ACSs

Question 1

Risk factors for Coronary Artery Disease (there are 11)

Answer 1

1. Family hx of MI
2. HTN
3. Smoking hx
4. Hyperlipidemia
5. Increasing age
6. Postmenopausal state
7. Obesity
8. Diabetes mellitus
9. Other vascular disease
10. Sedentary lifestyle
11. Cocaine/amphetamine use

Question 2

MI results LESS commonly from this … that limits myocardial O2 delivery

Answer 2

Severe anemia or hypoxemia

p.182

Question 3

NSTEMI is diagnosed how?

Answer 3

non-ST elevation with elevation of biochemical markers

Question 4

Physical exam/assessment should include:

Answer 4

1. Vital signs and general observation
2. Jugular vein distention
3. auscultation of the lungs and heart
4. Evaluation of the peripheral pulses
5. Detection of neurologic deficits
6. Assess for evidence of systemic hypoperfusion

Question 5

Are the following symptoms High/Intermediate/or Low risk for death:

• Increasing frequency/severity/duration of pain
• lower threshold for pain
• normal or unchanged electrocardiogram during pain
• normal troponin

Answer 5

Low risk

Question 6

Are the following symptoms High/Intermediate/or Low risk for death:

• Ongoing pain at rest (>20 min)
• Pulmonary edema, S3, or rales
• Hypotension
• Bradycardia, tachycardia
• Age >75
• Rest angina w/dynamic ST-segment changes >0.05 mV
• Elevated troponin

Answer 6

High risk for death

Considered to have a greater than 6% risk of dying w/in 6 months

Question 7

Are the following symptoms High/Intermediate/or Low risk for death:

• Prolonged rest pain (>20 min) now resolved
• Rest pain <20 min or relieved with nitroglycerin
• Age >70
• T wave inversions >0.2 mV
• Pathologic Q waves
• Slightly elevated troponin (<0.1 ng/mL)

Answer 7

Intermediate risk for death

Considered to have 3-6% 6-month mortality rate.

Question 8

What are some other reasons for prolonged chest pain?

Answer 8

• Aortic dissection/ aortic aneurysm
• Myocarditis
• Pericarditis
• Hypertrophic cardiomyopathy
• Esophageal and gastrointenstinal disorders
• Pulmonary diseases: pneumothorax, PE, pleuritis
• Hyperventilation syndrome
• Aortic syndrome
• Musculoskeletal or chest wall dzs: costochondral pain
• Psychogenic pain

Question 9

New-onset shortness of breath and/or new L BBB should be considered possible evidence for what?

Answer 9

ACS, particularly in women and diabetic patients, who may have atypical presentations.

Question 10

What heart sound MAY be heard during episodes of pain?

Answer 10

S4

Question 11

Should NSTE-ACS patients be able to be independent in their room?

Answer 11

No, bed or chair rest.

Question 12

O2 and cardiac patients. Does everyone get it?

Answer 12

No, only those showing hypoxemia (<90%) or dyspnea.

Evidence is showing that supplemental O2 for those w/normal oxygenation has untoward effects:
Increased coronary vascular resistance, reduced coronary blood flow, increased risk of death.

Question 13

What anti-ischemic analgesic agents are used?

Answer 13

Nitroglycerin

Morphine for refractory pain

Question 14

What anti-ischemic anti-platelets are used?

Answer 14

Aspirin
Clopidogrel (Plavix)
Prasugrel (Effient) - contraindicated if hx of stroke
Tricagrelor (Brilinta)

Question 15

What anticoagulant agents are used?

Answer 15

• Heparin (unfractionated or LMWH)

Bivalirudin

Fondaparinux

Question 16

What medications should not be initiated r/t potential increase risk for major adverse cardiac events, especially long-term use.

Answer 16

NSAIDS

*other than ASA (acetylsalicylic acid) and COX-2 inhibitors

Question 17

The following symptoms are contraindications for what medication?

• HR <50
• Mod-severe LV dysfunction (uncompensated)
• Shock or increased risk for cardiogenic shock
• Marked first-degree AV block (w/PR >0.24 s)
• Second-degree or third-degree HB (w/out pacemaker)
• Systolic BP <90
• Peripheral hypoperfusion
• Active bronchospastic dz (asthma, COPD)

Answer 17

B-Blockers

Propanolol
Metoprolol
Atenolol
Carvedilol

Question 18

Anti-Ischemic Therapy Rx for NSTEMI:

Answer 18

• Nitroglycerin
• Morphine sulfate
• B-Blockers (unless contraindicated)
• Diltiazem (calcium channel blocker)

Question 19

What does T wave inversion suggest?

Answer 19

Ischemia

Question 20

When is nitro contraindicated?

Answer 20

RIGHT sided MI

nitro will reduce preload. these pts are preload-dependent… they will decompensate.

Question 21

Best vasopressor?

Answer 21

Norepinephrine - Levophed

Question 22

Most common finding in pt’s w/NSR? This will indicate decreased LV compliance at the end of ventricular filling:

Answer 22

S4

Bibasilar crackles e/t pulmonary edema may also be present and helpful in assessing the hemodynamic status.

Question 23

What neuro exam should be done?

Answer 23

Limited. To determine prior stroke or cognitive deficits.

Question 24

Is PCI contraindicated by the presence or need of TTM?

Answer 24

No. Coma nor TTM should not prevent PCI.

Question 25

Ideally, thrombolytic therapy should be initiated w/in 30 minutes of arrival to hospital. Limitation of infarct size is optimized when fibrinolytis are given w/in 6 hours of symptoms onset. But they may have some benefit as long as 12 hours after onset.

Answer 25

FYI, if PCI cannot be performed w/in 120 min of arrival, fibrinolytic therapy should be considered.

Question 26

Fibrinolytic agents used in STEMI (4 of them):

Answer 26

* Streptokinase: 1.5 million units IV over 30-60 min * Alteplase: 15 mg IV bolus then 0.75 mg/kg (max 50mg) IV over 30 min, then 0.50 mg/kg (max 35mg) IV over 60 min. Reteplase Tenecteplase

Question 27

Continuing therapy includes what medications

Answer 27

Oral Beta Blockers: should be initiated w/in the first 24 hours after the STEMI pt stabilized. Long term use of these agent is helpful in all pts who are at risk for recurrent events. ACE inhibitors: decrease risk of death in all STEMIs Greatest benefit seen in those with LV dysfunction (EF <40%), anterior infarct, or pulmonary congestion

Question 28

Why aren't long-acting calcium channel blockers useful?

Answer 28

They may be useful as secondary therapy for recurrent MI but aren't appropriate for first-line treatment.

Question 29

Which calcium channel blockers are contraindicated in STEMIs?

Answer 29

Immediate-release nifedipine Diltiazem and Verapamil are also contraindicated in LV dysfunction and HF

Question 30

r/t HF or cardiogenic shock: Pt's w/systolic arterial pressure >100 and low cardiac output should be treated initially with what?

Answer 30

Vasodilator. IV nitroglycerin or nitroprusside (doses of 0.3 to 1 ug/kg/min, titrated by 0.5 Q 10 min).

Question 31

r/t HF or cardiogenic shock: After initial treatment of vasodilator. If arterial pressure decreases or cardiac output remains inadequate, what should be done next?

Answer 31

Inotropic support. Dobutamine should be initiated (1-2 ug/kg/min) and titrated to no greater than 15 ug/kg/min. Milrinone is an alternative w/less arrhythmogenic effect than dobutamine, though it is often associated with hypotension. ALSO loop diuretics IV or orally Q 2-4 H should be used to reduce pulmonary congestion. Use with caution in hypotensive patients.

Question 32

What do patients have when their systolic arterial pressure is <90 mm Hg and they have low cardiac output?

Answer 32

Cardiogenic shock

Question 33

What pressor should be started in cardiogenic shock?

Answer 33

Norepinephrine (Levophed)

Question 34

Interventional therapy w/assistive devices may be indicated in pts with pump failure who don't repond promptly to medical therapy. These devices can stabilize the hemodynamic status enough to allow PCI or coronary bypass surgery.

Answer 34

Evidence suggests that pts w/STEMI who develop shock w/in 36 hrs benefit from early invasive reperfusion regardless of the time delay from onset of MI. In pts with 1-2 vessel dz = PCI prefered. In pts with 3-vessel dz or significant left main coronary artery dz should undergo urgent consultation for coronary bypass surgery. PCI should also be performed in STEMI pts with severe HF and/or pulmonary edema and onset of symptoms w/in 12 hrs.