M2-C5-L45 --> Acute Myocardial Infarction

Front 1

INTRODUCTION

- In AMI, plaques can build up in what arteries?

- These atherosclerotic plaques can do what?

Back 1

- Coronary arteries

- Rupture

Front 2

DEFINITION

- what form at rupture site?

Back 2

- thrombus

Front 3

DEFINITION

- The thrombus results in reduction of blood flow to the portion of the myocardium supplied by the?

Back 3

- affected Coronary artery

Front 4

DEFINITION

- thrombus induced lack of blood flow leads to?

Back 4

- myocardial necrosis

Front 5

DEFINITION

- what are the biomarkers of Mycardial Necrosis? x2

Back 5

- Troponin

- CK-MB

Front 6

DEFINITION

- In addition to elevated biomarkers, at least 1 of 4 criteria must be met. What are they? x4

Back 6

(NC II)
o New Q-wave on EKG
o Coronary angioplasty
o Ischemic symptoms
o Ischemia on EKG
(ST elevation or depression)

Front 7

DEFINITION

- Non-ST elevation MI is associated with? x2

Back 7

- Acute Coronary Syndrome

- Unstable Angina

Front 8

DEFINITION

- Define Ischemia

- Ischemia clinical Sx?

- Ischemia subclinical Sx?

Back 8

- decreased blood supply

- chest pain

- cardiac dysfunction

Front 9

DEFINITION

- Define Injury

- Define Necrosis

Back 9

- DAMAGE to Cardiac muscle

- DEATH of Cardiac muscle

Front 10

DEFINITION

- Define Collateral

Back 10

a secondary blood pathway which provides blood supply following obstruction of the main channel

Front 11

DEFINITION

Q-wave Infacrtion

- myocardium wall involvement?

- state of coronary artery?

Back 11

Transmural
(involves entire wall thickness)

Totally obstructed coronary artery

Front 12

DEFINITION

Non-Q-wave Infacrtion

- myocardium wall involvement?

- state of coronary artery?

Back 12

Non-transmural
(only some myocardium layer affected)

Highly narrowed, but partly open cornary artery

Front 13

SIGNS & SYMPTOMS

- Primary Sx?

- Primary Sx duration

- Primary Sx description x4

Back 13

Crushing substernal chest pain

Usually lasts longer than 30 min

CP may be described as:
o Pressure
o Heaviness
o Tightness
o “Like an elephant sitting on the chest”

Front 14

SIGNS & SYMPTOMS

- Pain is UNrelieved by? x2

- Pain could also be?

Back 14

- Rest
- Sublingual nitroglycerin

Or
Pain is rapidly recurring

Front 15

SIGNS & SYMPTOMS

- What % of MI's have NO pain?

- This has greater prevalence in what population groups? x2

Back 15

- 20%

- DM
- Elderly

Front 16

SIGNS & SYMPTOMS

- Besides the chest, Pain may also occur in?

Back 16

- Back

Front 17

SIGNS & SYMPTOMS

- Pain may radiate to? x5

Back 17

(JEANS)
- Jaw
- Epigastrium
- Arms (Left or Right)
- Neck
- Shoulders

Front 18

SIGNS & SYMPTOMS

- MI Pain does NOT have what character?

Back 18

- Not Pleuritic in character

Front 19

SIGNS & SYMPTOMS

- list the non-pain Sx. x9

Back 19

(CLAWS SAND)
- Cough
- Lightheadness
- Anxiety
- Weakness
- Syncope

- SOB
- All-of-a-Sudden Death
- Nausea / Vomiting
- Diaphoretic

Front 20

LEVINE'S SIGN

- what is the sign?

- used to describe?

- MI Sensitivity?

- MI Specificity?

Back 20

Clenched fist held over the chest

chest pain

sensitivity of 80% for MI

Specificity is poor

Front 21

PHYSICAL EXAM

- Describe the skin on PE of MI pt x2

Back 21

- Diaphoretic

- Pallor

Front 22

PHYSICAL EXAM

- Pallor of skin is indicative of?

- Diaphoretic skin is indicative of?

Back 22

- Decreased O2

- CHF

Front 23

PHYSICAL EXAM

- Auscultation of MI pt might reveal what? x4

Back 23

o Crackles
o Murmur of mitral regurgitation
o S3 – early filling
o S4 – atrial kick

Front 24

PHYSICAL EXAM

Crackles indicative of?

Murmur of mitral regurgitation indicative of? x2

S3 – early filling indicative of?

S4 – atrial kick indicative of?

Back 24

o CHF

o Papillary muscle dysfunction
- Papillary muscle rupture

o Failing LV

o Failing LV

Front 25

PHYSICAL EXAM

- Increased venous pressure can be noted where?

- above is possibly indicative of? x2

Back 25

- Jugular Venous Pressure (JVP)

- RV infarction
- Severe LV Failure

Front 26

PHYSICAL EXAM

- Soft S1 & S2 is indicative of?

Back 26

- Decreased Contractibility

Front 27

PHYSICAL EXAM

- what inflammatory event could be involved in MI?

- how would you discover this on PE?

Back 27

- Pericarditis

- Auscultation: Pericardial Frictional Rub

Front 28

PHYSICAL EXAM

- Systolic murmur might be indicative of? x2

Back 28

- Mitral Regurgitation

- VSD

Front 29

ETIOLOGY

- Majority of MI etiology is from?
- what is the %?

- Remaining etiology from?
- list 2 things that can cause this?

Back 29

- Coronary Atherosclerosis (>90%)

- Coronary Artery Spasms

- Prinzmetal angina
- Cocaine

Front 30

ETIOLOGY

- Cocaine use increases risk how soon after use?

- Risk of MI goes up how much?

- Suspect in whom?

- do what in suspected patients

Back 30

- after 60 mins post use

- 24x's

- MI with normal coronaries

- Blood & Urine Tox screen

Front 31

ETIOLOGY

- MI caused by a Dissection of coronary Arteries may be from what etiologies? x3

Back 31

(CIA loves to Dissect)

- Coronary extension from Aortic dissection

- Iatrogenic

- Aneurysmal

Front 32

ETIOLOGY

- MI caused by a Coronary Embolism may be from what etiologies? x3

Back 32

(Embolic TRI)

- Thrombus of LV
- Rheumatic Heart Dz
- Infective Endocarditis

Front 33

ETIOLOGY

- MI caused by Thrombotic Dz may be from what etiologies? x4

Back 33

(T-SHOP)

- Sickle cell
- Hypercoagulable states
- Oral contraceptives
- Polycythemia vera

Front 34

ETIOLOGY

- describe the etiology involving O2

- List 3 types of etiologies that cause it?

Back 34

- O2 demand exceeds supply

(O2 Demanded by HAL steinbrenner)
- HYPO-tension
- Aortic stenosis
- LVH severe

Front 35

RISK FACTORS

- what are the NON-Modifiable Risk factors? x3

Back 35

(FAGS are NON-modifiable)

- Family Hx of premature CAD

- Advancing Age

- Gender
(male or postmenopausal women)

Front 36

RISK FACTORS

- what are the Modifiable risk factors? x6

Back 36

(Hyper Life style @ ODDS)

- HTN
- Sedentary life-style

- Obesity (esp. central)
- DM
- Dyslipidemia (high LDL, low HDL)
- Smoking

Front 37

RISK FACTORS

- list other risk factors? x4

Back 37

(HEEP)

- Hypertriglyceridemia

- Elevated Lipoprotein A
- Elevated Homocysteine

- Psychosocial factors
(stress, social isolation, depression)

Front 38

WORK UP

- what is the most important test?

- what does it help in doing?

Back 38

- EKG

- Helps guide management

Front 39

EKG

- do all ST-elevations indicate MI?

Back 39

NO

Front 40

EKG

- how would you distinguish an STEMI vs. others?

Back 40

- "Frowny" ST elevation is MI
(convex down)

- "Smiley" ST elevation is likely Pericarditis or J-point notching

Front 41

WORK UP LAB TESTS

- what PROTEIN is released in blood with myocardial damage?

- is it released early or later on in injury?

- used to Dx what?

Back 41

- Troponin

- Early

- DX MI

Front 42

WORK UP LAB TESTS

- A NORMAL Troponin level is a sensitive biomarker to do what?

- Would an ELEVATED Troponin also be helpful in the above?

- why or why not?

Back 42

- rule out MI

- elevated troponin is LESS useful to rule out MI

- other factors can elevate it.

Front 43

WORK UP LAB TESTS

- CKMB is released into circulation in amounts that correlate with?

Back 43

- Size of infarct

Front 44

WORK UP LAB TESTS

- what type of testing is necessary to rule out (or rule in) MI?

- what are the test values? x3

Back 44

- Serial testing

Values @
- Presentation
- 8 hours later
-16 hours later

Front 45

WORK UP LAB TESTS

- with a myocardial injury, describe the character of biomarker levels.

Back 45

- Elevation

- Peak

- Falling or Normalization

Front 46

WORK UP LAB TESTS

- Troponin Elevation time?

- CKMB Elevation time?

Back 46

- both are 4 to 6 hours

Front 47

WORK UP LAB TESTS

- Troponin Peak time?

- CKMB Peak time?

Back 47

- 24 to 36 hours

- 14 to 36 hours

Front 48

WORK UP LAB TESTS

- Troponin Normalizing time?

- CKMB Normalizing time?

Back 48

- 10 to 14 Days

- 2 to 3 days

Front 49

WORK UP LAB TESTS

- patient with CP caused by Pneumonia will need to get what test?

- what is seen on the test?

Back 49

- CXR

- Increased Opacity

Front 50

WORK UP LAB TESTS

- ECHO can detect what in MI?

- describe it

- what is the limitation for this?

Back 50

- Wall Motion Abnormality

- when wall of LV does not contract well

- can not distinguish Old from New WMA

Front 51

WORK UP LAB TESTS

- ECHO is also useful in assessing and evaluating what ? x2

Back 51

- Assessing EF

- Evaluate Complication of MI

Front 52

WORK UP LAB TESTS

- ECHO can see what complications of MI?*******

Back 52

(ECHO is MVP at this)

- Mural Thrombosis

- VSD

- Papillary Muscle Rupture

Front 53

TREATMENT

- what Tx's can you give? x7

Back 53

(Tx the BARON Anally with other meds)

- BB
- ASA
- Reperfusion
- O2
- NTG

- Analgesia

- other meds

Front 54

TREATMENT

- O2 given especially if O2 saturation is?

- O2 is recommended for MI pts when?

Back 54

- less than 90%

- first 6 hours

Front 55

TREATMENT

- ASA is given to produce what effect?

- Good in reducing what bad things? x3

- Dosage?

- Administered how?

Back 55

- Rapid Anti-thrombotic effect

- Mortality
- Re-infarction
- Stroke

- 160 to 325 mg

- should be chewed

Front 56

TREATMENT

- NTG is used in MI for what? x3

Back 56

- CP

- HTN control (transient control)

- Pulmonary congestion management

Front 57

TREATMENT

- NTG is contraindicated in? x5

Back 57

(HPBR)

- HYPO-tension

- PDE-inhibitor last 2 days

- RV infarct

- Bradycardia

- Tachycardia

Front 58

TREATMENT

- BB if used immediately will reduce? x4

Back 58

- Magnitude of Infarct

- Complications

- Re-infarct rate
- Frequency of life-threatening V-tach

Front 59

TREATMENT

- BB is associated with mortality in week 1 how?

- BB is associated with long-term mortality how?

Back 59

- 14% reduction during 1st week

- 23% reduction in long term

Front 60

TREATMENT

- what is the Analgesia of choice in management of Pain associated with STEMI?

Back 60

- Morphine

Front 61

TREATMENT

- Reperfusion Goal?

- what is the door-to-needle time for initiation of thrombolytic therapy?

- what is the Door-to-Needle time for initiation of Angioplasty?

Back 61

- Early reperfusion

- Less than 30 minutes

- Less than 90 minutes

Front 62

TREATMENT

- which is superior: Angioplasty or Thrombolytics?

Back 62

- Angioplasty

Front 63

TREATMENT

- what are the other meds you can use in Tx? x2

Back 63

- ACE-I

- Clopidogrel

Front 64

TREATMENT

- ACE-I's are especially in patients with? x4

Back 64

(Ace is now a Tacky PHD)

- Tachycardia

- Prior MI
- HF
- Depressed EF

Front 65

TREATMENT

- Clopidogrel is considered in what patients?

Back 65

- unable to take ASA

Front 66

TREATMENT OF HYPOTENSION

- what is the Tx for HYPOTENSION? x3

Back 66

- Balloon Counterpulsation
(if unresponsive to other interventions)

- IV fluids
(for pts without volume overload)

- Vasopressor
(if hypotension does not resolve with volume)

Front 67

TREATMENT OF HYPOTENSION

- what test do you run? x2

Back 67

- EKG
(check for rhythm distrubances causing hypotension)

- ECHO
(to eval complications)

Front 68

TREATMENT OF LOW-OUTPUT STATE

- what are the findings indicating HYPO-Perfusion due to Low CO? x4

Back 68

(Lowe's Outpost is a must COME )

- Cyanosis
- Oliguria
- Mentation decrease
- Extremity coldness

Front 69

TREATMENT OF LOW-OUTPUT STATE

- what is the mortality rate in these patients with HYPOperfusion due to low CO?

Back 69

- High Hospital Mortality rate

Front 70

TREATMENT OF LOW-OUTPUT STATE

- Do NOT administer? x2

Back 70

- BB
- CCB

Front 71

TREATMENT OF ARRHYTHMIAS

- Prophylactic use of Lidocaine reduces mortality how much?

- what is treated with electric shock?

Back 71

- no evidence that it does that?

- VF & VT

Front 72

TREATMENT OF ARRHYTHMIAS

- what normalize ionic balance do you want? x2

Back 72

- K+ at Greater than 4.0 mEq/L

- Mg at Greater than 2.0 mEq/L

Front 73

HOSPITAL MANAGEMENT

- Pts with STEMI should be admitted to?

- with Continuous monitoring of? x2

- with access to? x2

Back 73

- CCU

- EKG
- Pulse Ox

- Hemodynamic monitoring
- Defibrillation

Front 74

PROGNOSIS

- Prognosis depends on what 3 things?

Back 74

- Amount of myocardium involved

- Location of infarct

- Re-establishment of blood flow

Front 75

PROGNOSIS

- after total occlusion, myocardial necrosis is complete after?

- myocardium survival depends on? x2

- for myocardium survival, flow to ischemic area needs how much blood flow of Pre-occlusion level?

Back 75

- 4 to 6 hours

- blood getting past obstruction
- collaterals

- >40%

Front 76

PROGNOSIS

- Left Main artery supplies what bulk of LV mass?

- LM occlusion prognosis?

Back 76

- 70%

- Death in minutes

Front 77

PROGNOSIS

- Poor Prognosis Factors x7

Back 77

(Prognosis DIPS like in CHF)

- Cigarettes
- HTN
- Females (esp > 50)

- DM
- Increasing age
- Prior MI
- ST depression in AMI

Front 78

PREVENTION

- what are 2 management plans?

Back 78

- Lipid management

- Weight management

Front 79

PREVENTION

- in lipid management, what kind of diet is recommended?

- LDL should be under?

- how does lowering cholesterol impact MI? x2

Back 79

- Low in saturated fat & cholesterol

- LDL << 100 mg/dL

- Reduces NON-Fatal MI by 25%
- Reduces Fatal MI by 14%

Front 80

PREVENTION

- in weight management, evaluation for what?

- Criteria for central obesity in men and women

Back 80

- Metabolic Syndrome

- Men >40 inches

- Women >35 inches

Front 81

CONCLUSION

- Does myocardium regenerate?

- Does BB decrease Mortality?

Back 81

- NO

- Significantly

Front 82

CONCLUSION

- In MI treated patients receiving ASA and Lytics, what other drug can be added?

- addition of above drug improves what? x2

Back 82

- Clopidogrel

Improves:
- Patency
- Ischemia

Front 83

CONCLUSION

- what is the risk of Sudden Cardiac Death after MI?

- MI can also increase what?

Back 83

- increased risk of 2 to 3 times

- Arrythmias

Front 84

CONCLUSION

- what patients may be at increased risk of Arrythmias post MI?

Back 84

- Frequent Ventricular ectopy
(> = 10 / hour)

Front 85

CONCLUSION

- the larger the infarct, the.....

Back 85

higher the Post MI Mortality Rate

Front 86

CONCLUSION

- Presence of Post MI Angina indicates what?

Back 86

- Higher Mortality rate