Acute Mi (St Elevation)

Front 1

Most common cause of acute MI

Back 1

Destabilization of atherosclerotic plaque with subsequent thrombus formation

Front 2

Name 2 causes of acute MI where thrombolytic therapy is contraindicated

Back 2

Embolic phenomenon
Thoracic aortic dissection

Front 3

3 " big factors" in diagnosis of acute MI

Back 3

Symptoms
EKG
Serum cardiac markers


Dont need to meet all 3 - can meet just two - dont need to wait for cardiac markers

Front 4

Detects MI as a “hot spot” on the nuclear scan between 24 hours and 5 days after symptom onset – not useful in acute setting

Back 4

99mTc-pyrophosphate scan

Front 5

Positive scan (a “hot spot” on the nuclear scan) may be seen in:
Acute MI
Unstable angina pectoris
Active myocarditis
Cardiac transplantation rejection

Back 5

111In-antimyosin scan

Front 6

Differential diagnosis of chest discomfort - CARDIOVASCULAR

Back 6

-Acute MI
-Unstable angina
-Prinzmetal’s (variant) angina
-Acute pericarditis
-Valvular heart disease (AS, MVP, MS)
-Hypertrophic cardiomyopathy
-Thoracic aortic dissection
-Myocarditis (occasionally)

Front 7

Patient presents with jabbing sensation in chest, gets better on sitting up, worse when taking a breath - diagnosis

Back 7

Acute pericarditis

Front 8

Differential diagnosis of chest discomfort - PULMONARY

Back 8

-Pumonary embolism (PE)
-Pneumothorax
-Bronchitis
-Pneumonia
-Pleuritis (pleurisy)
-Asthma
-Severe pulmonary hypertension

Front 9

Differential diagnosis of chest discomfort _ GI

Back 9

-Esophagitis
-Esophageal spasm
-Gastritis
-Peptic ulcer disease (PUD)
-Biliary colic (cholecystitis, etc.)
-Pancreatitis
-Mallory-Weiss syndrome - tear from excessive vomitting (alcoholics)

Front 10

Differential diagnosis of chest discomfort - Musckuloskeletal

Back 10

-Costochondritis
-Tietze syndrome:Tenderness and swelling of the costal cartilage
-Myositis
-Somatic dysfunction
-Chest or upper extremity trauma
-Thoracic outlet syndrome – 1st rib dysfunction

Front 11

Differential diagnosis of chest discomfort - Neurological

Back 11

-Herpes zoster
-Intercostal neuralgia

Front 12

How do you decrease myocardial oxygen demand

Back 12

-Bed rest
-NPO until stable
-Double product Beta blockade (unless contraindicated)
Other antihypertensives (if BP is elevated)
Avoid agents known to cause reflex tachycardia
Digoxin - may be of value for tachycardia associated with hypotension or CHF
-Analgesics

Front 13

How do you increase myocardial oxygen supply

Back 13

-Supplemental O2
-Relieve pulmonary vascular congestion (if present)
-Diuretics, IV NTG, MSO4
-Acute revascularization
-Thrombolytic therapy
Standard of care (in hospitals without primary PCI capability)
-Mechanical revascularization
-Catheter-based intervention
-CABG surgery
-Intra-aortic balloon pump (IABP)-If cardiogenic shock and if cath lab available

Front 14

Benefits of using thrombolytic therapy

Back 14

-Lyses occlusive coronary thrombus rapidly
-Improves LV function
-Reduces both short-term and long-term mortality

Front 15

Risks of thrombolytic therapy

Back 15

-Bleeding
-Anaphylaxis (SK and APSAC)
-Hypotension
-Arrhythmia (reperfusion)

Front 16

Time frame for most beneficial use of thrombolytics

Back 16

Less than 6 hours from onset

Front 17

Less beneficial but still worthwile use of thrombolytic therapy - time frame

Back 17

6-12 hours from onset

Front 18

Time frame when thrombolytic therapy gives little apparent benefit unless there is ongoing chest discomfort or a “stuttering” course

Back 18

Over 12 hours from onset

Front 19

EKG criteria for acute MI

Back 19

-ST segment elevation > 1 mm in 2 or more contiguous precordial or limb leads
-New (or presumed new) LBBB
-ST segment depression with prominent R waves in leads V1 and V2, if this is thought to represent a posterior wall infarction rather than unstable angina

Front 20

Which therapy is standard of care in patients with MI

Back 20

Thrombolytic

Front 21

Name contraindications for thrombolytic therapy

Back 21

-Any prior intracranial hemorrhage
-Known structural cerebral vascular lesion (e.g., arteriovenous malformation)
-Known malignant intracranial neoplasm (primary or metastatic)
-Ischemic stroke within 3 months (except acute ischemic stroke within 3 hours)
-Significant closed-head or facial trauma within 3 months
-Suspected aortic dissection
-Active bleeding or bleeding diathesis – problem with coagulation (excluding menses)

Front 22

Indications for catheter based intervention

Back 22

-Patients at high risk for thrombolytic therapy
-Cardiogenic shock

Front 23

Indications for CABG

Back 23

-Patients with CAD which is not amenable to catheter-based revascularization
-Patients with mechanical complications of acute MI

Front 24

IV nitroglycerin should be avoided in _

Back 24

Right ventricular infarctions

Front 25

Medications to avoid unless a clear-cut indication exists in a patient with aMI

Back 25

-Calcium channel blockers
-Lidocaine
-IV magnesium

Front 26

Mechanical complications of MI

Back 26

Acute mitral regurgitation
Ventricular septal rupture
Ventricular pseudoaneurysm
Ventricular free wall rupture

Front 27

Most mechanical complications of MI can be diagnosed by _

Back 27

ECHO

Front 28

Most mechanical complications of MI can be treated by _

Back 28

IABP insertion followed by emergent open-heart surgery

Front 29

Peak incidence of mechanical complications of MI

Back 29

3-5 days

Front 30

Patient with MI + a. fib.flutter - management?

Back 30

-Electrical cardioversion if patient is unstable
-Otherwise, control ventricular rate with medical therapy (beta-bockade, digoxin) and anticoagulate.

Front 31

Patient with MI + V fib/V tach - do you need to do EPS

Back 31

Generally, EPS is not indicated if V. tach. or V. fib. occurs within 48 hours of acute MI.

Front 32

Treatment for patient with MI +
BRADYARRHYTHMIA
-Sinus bradycardia
-AV block
-Asystole

Back 32

-Observation only
-Atropine
-Temporary pacemaker (external or transvenous)
-Permanent cardiac pacemaker