CHD/ACS

Question 1

What is classic ACS initial therapy

Answer 1

MONA---
Morphine
Oxygen
Nitro (vasodilation)
Aspirin

Question 2

What are atypical symptoms of ACS that women can present with

Answer 2

Fatigue, GI, pulmonary

Question 3

What is angina (general)

Answer 3

clinical syndrome w/ chest, jaw, shoulder, or arm discomfort attributable to coronary ischemia (supply too little for demand)

Question 4

What are the subtypes of angina

Answer 4

• Typical: substernal, provoked by EXERTION/stress, relieved by REST
• Atypical: may be PLEURITIC, reproduced by palpation/MOVEMENT, lasts days or seconds

Question 5

What is stable vs unstable angina

Answer 5

• Stable: develops w/ EXERTION, resolves with REST. short duration
• Unstable: develops AT REST/minimal exertion. lasts longer. D/t insufficient blood flow w/o myocardial necrosis

Question 6

What is NSTEMI/STEMI

Answer 6

angina w/ elevated cardiac biomarkers indicating MI

-Actual muscle is dying

Question 7

What is NSTE-ACS

Answer 7

imbalance of myocardial oxygen consumption and demand causing ischemia/infarct

Question 8

How do you characterize an MI

Answer 8

High or low Troponin w/ at least 1 of following:

• Sx of ischemia
• New ST-T wave changes/LBBB
• Pathologic Q waves
• Loss of myocardium/new RWMA
• Intracoronary thrombus

Question 9

What patients would you use an ischemia guided strategy in, and what is the strategy

Answer 9

Low risk score (TIMI 0-2)
Extensive comorbidities
-Start on meds and plan for stress test

Question 10

What patients would you use an early invasive strategy in, and what is it

Answer 10

New ST depression, elevated trop, recurrent angina, CHF

-Send to cath lab

Question 11

What are some causes of NSTE-ACS

Answer 11

Atherosclerosis
Vasospasm 
Coronary embolism
Dissection
Non-obstructive (HTN, anemia, hyperthyroid)

Question 12

What are some possible findings in CHD PE

Answer 12

Levine's sign
New S4
Paradoxical splitting of S2
New murmur
Pericardial friction rub
CHF/shock

Question 13

What are the 3 P’s that tell you its LESS likely to be a STEMI/NSTEMI

Answer 13

Palpable
Positional
Pleuritic

Question 14

What are some CAD risk factors

Answer 14

DM
HTN
HLD
Tobacco
sex age FHx 
ESRD

Question 15

What categorizes ST depression and T wave changes

Answer 15

new ST depression 5mm (0.5mV) in 2+ leads

T wave inversion 1mm in 2+ leads

Question 16

What is the ACS early branch system

Answer 16

Patient comes in with ACS
EKG
Biomarkers
Risk stratify to determine approach

Question 17

How long does it take for Troponin to elevate

Answer 17

2-4 hours, persists 14 days

Question 18

What are causes of elevated troponin

Answer 18

Tacky/brady arrhythmia
Shock
HTN 
HF
Severe PE
Sepsis
Renal failure

Question 19

When is CKD helpful

Answer 19

when diagnosing reinfarction and assessing perfusion

Question 20

What are the TIMI risks

Answer 20

• Age 65+
• 3+ CAD RF (HTN, DM, HLD, FHx, smoking)
• CAD
• Elevated cardiac biomarker
• ASA w/in 7 days
• ST elevation
• Severe angina

Question 21

What are admission criteria for ACS

Answer 21

Recurrent symptoms
Ischemic changes on ECG
Elevated troponin
TIMI 3+

Question 22

What are standard medical therapies for NSTE-ACS

Answer 22

Oxygen
Anti-Platelet (ASA&P2Y12 inhibitor/)
Statins (high intensity)
Nitro 
Analgesics (NO NSAIDS)

Question 23

What is a P2Y12 inhibitor

Answer 23

an anti platelet given WITH ASA
Clopidogrel (Plavix)
*If possible hold clopidogrel 5 days prior to surgery

Question 24

What are GP IIa/IIb inhibitors

Answer 24

Anti-platelet used WITH ASA and heparin during AMI

Question 25

What anti-HTN med takes precedence when treating NSTE-ACS

Answer 25

BB- given within first 24 hours (but NOT in CHF, HB, or asthma) If BB contraindicated, use CCB Add CCB to BB if with persistent angina

Question 26

What are other NSTE-ACS therapies to initiate

Answer 26

ACE (if LVEF <40% ARB Ald. Antagonist (on ACE and BB with EF <40%)

Question 27

What are stress test options

Answer 27

Exercise ECG Echo (exercise or Dobutamine) Myocardial perfusion imaging (exercise or adenosine) --For those with abnormal baseline ECG

Question 28

What are the most specific and sensitive stress tests for detecting CAD

Answer 28

Sensitive: Vasodilator nuclear MPI Specific: Dobutamine Echo

Question 29

What post-hospital care should be given to patients

Answer 29

``` +/- cardiac rehab (if rule in and have MI) TLC Aspirin ACE/ARB BB ```

Question 30

What are likely causes of ACS with ST elevation

Answer 30

AMI STEMI Cocaine (young w/o RF) Vasospasm

Question 31

Who might you see a painless MI in

Answer 31

women elderly DM alcoholic

Question 32

What categorizes ST elevation

Answer 32

>1mm in 2+ leads >2mm in V2V3 for men >1.5mm in V2V3 for women

Question 33

What are key goal times for a STEMI

Answer 33

``` 12 lead ECG w/in 10 min Reperfusion w/in 24 hours FMC to device w/in 90 min Transfer to PCI w/in 120 min Fibrinolytic therapy w/in 120 min ```

Question 34

What is the best vessel to graft the LAD

Answer 34

Internal thoracic artery

Question 35

What is class I criteria for needing a CABG

Answer 35

Significant left main stenosis >70% stenosis of LAD and LCA three vessel CAD

Question 36

What is PCI therapy

Answer 36

Unfractionated Heparin w/wo GP IIb/IIIa inhibitor | *Initiate ASAP

Question 37

What are major contraindications for Fibrinolytics in STEMI

Answer 37

Prior ICH malignant neoplasm Ischemic stroke aortic dissection

Question 38

What is fibrinolytic therapy

Answer 38

Streptokinase Urokinase tPA

Question 39

What are complications of infarctions

Answer 39

arrhythmias/conduction abnormality HF shock mechanical defect Inflammatory (pericarditis)

Question 40

What will you see with a papillary muscle rupture

Answer 40

Systolic Apical murmur and pulmonary edema

Question 41

What will you see with an IVS rupture

Answer 41

holosystolic murmur at LSB