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48 Cards in this Set
- Front
- Back
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What is acute coronary syndrome |
Describes myocardial ischemic chest pain |
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What conditions make up acute coronary syndrome |
1. Unstable Angina 2. NSTEMI 3. STEMI |
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What causes ischemic symptoms |
Imbalance between O2 supply and demand |
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What causes the abrupt change in O2 supply in ACS |
Plaque rupture and thrombosis |
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What causes a STEMI |
Complete occlusion
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What causes an NSTEMI or Unstable Angina |
Partial occlusion |
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What are some characteristics of Ischemic (low O2) chest pain |
1. SOB, N/V, Diaphoresis, fatigue 2. Provoked with exertion or emotional stress 3. Radiate to arm, neck and jaw 4. Pain poorly localized or pressure 5. Relieved with Nitroglycerin |
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What are some characteristics of chest pain that are less likely a cardiac origin |
1. Pleuritic 2. Mid-lower abdomen 3. Reproducible with palpation 4. Lasts a few seconds 5. Radiates to lower extremities 6. Pain that is sharp or stabbing |
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What are some risk factors for CAD |
1. DM 2. HTN 3. FHx 4. Hyperlipidemia 5. Smoking |
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What are risk factors good at determining |
How serious the ACS can be
Poor outcome if ACS is established |
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How do women typically present |
More likely to present with angina equivalents or atypical radiation |
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Is in-hospital risk for mortality higher or lower for women |
Higher due to NSTEMI (long time to get EKG, less anticoagulation, less anti platelet, less PCI) |
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What is the pathophysiology of cocaine on the heart |
Coronary vasospasm Thrombosis Increased myocardial demand |
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When should you think of cocaine as the cause of chest pain |
if pt < 40 y/o and has ACS |
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1. Are there any cardiac biomarkers with Unstable Angina
2. Any EKG changes |
1. No, because no cell death
2. May be present |
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1. Does NSTEMI have cardiac biomakers
2. Are there any EKG changes |
1. Yes
2. There are changes but not in the ST segment |
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What provokes a STEMI |
Reduced coronary blood flow resoling in myocardial ischemia |
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1. Are there positive cardiac biomarkers for a STEMI
2. Are there any changes in the EKG |
1. Yes
2. ST elevation |
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What are the clinical presentations for Unstable Angina/NSTEMI |
1. Chest pain of new onset 2. Pain progressing in severity, duration, and frequency 3. Chest pain at rest 4. Chest pain needed treatment 5. Changes in EKG |
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When should and EKG be done |
Upon arrival in ER |
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Do you just do 1 EKG |
No, need to do serial EKG because 55% of the time 1st EKG is normal |
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What are some changes to the EKG that are predictive of poor outcomes with ACS |
1. ST segment deviations greater than 1 mm (1 block)
2. T wave inversion in multiple leads and > 2 mm |
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If a patient has symptoms of ACS and a NEW left bundle branch block what should it be presumed to be |
STEMI |
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If a patient has symptoms of ACS and an OLD left bundle branch block what is presumed |
Worse prognosis |
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What are biomarkers |
Intracellular proteins that are released from cardiac cells when they die |
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What are the 3 cardiac biomarkers measured |
1. Troponin (Gold Standard) 2. Creatine Kinase (CK-MB) 3. Myoglobin |
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What is the second choice biomarker |
CK-MB |
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1. When is CK-MB elevated 2. What is its Peak 3. When is it eliminated |
1. 3-4 hours 2. ~ 1 day 3. 2 days |
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1. When is High Sensitivity Troponin released 2. How long does it stay elevated for
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1. Early 2. 7-14 days |
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What does a negative TNT mean |
You can rule out an MI |
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What must happen to the TNT to be able to diagnose an MI |
TNT values must rise |
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1. When is myoglobin elevated 2. What is its peak 3. Should you use it |
1. 1 hour 2. 6 hours 3. No |
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What are the 7 TIMI Risk Stratification for Death/MI |
1. Age > 65 2. At least 3 risk factors for CAD 3. Known CAD 4. Prolonged rest pain > 20 min 5. Dynamic ST deviation > 0.05 mv 6. Use of ASA within 7 days 7. Elevated biomarkers (esp TNT) |
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What are the TIMI Risk Scores |
0 = 2% risk of death/MI in 30 days 1 = 5% (low) 2 = 10% (low) 3 = 20% (moderate) 4 = 40% (high) 5 = 100% (high) |
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What are 6 other risk factors for adverse outcome that are not included in the TIMI score |
1. Increase risk of CHF (low ejection fraction) 2. Low BP 3. High HR 4. Elevated Cr 5. DM 6. Male |
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What is the treatment of STEMI |
Morphine Oxygen Nitrates ASA
Beta Blocker ACEi Clopidogrel Heparin |
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What is Morphine used for |
Pain when STEMI is unresponsive to nitrates |
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Should you used morphine for unstable angina and STEMI |
No because can increase mortality |
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What is the target for oxygen |
> 90% |
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How much Nitrate should you give |
0.4 mg sublingual q5min Repeat twice if needed |
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When should you be cautious with Nitrates |
1. Systolic < 90 2. HR > 100 3. RV infarction 4. Phosphodiesterase inhibitors (viagra within 24 hours, Cialis within 48 hours) |
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How much ASA should be given |
160-325 mg chew and swallow |
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Which intervention has the greatest survival improvement |
ASA |
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How much Clopidogrel should be given |
Loading dose 300 mg then 75 mg /day
600 mg load prior to percutaneous coronary intervention |
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Which works better LMWH or UFH |
both work the same
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What should you not do with Heparin |
Switch from one form to another because it can increase the risk of bleeding |
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When do you give a beta blocker |
24 hours if no sign of CHF or shock |
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When do you give an ACEi |
Within 24 hours of onset of ACS particularly in patients with depressed LV function or CHF |
