453: Test 2 ACS and MI

Question	Answer
Leading cause of death in the US? Most common type of cardiovascular disease?	Cardiovascular disease CAD most common Atherosclerosis most common cause of CAD
______________ (CRP) – marker of inflammation. Chronically elevated CRP associated with unstable plaques. _________ often given to these patients	C-reactive protein Folic acid
Goals for Ideal CV Health for Adults 20 years and older	Total cholesterol < 200 mg/dL BP < 120/80 (some caveats here) Fasting glucose - < 100 mg/dL BMI < 25 Smoking abstinence Physical activity > 150 min/week, moderate intensity Heart Healthy Diet (eg. DASH)
Pathophysiology ACS specific to OCCLUSION	OCCLUSION OF CORONARY ARTERY endothelial damage occurs--> ARTHEROSCLEROTIC PLAQUE DISRUPTION AND PLATELET AGGREGATION thrombus formation
Pathophysiology ACS specific to VASOSPASM	Vasospasm is primary but much less common then plaque rupture. 10 % 0f MI’s occur with no CAD. May be higher in women! Secondary vasospasm occurs in reaction to rupture and contributes to→ thrombus formation.
Management of ACS	Assess immediately to diagnose STEMI or NSTEMI? Normal ECG - low risk for AMI, but important to continue evaluating
Managment of ACS STEMI vs NSTEMI	STEMI- get the artery open ASAP NSTEMI- provide anti-ischemic and anti-platelet therapy ASAP
ACS time frame: Door to needle____ Door to ballon____	Door to Needle<30 min Door to Balloon <90 min
What should be administer for a patient with chest pain after a history and focus physical exam?	ASA
Acute Coronary Syndrome: work up includes completed H&P, Trop I, CK MB, EKG what do these findings indicate: No ST-segment elevation Neg Markers	Unstable angina
Acute Coronary Syndrome: work up includes completed H&P, Trop I, CK MB, EKG what do these findings indicate: No ST-segment elevation Pos Markers	NonSTEMI
Acute Coronary Syndrome: work up includes completed H&P, Trop I, CK MB, EKG what do these findings indicate: ST-segment elevation Pos Markers	STEMI
Difference between how men and women present with ACS/MI women	Women: SOB and fatigue are very common presenting factors Absence of chest pain at presentation is associated with higher mortality. #1 cause of death in women
What in the heck differentiates stable and unstable angina??	Unstable angina is in a patient who usually has angina but this time is different then before
Difference between how men and women present with ACS/MI Men	More traditional signs of a MI
What’s the Evidence for Women with ACS?	Women’s Ischemic Syndrome Evaluation (WISE) study. Half of the women have microvascular disease – blockage in the smallest vessels. Doesn't always show up in coronary angiography. Stroke accounts for a larger % of CVD events in women compared with men.
Tx of MI in ED	Triage appropriately Cardiac monitor (12 lead EKG) Meds: ANTI-PLATELET (ASA), nitrates, beta blockers and anticoagulants Urgent cardiac cath for NSTEMI **Direct PCI (percutaneous coronary intervention) or fibrinolytic agent for STEMI and cath lab!
Patient History and Physical Exam with ACS/MI	assess pain- PQRST (PAIN, QUALITY, RADIATION AND RECURRENCE, SEVERITY & TIME FRAME) dyspnea, epigastric, upper extremity pain? age, race, co-morbidites, family/social hx
The million other things chest pain could be besides an MI (reference not memorization)	♥ Aortic Dissection ♥ GERD ♥ Pulmonary Embolism ♥ Pleurisy ♥ Perforating Ulcer ♥ Chest wall pain ♥ Tension Pneumo ♥ Peptic Ulcer ♥ Pericarditis ♥ Panic Attack ♥ Myocarditis ♥ Bilary/pancreatic pain ♥ Vasospastic angina ♥ Cervical disc ♥ Neuropathic Pain♥ Takotsubo disorder ♥ Psychiatric ♥ Cardiomyopathy
EKG and MI	Goal: 12 lead in first 10 minutes NORMAL EKG DOESNT DX ACS/MI ST SEGMENT ELEVATION is primary identifier of STEMI T-wave inversions and pathologic Q-waves develop. These differentiate “old” MIs
ST DEPRESSION tend to imply	ISCHEMIA
ST ELEVATION tends to imply	INFARCTION
Anterior STEMI results from occlusion of the ________________	LEFT ANTERIOR DESCENDING (LAD)
Anterior myocardial infarction CARRIES THE ______ PROGNOSIS of all infarct locations, mostly due to larger infarct size.	WORST
ST SEGMENT ELEVATION IN THE ______LEADS AND THE ________ LEADS	PRECORDIAL LEADS (V1-6) HIGH LATERAL LEADS (I AND aVL) Reciprocal ST depression in the inferior leads (mainly III and aVF).
__________MI account for 40-50% of AMIs USUALLY OCCURRING IN THE________	inferior MI RCA
Inferior MI ST ELEVATION IN LEADS_________	II, III AND aVF Progressive development of Q waves in II, III and aVF Reciprocal ST depression in aVL (± lead I)
Pharm management in MI first medication priority and why	ASPRIN TO DECREASE PLATELET ADHESIVENESS- CHEWABLE
Pharm management of MI and why	Morphine: decrease pain & Myocardial 02 consumption/vasodilates vasculature O2: 02 demand & optimizes delivery Nitrates: Relieve ischemic pain by ^ flow & decreasing the workload through vasodilation. Give: Nitroglycerin (sublingual, spray,topical,IV) Beta Blockers: Relieve ischemia by decreasing contractility, HR & ventricular wall tension Give: Atenolol, Metoprolol
Considerations with pharm management in a MI patient	Start PO in 1st 24 hours unless heart failure, low CO, heart block, prolonged PR, active asthma, reactive airway Dx Do not give IV Beta blockers to STEMI patients
Cardiac Markers: ________ is the preferred biomarker!	TROPONIN Troponin is sensitive and specific, it detects even minimal damage to the myocardium ultra sensitive
HOW TO PROPERLY MONITOR TROPONIN	OBTAIN BASELINE THEN IN 6 HR AND 12 HR. CHEST PAIN CENTERS MAY OBTAIN EVERY 4 POSITIVE IS > OR = 0.04
OTHER CAUSES OF ELEVATED TROPONINS	cardiac contusion myocarditis sustained tachycardia apical ballooning (angioplasty) chronic renal disease HF, sepsis, burns extreme exertion
Other cardiac markers: What are they? What do they measure?	CK/CK-MB: Iso leak in 6-24 hrs. Can cause false positive if only marker used. CK-MB fraction is specific for cardiac damage. MYOGLOBIN: (sensitive) elevation 1-2 hr after symptom onset. Not specific for MI cause lg amount in skeletal muscles.
What is BNP? WHAT DOES IT TRIGGER?	B-Type Naturetic Protein is a marker that is released when there is stretch occurring in the ventricle. The more stretch the more the muscle is placed under jeopardy of failure. NORMAL BNP <100
KEY COMPONENTS OF RELIABLE EVIDENCE BASED ACUTE MI CARE (7 steps)	1. Early administration of Aspirin 2. Aspirin ordered as a dc medication 3. Early administration of beta blockers 4. Beta Blockers ordered as a dc med 5. ACE1 or ARB ordered as a dc med for patients with LV systolic dysfunction 6. Timely reperfusion w/ fibrinolytics or PCI 7. Smoking cessation counseling given
If a patient has 2 sets of negative cardiac enzymes and no significant ECG changes he/she will be sent for some form of direct evaluation of the heart What will this include?	exercise stress test or stress echo nuclear stress i.e. Persantine, Thalium Dobutamine Echo
OBJECTIVES OF EXERCISE STRESS TESTS	Diagnose functionally significant coronary artery disease Evaluating functional capacity need for medical or surgical therapy
LIMITATIONS OF THE EXERCISE STRESS TEST	Women- high false positive BETA BLOCKERS BLOCKS MAX HR & MAX WORK SO DECREASED SENSITIVITY BBB and pre-excitation conduction abnormalities make stress tests uninterpretable
What would make us want to immediately stop a stress test?	in class
When to use a chemical stress tests?	Preferable to standard exercise stress in patients with: abnormal resting ECG, BBB, LVH, pacemaker. It also helps to localize the culprit lesion which may help direct PCI
Pharmacologic Stress Test: Uses___________,___________, or____________ which:	Dobutamine, Adenosine, Dypridamole ↑ myocardial work load in patients unable to exercise Adenosine & Dypridamole are contraindicated in patients with bronchospasm or high grade AV block Theophylline and caffeine decrease the effectiveness of the test
If the stress test is positive then the patient will be sent for a ________ _______ where direct visualization of the______ arteries can be done. If significant occlusions are noted, they are opened with______ and possible stent placement whenever possible	cardiac catheterization coronary angioplasty
stable vs unstable angina	unstable is different angina then their regular angina

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453: Test 2 ACS and MI

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