/o male presents to the ER with chest pain that he describes as a discomfort occurs rest. He also reports dizziness, hyperventilation, anxiety, palpitations, and fatigue. This is a red flag for

pneumonia

A 67 y/o male presents to the ER with chest pain that he describes as sharp and worsens when he breaths. He also reports a fever, cough, and is satting at 92% on RA. This is a red flag for…

Esophageal rupture

A 67 y/o male presents to the ER with chest pain that he describes as substernal and sharp that started about an hour ago after he vomited. He appears sick, dyspneic, and diaphoretic. This is a red flag for

Chest wall pain

A 67 y/o male presents to the ER with chest pain that he describes that is sharp and is positional. The pain worsens when the chest is palpated. This is a red flag for…

GERD

A 67 y/o male presents to the ER with chest pain that he describes burning in the lower half of his chest. He states that he has this acidic taste in his mouth. This is a red flag for…

Peptic ulcer disease

A 67 y/o male presents to the ER with chest pain that he describes as dull, boring in the mid epigastric regions that often wakes him up at night. He says that they get better when he takes a tums. This is a red flag for…

Elevation of cardiac biomarkers (Trop) + EKG changes(override)/severe ischemia symptoms/imaging shows loss of myocardium

What are the diagnostic criteria for AMI?

Serial EKG (1st one in 10 min), cardiac panel (myoglobin, CK-MB, trop), echo (how much myocardium is involved)

A 55 y/o female presents to the ER with chest pain that started 2 hours ago. What does your work-up consist of?

Bed rest, Aspirin (162-325mg), heparin/LMWH (prevents further clots), Nitro, O2 is satting poorly, morphine (if pain is uncontrollable), beta blockers, ACEI (w/ 24 hours if EF is low), monitoring, diazepam, anti-nausea, stains within 14 days

What is our ACUTE treatment plan?

Irreversibly inhibits COX-1, helps prevent new clots and the growth of current

Why do we give MI peeps aspirin (162-325 mg)

clopidogrel (ticagrelor, prasugrel)

What can be used for patients allergic to aspirin or after the placement of a stent

hypotensive patients, RV infarction

Who are we not giving Nitro to (unless we want to lose our license or something)

beta blockers

What do we give all hemodynamically stable MI patients because it is associated with lower rates of hospitalization, has antiarrthythmic, anti-ischemic, and antihypertensive properties?

ACEI (ARBs if intolerable)

What is given to all MI patients within 24 hours to limit ventricular remodeling and reduce incident of HF?

atorvastatin, rosuvastatin (high intensity)

What statins are we starting in MI patients within 14 days

PCI (percutaneous coronary intervention - placement of stents/balloon angioplasty)

What is the surgical therapy of choice in MI?

door to ballon in less than 90, cardiogenic shock patients, high bleeding risk patient

Rules for PCI

reduced reocclusion rate, early risk stratification, reduced mortality, stroke, reinfarction, reduced risk of intracranial hemorrhage, shorter length of hospitalization

Primary PCI pros

DM, left main stenosis greater than 50%, triple vessel, severe disease

Who are we doing a CABG on - note not a slam dunk kinda provider/provider basis?

Fibrinolytics (reneteplase, alteplase, tenecteplase) given within 30 min

Okay so you are working in a rural ER (idk Dalhart, Texas for example) and its the middle of a blizzard - no helicopter or ambulance is getting in or out of the city. You have a patient that comes in to the ER for chest pain. MI is confirmed with ST elevation in the inferior and lateral leads - what can we do since there’s no cath lab?

Hx of intracranial hemorrhage, ischemic stroke in the last 3 months, cerebral vascular malformation, aortic dissection symptoms, active bleeding, closed-head/facial trauma in the last 3 months

Absolute C/I for fibrinolytics

poorly controlled HTN, ischemic stroke history, dementia, intracranial disease, traumatic CPR, major surgery within last 3 weeks, internal bleeding in last 2-4 weeks, non-compressible vascular punctures, pregnant, warfarin use

Iffy C/I for fibrinolytics

coenzyme Q10, omega 3 poly-unsaturated fatty acids

Alternative therapies for MI that aren’t super efficacious - small studies, no benefit shown, etc

moderate coffee, mediterranean diet, flu vaccine, NO NSAIDs, estrogen use has low increased risk, testosterone supplements have increased risk

Other treatment considerations for MI

Stop smoking, control Bp, AR statin, reduce saturated fats, increase fiber, exercise, lose weight, ASA/clopidogrel, ACEI for low EF, beta blockers

Prevention of secondary MI

papillary muscle rupture, ventricular free wall rupture, ventricular septal rupture, true ventricular aneurysm, Dressler’s syndrome (pericarditis)

What are some mechanical complications of MI