MI

your patient and wife says they'd rather wait until EMS gets to the clinic. What would you tell them will happen when EMS is on the scene?

- 12 lead EKG - prehospital fibrinolytic (if capable & EMS-to-needle within 30 min)

3 main presentations of unstable angina

1) Rest angina 2) New onset angina 3) Increasing angina

DDx Chest pain- Acute coronary syndrome other cardiovascular causes

Aortic dissection (really bad back pain) Aortic stenosis Pericarditis Myocarditis Hypertropic cardiomyopathy Aortic regurgitation Mitral valve prolapse Severe anemia

Typical vs. Atypical chest pain Atypical Chest pain

Associated symptoms or anginal equivalents (dyspnea, n/v, indigestion, diaphoresis, syncope)

CK-MB is specific to ___________ whereas troponin is specific to _____________

CK-MB: cardiac muscle troponin: MI

Ddx Chest pain: GI causes-

Esophageal spasm or reflux Esophageal rupture Peptic ulcer disease Biliary or pancreatic disease

Inferior MI

II, III, aVF

_______________is indicated for relief of ongoing ischemic discomfort that responds to nitrate therapy, control of hypertension , or management of pulmonary congestion

IV NTG

if the patient admits that _____________helped when angina, it would be cardiac. if not focuse on other etiology

NTG

what is this angina? angina of at least CCS III severity with onset within 2 months of initial presentation

New onset unstable angina

DDx Chest pain- Pulmonary causes

Pulmonary embolus Pneumothorax Pleurisy = Pleuritic (when taking a deep breath) --> D-dimer

Aspirin use in STEMI

dosing: 162-325 (just give the big dose)

Significant Q wave where none previously existed should be noted because it is

impulse traveling away from the positive lead necrotic tissue is electronically dead --> old or acute transmural MI

Qualifications of PCI

1) STEMI (including posterior MI), MI w/ new or presumably new LBBB 2) PCI of infarct artery within 12 hrs of symptom onset 3) Balloon inflation within 90min of presentation 4) Skilled personnel available (>75 procedures / yr) 5) Appropriate lab environment (lab >200PCIs/ yr, at least 36 primary PCI for STEMI) 6) cardiac surgical backup available 7) Medical contact to balloon or door-to-balloon = 90min 8) PCI preferred if >3 hrs from symptom onset 9) Primary PCI if pt with severe CHF and/or PE and onset of symptoms w/in 12 hrs

What is the definition of typical angina?

1) substernal chest discomfort with a characteristic quality and duration that is 2) provoked by exertion or emotional stress and 3) relieved by rest or NTG Pain + what makes it tick + what makes it go away

what you tell your patient who is experiencing chest pain with prescribed nitroglycerin (NTG) at home?

1) use 0.4mg NTG x 3 q 5 min -------if symptoms don't improve 2) Call 911

Times to remember in STEMI

10 min: time for ED eval 30 min: door to needle 90 min: door to balloon 3 hours (symptom onset) --> fibrinolytic vs PCI therapy 12 hours (symptom onset): time limit for revascularization therapy

Emergent diagnostic testing for STEMI includes:

12 lead EKG (cannot tell which part of the heart is damaged if only II lead, rhythm strip printed) Cardiac enzymes (CPK, CKMB, troponin): leakage of the cardiac cell enzymes CBC ( r/o anemia) BMP, CMP (electrolyte, potassium & magnesium) Coagulation studies (r/o liver problems, INR before getting to the cath lab) D-dimer (r/opulmonary embolism) PA and lateral CXR (r/p pneumonia, PE, dissection

for how long will troponin be elevated after STEMI

14 days

A patient with chest pain suspected of having STEMI should take ___________ while arrival of prehospital EMS.

162 to 325mg of aspirin (chewed)

what is the peak time of Troponin?

20 hrs

Troponin rises after ___________hrs after STEMI

3-6 hrs

the mortality drops by __________% if ASA taken for STEMI what is the only contraindication?

48% - true ASA allergy

Options for transport of patients with STEMI and Initial reperfusion treatment Your patient is presenting at your UC with onset of STEMI symptoms. How long do you have until you activate (dispatch) EMS?

5 min

Plavix should be held for how long prior to CABG?

5-7 days

If there is negative troponin within ________hrs of onset of S&S , it effectively rules out the MI

6 hours

Options for transport of patients with STEMI and Initial reperfusion treatment You have called the EMS after identifying a patient with suspected STEMI. How long does your patient have after dispatch activation till EMS gets to the site?

8 min

Your patient's wife says it will be quicker for them to drive to the local hospital after you identify that he might have a STEMI. how long do you advise the patient and the wife that he has till PCI once they hit the hospital door?

90 min Door to balloon time is 90 min

Once the patient is transferred to the local hospital by EMS, how long does he have until PCI?

90 minutes EMS- to - balloon: 90 min

Nonspecific serum markers that are elevated in MI but nonspecific are

AST LDH Myoglobin (rapid release & return to baseline but elevated with muscle infarct and renal failure)

Ddx Chest pain: Psychogenic causes

Anxiety/depression/ panic attack Psychosis Secondary gain

Etiologies of ischemia

Atherosclerosis Congenital coronary anomalies Coronary arteritis Radiation therapy Cocaine Aortic stenosis Hypertrophic cardiomyopathy (untreated HTN--> LVH)

which cardiac biomarker is sensitive to cardiac muscle damage?

CK- MB

which cardiac biomarkers sensitive to skeletal muscle damage?

CK- MM

which cardiac biomarker is sensitive to brain and kidney

CK-BB

Typical vs. Atypical Chest pain TYPICAL Chest pain

Chest discomfort w/ variable characteristics : pain, pressure, tightness, crushing, squeezing, stabbing, choking sensation : substernal origin with variable radiation to arm, neck, or jaw : especiallly when associated with exertion : duration in minutes (5-30) but not seconds or hours This patient present with typical chest pain with verbal c/o xyz...

Grade this angina per ACC angina classification Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation

Class I angina

Grade this angina per ACC Angina classification angina occurs on walking 3 blocks and climbing 2 flights of stairs. Angina occurs with cold, wind, and under emotional stressed.

Class II angina

Grade this angina per ACC angina classification Angina occurs when walking 1 block and climbing 1 flight of stairs at a normal pace

Class III angina

Grade this angina per ACC per angina classification angina symptoms may be present at rest

Class IV angina

Ddx Chest pain Musculoskeletal causes-

Costochondritis Muscle strain Thoracic outlet syndrome Degenerative spine disease

Morphine use in STEMI

Dosing: 2-4mg IV w/ 2-8mg IV repeated q 5-15 min --> analgesic of choice --> decreases preload

Acronym for reading 12-lead ekg

I See in All Leads I: II, II, aVF (inferior) See: V1, V2 (Septal) All: V3, V4 (Anterior) Leads: V5, V6, aVL, I (Lateral)

Angina is graded by ACC classification.

I. Ordinary physical activity does not cause angina: such as walking or climbing stairs. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation. II. Slight limitation of ordinary activity: angina occurs on walking or climbing stairs rapidly; walking uphill; walking or stair climbing after meals; in cold, in wind, or under emotional stress; or only during the few hours after awakening. Angina occurs on walking > 2 blocks on the level and climbing >1 flight of ordinary stairs at a normal pace and under normal conditions III. Marked limitations of ordinary physical activity: Angina occurs on walking 1-2 blocks on the level and climbing 1 flight of stairs under normal conditions and at a normal pace IV. Inability to carry on any physical activity without discomfort: anginal symptoms may be present at rest

what is this angina previously diagnosed angina that is distinctly more frequent, longer in duration or lower in threshold (increased by at least one CCSC class within 2 months of initial presentation to at least CCS III)

Increasing unstable angina

the patient gets there within 15 minutes to the local hospital. The hospital is not capable of PCI. what should occur now?

Interhospital transfer to PCI capable. Time is still ticking. EMS-to-balloon is 90 min. you have 75 min

Acute pharmacologic interventions in STEMI

MONAB Morphine (decreases preload & decreases circulatory volume & cardiac output) Oxygen Nitroglycerine (vasodilation--> increase cardiac blood flow) Aspirin (coronary artery disease, prevent thrombosis) Beta blockers (Keep neurohormonal changes, decreases cardiac output, keep rate down)

ST segment elevation of greater than 1mm in at least 2 contiguous leads is significant of

Myocardial infarction directly related to portionts of myocardium rendered electrically inactive

Heightened or peaked T wave

Myocardial injury

st depression is significant in ______________

Myocardial ischemia

flipped T wave indicates__________________

Myocardium damage

What medications to put patient on after MI (Management of patient after MI)

PABAS Plavix (p stent + Drug eluting stent) Aspirin ( 325mg) Beta blocker Ace inhibitor/ ARB Statin Therapy

What is this angina angina occuring at rest and usually prolonged (>20min) occuring within a week of presentation

Rest unstable angina

contraindication of NTG

SBP <90 or >= to 30mmHg below baseline Severe bradycardia (<50bpm) Tachycardia (>100bpm) or suspected RV infarction concurrent administration of Phosphodiesterase inhibitor (PDE-5) for DE w/in the last 24 hrs (48hrs for tadalafil/cialis)

EKG changes in STEMI would reveal what?

ST elevation = 1mm or more in limb leads = 2 mm or more in precordial leads

_______________: protein that regulates interaction of actin and myosin

Troponin

_______________ is a diagnostic & prognostic value in myocardial injury

Troponin T & I

After PCI, if there is no post intervention MI, which level will be up & which level will be down?

Troponin elevated (even more than before the intervention) CK-MB (down)

Which cardiac biomarker is considered the Gold Standard to diagnose STEMI?

Troponins

T/F physical exam is often normal in ischemic heart disease

True

Higher the troponin I level is related to mortality after NSTEMI T/F

True % mortality at 42 days 0.4~ 1.0 = 2% >9.0 = 8%

T/F NSTEMI has elevated troponin levels

True. myocardium damage= troponin if negative troponin level with chest pain + no ST elevation = unstable angina

Posterior MI

V1, V2

Septal MI

V1, V2

Anterior MI

V3, V4

Lateral MI

V5, V6, I, aVL

BB use in STEMI- should it be given if fibrinolytic therapy or PCI is done?

YES. oral Bb therapy should be administered promptly without a contraindication regardless of fibrinolytic / PCI therapy (1st 24 hrs of MI) IV Bb given promptly to STEMI pts esp. if a tachyarrhthmia or htN Contraindications: Hypotension, bradycardia

What is NOT a life-threatening diagnosis with chest pain? a. mitral valve prolapse b. aortic dissection c. pulmonary embolism d. tension pneumothorax e. ruptured viscus

a. mitral valve prolapse

possible physical findings in ischemic heart disease (although often normal)

diaphoresis or other signs of hypoperfusion Congestive signs: JVD, rales, S3 Abnormal heart sounds: S3, new murmur Hypoxia Arrhytmias, especially ventricular (PVCs, a couple runs of V tach), although must rule out MI with new onset afib

STEMI patients should be place don plavix regardless of reperfusion therapy (fibrolysis, PCI, or neither) TRUE 75mg PO daily x14 days (1 yr if <75 yo)

even if they didn't have any intervention, they should be placed on Plavix

Why we shouldn't give NSAIDS to MI patients (except ASA)

increased risk of mortality reinfarction HTN HF Myocardial rupture

What is Atypical angina?

meets 2 of the typical angina definition/ characteristics

What is noncardiac chest pain?

meets only one or none of the typical angina characteristics

CPK is common in where?

skeleta, smooth and cardiac muscle + brain and kidney

troponin C is common to __________ & ________muscle

skeletal & cardiac muscle

ischemia means what?

without blood flow - Cardiac ischemia = emergency! Don't try to do 12 lead EKG --> Immediate Hospital Transfer