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75 Cards in this Set
- Front
- Back
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Reperfusion therapy for AMI and restoration of vessel patency has the following benefits {4}
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1. Reduced infarct size
2. Preserves LV function 3. Reduces mortality 4. Prolongs survival |
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Regarding Primary PCI being superior to
thrombolytic therapy, which is incorrect? 20 lives / 1000 treated. |
3. Primary PCI has reduced stroke compared with Thrombolysis : 1% vs 2%
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Urgent PCI in STEMI can be considered in which patients { 6 answers}
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1. PCI Centre of Excellence
2. Thrombolysis contraindication 3. High risk {but predicted small / moderate benefit from thrombolytic therapy} - Elderly / Diabetic 4. Cardiogenic shock {up to 12-36 hours after infarction} 5. Failed thrombolysis (Rescue PCI ) 6. Previous CABG |
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Which medications are initiated < 24 hours of AMI {unless contraindicated} ? [4]
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1. BBlockers
2. Heparin {LMW/UFH} 3. ACEI or ARB 4. HMG CoA reductase inhibitor {Statin} |
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Absolute contraindications to Thrombolysis in AMI (5).
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1. Previous haemorrhagic stroke
2. CVA within 6 months 3. Intracranial neoplasm 4. Active internal bleeding < 2 weeks 5. Aortic dissection {known/suspected} |
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Relative contraindications for thrombolysis in AMI (10}
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1. Severe UNCONTROLLED hypertension {>180/110}
2. INR > 2.5 {oral anticoagulation therapy} 3. Recent major Trauma - Surgery < 4 weeks { including head trauma} 4. Pregnancy 5. {TRAUMATIC} CPR 6. Active peptic ulcer disease 7. Previous allergic reaction thrombolytic drug used 8. Recent STK {use different drug} 9. History of prior CVA / intracerebral pathology 10. Chronic HTN |
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Which fact is incorrect regarding thrombolysis benefits versus placebo:
1. Within 6 hours = 30 lives saved per 1000 2. Within first hour = 40 lives saved per 1000 3. Within 7-12 hours = 20 lives saved per 1000 4. Largest benefits are in anterior infarction 5. Largest benefits are seen in inferior infarction. |
5. Inferior - less benefits
{0.8% absolute mortality reduction}
reduction. |
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Streptokinase facts
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1. First generation FIBRINOLYTIC
2. "non specific" 3. Produces "systemic lytic state" 4. Associated with increased bleeding / ICH when given with heparin 5. ANTIGENIC 6. Hypotension + Bradycardia |
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t-PA facts
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1. Non antigenic
2. More fibrin selective 3. Less systemic bleeding 4. Higher patency rates than STK |
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Third Generation Fibrinolytics Facts
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1. Reteplase / tenecteplase
2. Bioengineered products of t-PA 3. Longer half-lives 4. Similar efficacy and side effect profiles to Second generation fibrinolytics |
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Which fact is incorrect regarding thrombolysis in AMI ?
1. GUSTO-1 showed a reduce mortality of t-PA vs STK 5.3 vs 7.3% 2. GUSTO-1 showed increased {small} in haemorrhagic stroke of t-PA vs STK 3. GUSTO-1 showed an extra 10 lives saved per 1000 patients treated 4. t-PA can result in 5 disabled stroke survivors per 1000 treated. 5. Risk of lethal and non lethal stroke is increased with Age / Recent stroke and Hypertension on arrival. |
1. Gusto-1 : tPA vs. STK mortality = 6.3 vs 7.3%
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Invasive Strategy-PCI --> {Consider transfer} for PCI if { 7 facts}
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1. Door to balloon time < 90 minutes
2. High Risk STEMI a. Age > 75 b. Extensive Anterior infarction { + late presentation } c. High risk of bleeding d. Previous MI/CABG e. Killip Class > 3 3. Symptom onset > 3 hours |
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Thrombolysis preferred over PCI in the
following situations |
1. Early presentation
[ < 3 hours from symptom onset and delay to invasive strategy] |
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ISIS-2 Study Facts
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1. International Study of Infarct Survival
2. Aspirin reduced mortality by 23% 3. Aspirin gave 50% reduction in REINFARCTION and STROKE 4. Streptokinase reduced mortality by 25% 5. Aspirin and STK had an additive effect-reducing mortality by 42% |
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Clopidogrel in STEMI
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1. Confers significant additional benefit with
aspirin vessel reocclusion |
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Antithrombin therapy in STEMI
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1. UFH and LMWH
2. UFH = lives saved per 1000 treated 3. LMWH = 21 deaths / MI events prevented per 1000 treated [ 4 major non fatal bleeds] |
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5 contraindications for commencing ORAL B Blockers within 24 hours in STEMI.
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1. Pulmonary oedema
2. Hypotension 3. Bradycardia 4. Advanced AV block 5. Asthma |
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Which is incorrect regarding Complications of AMI?
1. Cardiac failure develops when >30% LV circumference is affected. 2. Cardiogenic shock or death occurs when > 40% of LV circumference is affected. 3. Reinfarction in the first 10 days post AMI occurs in < 3% 4. Transient Mitral valve dysfunction is common after AMI. 5. Severe Mitral regurgitation / papillary muscle rupture occurs in 4% patients after AMI. |
3. Reinfarction in the 10 days post AMI occurs in 5 -10%
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Emergent PCI is demonstrated to offer Clinical benefit to patients with ACS/ NSTEMI, with 3 high risk features:
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1. Elevated Troponins
2. Recurrent chest pain 3. Recurrent ECG changes |
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( ARC Guidelines) Which is correct regarding Acute Coronary Syndromes?
A. The benefits of fibrinolysis are greatest in an inferior STEMI. B. PreHospital fibrinolysis does not have similar outcomes to PCI in Anterior STEMI in age < 65 with chest pain onset < 1-2 hours. |
D.
A = Anterior STEMI B = It does ( CLass B ; LOE II ) C = PCI should be pursued - rather than opting for a "no treatment "strategy". |
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(ARC Guidelines) Which of the following is
incorrect regarding ACS ? inflation, is 90 minutes if presenting > 1 hour since symptoms onset. |
C. PCI Superior to Thrombolysis with chest pain onset and treatment between 45-180
minutes. { up to 3 Hours } |
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(ARC Guidelines) Which of the following is an
absolute contraindication to Fibrinolysis?
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B.
D. Active Internal Bleeding within 2 weeks = Absolute contraindication. |
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(ARC Guidelines) Which of the following is not a Relative Contraindication to fibrinolysis?
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B. = Absolute
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(ARC Guidelines ) Which of the following is
incorrect regarding treatment of STEMI? (routine use of fibrinolysis prior to PCI) Centres is supported if they present between 3-12 hours, and the transfer can be achieved within 2 hours. |
A Facilitated PCI is not recommended
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(ARC Guidelines) True of False? :
Patients treated successfully with fibrinolysis, in a non-PCI capable Cantre, should be transferred for angiography / eventual PCI within 6-24 hours after fibrinolysis. |
Yes
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( Cameron) Which is incorrect regarding the
Likelihood ratios, and ruling in AMI ? |
A. 4.7 (nearly 5 times increased likelihood)
"Burning" / Indigestion - like pain has LR 2.8 ! |
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DDx for ST Elevation on the ECG ?
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1. STEMI
2. Myopericarditis 3. LV aneurysm 4. Hypothermia 5. Hyperkalaemia ( Hypercalcaemia) 6. LVH 7. Brugada Syndrome (Type I > Type II, III) 8. BER |
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Which is incorrect regarding diagnosing AMI?
normal ECG does not rule out ACS. |
C. The sensitivity is limited.
supporting ischaemia, BUT it also may be old infarcted tissue. |
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(Cameron) In regards to an alternative cause of chest pain +/- ST elevation : Thoracic dissection, which of the following is incorrect?
A. the CXR is 80% sensitive and specific for thoracic dissection. B. The most common abnormal finding on CXR is superior mediastinal widening ( in 50-75% of cases) C. The CXR is normal 20% of the time. D. The Helical CT Angiogram of the thorax has a 95-100% sensitivity and specificity for thoracic dissection. |
D. Sensitivity 83 -100%
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Which is incorrect regarding AMI and
arrhythmias? C. Higher grade arrhythmias can be treated with Lignocaine or amiodarone. |
D. Sustained VT is uncommon in AMI.
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What is the mnemonic for the TIMI risk score for Unstable Angina / NSTEMI ?
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"AMERICA"
Age > 65 Markers elevated ( Cardiac biomarkers) ECG changes of > 0.5 mm on initial ECG Risk Factors ( > 3 ) - HTN - Smoking - Hchol - Diabetes - FHx premature cardiac disease (PCD) Increasing angina ( > 2 episodes in 24 hours) Coronary artery disease (stenosis > 50%) Aspirin use within 7 days |
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What are the % risks for TIMI scores?
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0-1 = 5%
2 = 10% 3 = 15% 4 = 20% 5 = 25% 6 = 40% = % risk at 14 days of all cause mortality / new AMI/ recurrent ischaemia requiring revascularisation. These patients will benefit from more aggressive medical Mx ( early catheterisation) |
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(Cameron)
In which correct order is the likelihood ratios of Clinical features for diagnosing AMI - from highest to lowest? |
B. LR : 2.8 , 2.3 , 2.0
Radiation to Right arm = 4.7 Burning-like / indigestion = 2.8 Exertional = 2.4 Left arm radiation = 2.3 Diaphoresis = 2.0 Nausea / vomiting = 1.9 Similar to previous AMI = 1.8 Pressure = 1.3 |
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In regards to Sgarbossa's ECG criteria for AMI, which of the following is incorrect?
A. It is highly specific for AMI with LBBB. B. A score of > 3 has a 90% specificity for AMI C. There are 3 criteria D. The highest criterium score is with Concordant ST depression > 1mm in V1-V3 |
D. Scores 3
The highest is Concordant ST elevation > 1mm in leads with a + QRS. |
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Which of the following is incorrect regarding Sgarbossa's criteria for AMI in the setting of LBBB?
A. Concordant ST elevation > 1mm in leads with a QRS complex scores the highest ( 5) B. Excessively discordant ST elevation > 5 mm, in leads with a negative QRS complex scores 3. C. Concordant ST depression > 1mm in leads V1-V3 scores the second highest. D. A total score > 3 is associated with a worse prognosis. |
B. scores 2
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What are the Sgarbossa Criteria?
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1. Concordant ST elevation > 1mm in a + QRS complex = 5 points
2. Concordant ST depression > 1mm in V1-V3 = 3 points 3. Discordant ST elevation > 5mm with a negative QRS complex = 2 points 2015 Modified Sgarbossa Criteria : > 1 lead with Excessive discordant ST Elevation > 1mm [ > 25% of preceding S wave ] |
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Which of the following is incorrect regarding the National heart Foundation of Australia
Reperfusion Strategies for STEMI ? inflation time is achievable within 120 minutes . presenting less than 1 hour is 60 minutes . |
D. Maximal acceptable delay until balloon
inflation when presenting between 1-3 hours = 90 minutes. |
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Outline the Maximal acceptable delays from
presentation to balloon inflation time when presenting - within 1 hour - between 1-3 hours - between 3-12 hours. |
< 1 hour = 60 minutes
1-3 hours = 90 minutes 3-12 hours = 120 minutes > 12 hours : reperfusion not recommended if asymptomatic and stable. |
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Which of the following is incorrect? [ Tintinalli] A. Atypical / painless presentations are more likely in the Elderly and Women. B. A 25% loss of the LV leads to CHF C. A 50% loss of the LV leads to Shock. D. Cardiac risk factors are a poor Emergency Department predictors of AMI / ACS. |
C. 40% |
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Which is incorrect regarding AMI: [Tintinalli] A. Anterior AMI leads to tachyarrhythmias. B. Mobitz Type II block is usually associated with Inferior AMI. C. Complete Heart Block (CHB) can occur with both inferior and anterior AMI. D. Inferior AMI is associated with both first degree and Mobitz Type I block. |
B. Mobitz Type II Block usually associated with Anterior AMI. |
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Which AMI percentage is correct? [ Tintinalli ] A. Pericarditis is seen in 10% of AMI's 2-4 days post AMI. B. Dressler's Syndrome occurs 2-10 weeks post AMI. C. Free wall Myocardial rupture occurs < 24 hours post AMI. D. Papillary muscle rupture occurs in 1 per 1000 AMI from day 1 to 14 post AMI. |
B. A = 20% C = 1-5 days post MI. D = 1 in 100 (1%) |
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Which percentage of Inferior AMI involve the Right ventricle ? [ Tintinalli ] A. 10% B. 20% C. 30% D. 40% |
C. 30% with increased mortality and complications. |
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Which is incorrect regarding AMI and the ECG? [ Tintinalli ] A. Patients with a normal / non specific ECG have a 1-5% incidence of AMI. B. New ischaemic ECG changes increase the risk of AMI from 25% to 75% C. V4R ST elevation is highly suggestive of RV infarction. D. Patients with a normal / non-diagnostic ECG have a 2% incidence of unstable angina. |
D. 4 - 23% incidence. |
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[ Tintinalli] Elevated troponins in NSTEMI increase the the short term risk of death by what factor? A. 2 fold B. 3 fold C. 4 fold D. 5 fold |
B. |
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[ Tintinalli] Which troponin type is elevated more in renal failure, troponin T { cTnT } or troponin I { cTnI} ? |
Troponin T |
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[ Tintinalli] With RV pacing, concordant ST depression in leads V1 to V3 is how specific for AMI? A. 35% B. 50% C. 80% D. 99% |
C. |
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[ Tintinalli] Which of the following is incorrect regarding Odds ratios and LBBB-AMI ? A. Concordant ST elevation > 1mm with the QRS complex has the highest odds ratio for AMI. B. Concordant ST depression > 1mm in V1-V3 has an odds ratio of 6 for AMI. C. Discordant ST Elevation > 5mm with the QRS complex has an odds ratio of 4 D. Concordant ST elevation > 1mm with the QRS complex has an odds ratio of 10. |
D. 25 ! B. = 6.0 C. = 4.3 |
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[ Tintinalli] What percentage is the estimation for false positive interpretations of the ECG as STEMI ? A. 1-5 % B. 5-10% C. 10-15% D. 15-20% |
C. 11-14% |
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[ Tintinalli] In the setting of an inferior wall AMI, which additional lead (s) ST elevation would suggest a Left circumflex lesion rather than Right coronary lesion ? |
ST elevation in leads : - V5, V6 or - V1 ( with lead I isoelectric or elevated ) |
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[ Tintinalli] A new Systolic murmur in AMI can represent what 3 possible lesions? |
1. Papillary muscle dysfunction 2. Flail leaflet of mitral valve with resultant mitral regurgitation 3. Ventricular septal defect (VSD) |
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[ Tintinalli ] In AMI, what 5 complications can the presence of reciprocal ST segment changes predict ? |
1. Larger infarct distribution 2. Increased severity of underlying coronary artery disease (CAD) 3. More severe pump failure 4. Higher likelihood of cardiovascular complications 5. Increased mortality . |
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List 5 conditions where there is ST segment elevation in the absence of AMI ( "Mimics") |
1. LBBB 2. Paced rhythm (VPR) 3. LV aneurysm 4. Benign Early Repolarisation (BER) 5. Hyperkalaemia 6. Myo-pericarditis 7. Cardiomoyopathy (HOCM) 8. Left ventricular hypertrophy (LVH) 9. Hypothermia |
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List 5 conditions where there can be ST depression in the absence of ischaemia. |
1. Hypokalaemia 2. Digoxin effect 3. LBBB 4. Paced rhythm (VPR) 5. LVH |
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[ Tintinalli] What 3 factors in STEMI presenting within 3 hours, is the decision for PCI versus fibrinolysis based upon ? |
1. Institutional expertise 2. Availability of Cath Lab. 3. Individual patient risks for fibrinolysis complications. |
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{ Tintinalli} What it the timing of door-balloon inflation time where PCI is seen as the preferred reperfusion method ? |
PCI preferred with Door-Balloon inflation time < 90 minutes. |
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[ Tintinalli] In regards to AMI and bundle branch blocks, which of the following is incorrect ? A. Bifascicular block represents a large infarct. B. New RBBB often leads to Complete Heart Block (CHB) C. Left Anterior Hemiblock is associated with a higher mortality than left posterior hemlock. D. New RBBB occurs most commonly anteroseptal AMI. |
C. Posterior Hemiblock > Anterior Hemiblock in regards to mortality. |
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List 3 indications for Acute Temporary Transcutaneous pacing in AMI. |
1. Unresponsive symptomatic Bradycardia 2. New LBBB and bifascicular block. 3. Mobitz II / Higher AV blocks 4. RBBB or LBBB with first degree AV block |
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[ Tintinalli] In regards to AMI and bradyarrhythmias, which of the following is correct ? A. Pacing has no bearing on mortality reduction. B. Ventricular premature contractions ( PVC / VEB ) are common, and prognosticate complications. C. Ventricular tachycardia shortly after AMI portends a poor prognosis. D. Ventricular fibrillation shortly after AMI has a significant effect on mortality and prognosis. |
A. B = PVC do not prognosticate AMI complications C = VT does not. D = VF does not |
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[Tintinalli] In regards to AMI and arrhythmias, which of the following is correct? A. Intraventricular conduction disturbances occur in 40% of AMI patients. B. Left posterior hemiblock is more common than Left anterior hemiblock. C. The most frequently occurring bradyarrhythmia in AMI is Mobitz II block. D. The most frequently occurring tachyarrhythmia with AMI is Accelerated idioventricular rhythm. |
D. A = 10-20% B = Left anterior hemiblock more common C = Sinus bradycardia |
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[ Tintinalli] List in order of decreasing frequency , the following bradyarrhythmias with AMI: 1. Asystole 2. Sinus bradycardia 3. First degree AV block 4. Mobitz Type II AV block 5. Mobitz Type II AV block 6. 3rd degree heart Block. |
Most common to least common : 1. Sinus bradycardia 35-40% 2. First degree AV Block 5-15% 3. Second Degree Mobitz I AV Block I5-10% 4. 3rd Degree AV block 5-8% 5. Asystole 1-5% 6. Second degree Mobitz II AV block 0.5-1.0 % |
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[ Tintinalli] List in order of decreasing frequency, the following Tachyarrhythmias with AMI: 1. Ventricular fibrillation (VF) 2. Atrial fibrillation (AF) 3. Atrial Flutter 4. Non sustained Ventricular Tachycardia (VT) 5. Accelerated Idioventricular rhythm 6. Sinus tachycardia 7. ventricular premature beats (VEB / PVC) |
Most common to least common : 1. Ventricular premature beats ** 99% ( not necessarily tachycardia) 2. Accelerated Idioventricular Rhythm 50-70% 3. Non sustained Ventricular Tachycardia (VT) 60-70% 4. Sinus tachycardia 30-35% 5. Atrial fibrillation (AF) 5-10% 6. Ventricular fibrillation (VF) 4-7% 7. Atrial Flutter 1-2 % |
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[Tintinalli ] List the 3 main benefits of Beta Blockers in AMI |
Beta blockers Benefits In AMI : 1. Antiarrhythmic 2. Anti-ischaemic 3. Antihypertensive |
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[Tintinalli] Which of the following is INcorrect regarding nitrates and AMI ? A. IV nitrates should be titrated to symptom resolution . B. Nitrates inhibit platelet aggregation C. Nitrates used in patients not thrombolysed for AMI has a mortality benefit. D. Nitrates have a bearing on cardiovascular complications and infarct size. |
A = IV nitrates titrated to Blood pressure reduction [ 10% of MAP in normotensive ; 30% in hypertensives ] B = They do. C= Nitrates have 35% mortality reduction D = (1) Decrease rate of cardiovascular complications AND (2) reduced infarct size AND (3) improve regional function |
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List 4 known acute medical disorders associated with AMI . |
1. GI Bleeding 2. Stroke 3. Sepsis 4. Acute anxiety / emotional upset |
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Which of the following should not be given with AMI from cocaine use? A. Aspirin B. Nitrates C. Benzodiazepines D. B Blockers |
D. B Blockers contraindicated |
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Which of the following is incorrect regarding Symptoms of acute coronary syndrome (ACS) shortly after PCI ? A. Bare metal stents are more likely to restenose in the short term. B. Subacute thrombotic occlusion after stent placement occurs in < 1% patients. C. Stent occlusion usually presents between day 2 and day 14 post PCI procedure. D. Drug eluting stents tend to present with late stent thrombosis. |
B. Thrombotic occlusion of stents post AMI occurs in 4% patients. Bare metal = early occlusion Drug-eluting = late occlusion |
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List the 3 main mechanical complications of AMI. |
1. Free wall rupture 2. Rupture of inter ventricular septum 3. Papillary muscle rupture |
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Which is incorrect regarding Free wall rupture post AMI? A. It usually occurs in the first 24 hours post AMI. B. It occurs in 10% of AMI fatalities C. Death is typically from pericardial tamponade in greater than 90% cases. D. The treatment is surgical. |
A. Free wall rupture occurs : Days 1 to 5 |
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Which is correct regarding Rupture of the inter ventricular septum in AMI ? A. It is a right-to- left shunt. B. The murmur is holosystolic - best heard at the apex. C. There is a palpable thrill. D. It is more common with inferior AMI. |
C. A = left-to-right shunt B = Holosystolic murmur heard best at lower left sternal border (LLSE) D = More common with Anterior AMI |
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Which is correct regarding Papillary muscle rupture with AMI ? A. It occurs in 5% AMI. B. It typically occurs on day 2 post AMI. C. The murmur is a new holosystolic type with mitral regurgitation. D. The anteromedial papillary muscle is most commonly ruptured. |
C. A = 1% AMI B = Typically occurs days 3-5 D = the posteromedial papillary muscle most commonly ruptured. |
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In regards to post AMI pericarditis, which of the following is incorrect ? A. It occurs in 5% patients with AMI. B. It generally occurs days 2-4 post AMI. C. Pericardial effusions are more common than pericarditis. D. Pericarditis can be present in the absence of a pericardial effusion. |
A. Post AMI pericarditis in 10-20% |
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In regards to Dressler Syndrome Post AMI, which of the following is correct ? A. It occurs 1-2 weeks post AMI. B. Treatment is with high dose aspirin. C. NSAIDS are added to aspirin for Dressler Syndrome. D. Dressler Syndrome = chest pain + pleuropericarditis - without fever. |
B. aspirin 650 mg QID A = 2-10 weeks post AMI C = NSAIDS interfere with aspirin's anti platelet activity (and can cause myocardial scar thinning and infarct expansion) D = Fever is present |
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Which of the following is incorrect regarding the Killip classification system ? A. It risk stratifies Myocardial infarction patients. B. It has 4 classes : I - IV C. The original study was a RCT in 1967 D. Class III has frank pulmonary oedema. |
C. The study was a case series with unblinded, unobjective outcomes, not adjusted for confounding factors, nor validated in an independent set of patients. The setting was the coronary care unit of a university hospital inthe USA. |
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List the symptoms / signs of the 4 Classes of the Killip Classification System. |
Class I : No signs of heart failure Class II : elevated JVP / S3 gallop / Lung crackles Class III : Frank Pulmonary oedema Class IV : Hypotension / Cardiogenic shock Evidence of peripheral vasoconstriction: ( Oliguria / cyanosis) |
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What are the current 30 day mortality rates in each Killip Classification ? |
Class I : 2.8% 3% [5%] Class II : 8.8% 9% [ 15-20% ] Class III: 14.4% 15% [ 40%] Class IV : 81% 80% ** Alternative source Figures from Dunn |
