4.1 C) Vi) Cardiovascular Myocardial Infarction

Front 1

Reperfusion therapy for AMI and restoration of vessel patency has the following benefits {4}

Back 1

1. reduced infarct size
2. preserves LV function
3. reduces mortality
4. prolongs survival

Front 2

Regarding Primary PCI being superior to thrombolytic therapy, which is incorrect?
1. primary PCI has reduced short term mortality 5.3% vs 7.4%
2. Primary PCI has reduced non fatal reinfarction 2.5% vs 6.8%
3. Primary PCI has reduced stroke 2.3% vs 4.5 %
4. The survival benefit of Primary PCI vs thrombolytic therapy is 20 lives / 1000 treated.
5. Primary PCI has better outcomes in high-risk patients.

Back 2

3. 1% vs 2%

Front 3

Urgent PCI in STEMI can be considered in which patients { 6 answers}

Back 3

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
6. Previous CABG

Front 4

Which medications are initiated < 24 hours of AMI {unless contraindicated}? [4]

Back 4

1. BBlockers
2. heparin {LMW/UFH}
3. ACEI or ARB
4. HMG CoA reductase inhibitor {Statin}

Front 5

Absolute contraindications to Thrombolysis in AMI (5).

Back 5

1. Previous haemorrhagic stroke
2. CVA within 6 months
3. Intracranial neoplasm
4. Active internal bleeding < 2 weeks
5. Aortic dissection {known/suspected}

Front 6

Relative contraindications for thrombolysis in AMI (10}

Back 6

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

Front 7

Mnemonic for Relative Contraindications for Thrombolysis in AMI:
THROMBOSEA

Back 7

T Traumatic CPR
H Hypertension-uncontrolled
BP > 180/110
R Recent Trauma / Surgery <
4 weeks {head included}
O Obstetric = pregnancy
M..
B Brain pathology{ CVA /other}
O Oral anticoagulation
INR > 2.5
S Streptokinase use
E elevated BP {Chronic}
A Allergic reaction

Front 8

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.

Back 8

5. inferior - less benefits {0.8% absolute mortality reduction}
anterior : 3.7% absolute mortality reduction.

Front 9

Streptokinase facts

Back 9

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

Front 10

t-PA facts

Back 10

1. Non antigenic
2. More fibrin selective
3. less systemic bleeding
4. higher patency rates than STK

Front 11

Third Generation Fibrinolytics Facts

Back 11

1. Reteplase / tenecteplase
2. Bioengineered products of t-PA
3. Longer half-lives
4. Similar efficacy and side effect profiles to Second generation fibrinolytics
5. Simpler to administer.

Front 12

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.

Back 12

1. 6.3 vs 7.3%

Front 13

Invasive Strategy-PCI --> {Consider transfer} for PCI if { 7 facts}

Back 13

1. Door to balloon time < 90 minutes
2. High Risk STEMI
a. Age > 75
b. Extensive Anterior
infarction { + late pres.}
c. High risk of bleeding
d. Previous MI/CABG
e. Killip Class > 3
3. Symptom onset > 3 hours

Front 14

Thrombolysis preferred over PCI in the following situations

Back 14

1. Early presentation [ < 3 hours from symptom onset and delay to invasive strategy]

2. Invasive strategy NOT AN OPTION:
a. Cath Lab occupied/ not
available
b. Lack of access to skilled
PCI Lab.
c. Vascular access
difficulties
3. Delay to invasive strategy
a. Prolonged Transport
b. Door-to-Balloon >1 hr
c. Medical contact-to
-Balloon > 90 minutes

Front 15

ISIS-2 Study Facts

Back 15

1. International Study of Infarct Survival
2. aspirin reduced mortality by 23%
3. Aspirin gave 50% reduction in REINFARCTION and STROKE
3. Streptokinase reduced mortality by 25%
4. Aspirin and STK had an additive effect-reducing mortality by 42%
5. treatment for mean 1 month
= 25 fewer deaths
= 10-15 fewer episodes of
non-fatal reinfarction
and non-fatal stroke per
1000 treated

Front 16

Clopidogrel in STEMI

Back 16

1. confers significant additional benefit with aspirin
2. with Thrombolysis : reduces risk of early vessel reocclusion
WITHOUT RISE IN BLEEDING
3. PCI + Stent = benefit
[ benefit less evident with PCI minus stent ]

Front 17

Antithrombin therapy in STEMI

Back 17

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]

Front 18

5 contraindications for commencing ORAL B Blockers within 24 hours in STEMI.

Back 18

1. Pulmonary oedema
2. Hypotension
3. Bradycardia
4. Advanced AV block
5. asthma

Front 19

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.

Back 19

3. Reinfarction in the 10days post AMI occurs in 5-10%

Front 20

Emergent PCI is demonstrated to offer Clinical benefit to patients with ACS/ NSTEMI, with 3 high risk features:

Back 20

1. Elevated Troponins
2. recurrent chest pain
3. Recurrent ECG changes

Front 21

( 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.
C. PCI is contraindicated at 4 hours, in the presence of contraindications to fibrinolysis.
D. PCI ( +/- CAGS) is the preferred option in patients with STEMI and shock.

Back 21

D.

A = Anterior STEMI
B = It does ( CLass B ; LOE II )
C = PCI should be pursued -rather than opting for a "no treatment "strategy".

Front 22

(ARC Guidelines) Which of the following is incorrect regarding ACS?
A. In patients presenting within 12 hours of chest pain onset, perfusion via PCI or fibrinolysis, has been demonstrated to improve outcomes.
B. In patients presenting > 12 hours after the onset of of chest pain, with cardiogenic shock, PCI is still considered beneficial.
C. For PCI to remain superior to fibrinolysis, the PCI delay must not be greater than 45-120 minutes.
D. The maximum acceptable delay from PRESENTATION to balloon inflation, is 90 minutes if presenting > 1 hour since symptoms onset.

Back 22

C. 45-180 minutes.

Front 23

(ARC Guidelines) Which of the following is not an absolute contraindication to Fibrinolysis?
A. Systolic BP > 180 mmHg
B. Ischaemic stroke within 6 months
C. Recent major Trauma / Surgery within 3 weeks
D. GI bleeding within 4 weeks.

Back 23

A.

Front 24

(ARC Guidelines) Which of the following is not a Relative Contraindication to fibrinolysis?
A. Pregnancy- within 1 week post partum
B. CNS AVM / neoplasm
C. Traumatic resuscitation
D. Active Peptic ulcer disease

Back 24

B. Absolute

Front 25

(ARC Guidelines ) Which of the following is incorrect regarding treatment of STEMI?
A. Facilitated PCI is recommended in STEMI. (routine use of fibrinolysis prior to PCI)
B. Rescue PCI is PCI performed after failed thrombolysis.
C. Rescue PCI has a Class A, LOE I for its use.
D. The transfer of STEM patients from Community Hospitals to PCI Centres is supported if they present between 3-12 hours, and the transfer can be achieved within 2 hours.

Back 25

A It is not recommended
Class B ; LOE II.

Front 26

(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.

Back 26

Yes
Class B LOE II

Front 27

( Cameron) Which is incorrect regarding the Likelihood ratios, and ruling in AMI ?
A. The highest likelihood ratio is for Right arm / shoulder radiation : 3.7
B. Diaphoresis association has a LR of 2
C. LR of approx. 2 for "Similar to previous AMI".
D. Radiation to left arm is less than radiation to right arm.

Back 27

A. 4.7 (nearly 5 times increased likelihood)

Front 28

DDx for ST Elevation on the ECG?

Back 28

1. STEMI
2. Myopericarditis
3. LV aneurysm
4. Hypothermia
5. Hyperkalaemia ( Hypercalcaemia)
6. LVH
7. Brugada Syndrome (Type I > Type II, III)
8. BER

Front 29

Which is incorrect regarding diagnosing AMI?
A. 20-50 % of ECG's are normal / non-specific in AMI
B. Troponin I does not definitively rise until 4-6 hours post AMI
C. Echocardiography is highly sensitive for AMI.
D. Negative echocardiography, in the setting of a typical history and normal ECG does not rule out ACS.

Back 29

C. The sensitivity is limited.
Regional wall motion can be evidence supporting ischaemia, BUT it also may be old infarcted tissue.

Front 30

(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.

Back 30

D. Sensitivity 83-100%
Specificity 90-100%

Front 31

Which is incorrect regarding AMI and arrhythmias?
A. When Heart Block occurs with an Anterior AMI, a temporary pacer is usually required.
B. Accelerated idioventricular rhythm is not uncommon post reperfusion- and does not require active treatment C. Higher grade arrhythmias can be treated with Lignocaine or amiodarone.
D. Sustained VT lasting > 30 seconds is not uncommon in AMI.

Back 31

D. It is uncommon.

Front 32

What is the mnemonic for the TIMI risk score for Unstable Angina / NSTEMI ?

Back 32

"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
Increasing angina ( > 2 episodes in 24 hours)
Coronary artery disease (stenosis > 50%)
Aspirin use within 7 days

Front 33

What are the % risks for TIMI scores?

Back 33

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)

Front 34

(Cameron)In which correct order is the likelihood ratios of Clinical features for diagnosing AMI - from highest to lowest?
A. Diaphoresis, pressure , exertional
B. Burning-indigestion-like , Left arm radiation, diaphoresis
C. Nausea and vomiting, diaphoresis, Similar to previous AMI
D. Radiation to Left arm, radiation to Right arm, pressure.

Back 34

B. LR : 2.8 , 2.3 , 2.0

Front 35

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

Back 35

D. Scores 3
The highest is Concordant ST elevation > 1mm in leads with a + QRS.

Front 36

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.

Back 36

B. scores 2

Front 37

What are the Sgarbossa Criteria?

Back 37

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