IPAP EM - Exam 1 - (ACS)

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Ischemic Heart Disease

This represents a spectrum from chronic stable angina to acute MI.

Acute Coronary Syndrome

This describes patients who present with acute chest pain and other symptoms of myocardial ischemia.

Angina

This is chest pain from decreased blood flow (O2 and nutrients) to cardiac tissue. Reversible

Infarction

This is chest pain from necrosis of cardiac tissue from complete blockage of blood flow.

No

Is Infarction reversible?

1) Left Circumflex

2) Left Anterior Descending (LAD)

The Left Coronary Artery (LCA) bifurcates to form what?

Supplies some anterior wall and a large portion of the lateral wall

What does the Left Circumflex supply?

Supplies the anterior and septum

What does the Left Anterior Descending (LAD) supply?

1) Supplies the right side of the heart

2) Supplies blood to the inferior aspect of the left ventricle through the posterior descending artery

What does the Right Coronary Artery (RCA) supply?

Ischemia

This occurs occurs when there is an imbalance between oxygen supply & demand

Usually occurs due to fixed atherosclerotic disease and a reduction in myocardial blood flow.

What usually causes Ischemia?

1) Coronary artery spasm

2) Disruption of atherosclerotic plaque

3) Platelet aggregation

4) Thrombus formation

What pathologies cause Ischemia?

Stable Angina

This ischemia occurs at relatively fixed and predictable points of activity and changes slowly over time.

Unstable angina

This Ischemia is relatively unpredictable (i.e. at rest) and changes occur rapidly.

Yes

Is Unstable angina reversible?

Degree and duration of ischemia

What determines if patient will have reversible angina or infarct

"Any history of heart problems?"
If so, "How does this (current episode) compare?"

First best questions:

"Have you ever been diagnosed with angina/heart attack?"
"Is this your typical angina/heart attack pain (or is there a change from the baseline)?"

Next best:

"Do you have?"
SOB
Dyspnea with exertion
**Nausea/vomiting
**Diaphoresis
Syncope
Heart palpitations
Lightheadedness
Epigastric pain

Have conducting the LOPQRST, what particular things do I want to know about in the history?

Because they have positive predictive value if they stand alone without chest pain

Why is Nausea/Vomiting & Diaphoresis so important?

1) Substernal or retrosternal pain

2) Chest pain that is described as a pressure, squeezing or heaviness as opposed to sharp pain.

3) Pain that radiates to the left arm, left jaw/neck

4) Atypical presentations
30% of AMI patients go unrecognized

In the history, what are concerning characteristics?

Unstable Angina

This is described as:

- Chest pain at rest

- New onset/changing pattern

- Increasing in frequency and duration

Angina

This usually < 10 minutes and usually resolves with 2- 5 min of rest or NTG

MI

This lasts longer than 20 minutes and little to no response to rest or NTG. The pain is usually more severe and there are more associated symptoms

False

T or F. Reproducible chest wall pain is not common

1) Women

2) Elderly

3) Diabetics

* Atypical presentations occur 30% of the time. Who does it affect?

They have had an abrupt vessel occlusion until proven otherwise

* What should I assume If the patient recently had angioplasty or a stent?

1) HTN

2) Tobacco use

3) DM

4) Hypercholesterolemia

5) ***Family history of CAD at an early age

What are the traditional risk factors for Acute Coronary Syndrome (ACS)?

1) Relatively poor predictors of ACS in the ED.

2) Derived from cohort studies of asymptomatic patients to determine the risk of developing CAD

3) The presence of symptoms are significantly more predictive of CAD than risk factors derived from asymptomatic patients.

How relevant are traditional risk factors for Acute Coronary Syndrome (ACS) in the ED?

Generally not helpful in determining if cardiac or noncardiac etiology. The patient can appear deceptively well without clinical signs of distress

Describe how helpful the Physical Exam is in the ED in Acute Coronary Syndrome (ACS)

Can be normall, elevated, or decreased

Describe the B/P in Acute Coronary Syndrome (ACS)

- S1 and S2 are diminished-poor contractility

- New systolic murmur-ominous sign- papillary muscle involvement, Mitral valve failure or VSD

Describe heart sounds in Acute Coronary Syndrome (ACS)

Figure out what the patient's baseline is!

What must be done when a patient comes into the ED with chest pain

ECG

***What is the single best test for chest pain?

Because most patients in AMI will NOT have ST changes on their first EKG

***Why do we do serial tracings on ECG?

ST depression or T wave inversion

If I have a NSTEMI, what should I look for?

Assume a normal baseline

Since we always want to get past tracings to compare EKGs, what would we assume if there were no past tracings available?

Ischemia

ST-segment depression, TWI =

Acute injury/necrosis

ST-segment elevations =

Myocardium has died (infarction)

Q-waves =

A right-sided lead V4 (V4R) prior to using nitroglycerin

What do ALL inferior wall acute myocardial infarctions need?

Reciprocal changes

In a patient that has an MI, what are S-T depression in leads distant from the leads suggesting ischemia/infarction called?

1) Highly supportive of AMI

2) Indicates a larger infarct pattern

What is the significance of Reciprocal changes?

Cardiac markers

What is the difference between unstable angina and NSTEMI?

"Goal of treatment is to achieve immediate reperfusion and limit infarct size."

**What is the goal of treatment in an MI?

Percutaneous Coronary Intervention (PCI)

**What is preferred method of reperfusion therapy if the expected first-hospital-door to first-balloon-inflation time is < 90 minutes."

Oxygen (2-4 L/m NC even if O2 sat is nl) and Pulse Ox
Monitor for dysrhythmias
IV access (preferred one puncture accesses-Lytics)

What is the safety net?

Stent/angioplasty-Cardiology

What is the mechanical form of reperfusion?

1) Fibrinolytics

2) Antiplatelets

What is the medication form of reperfusion?

Angioplasty

What is the most common Percutaneous Coronary Intervention (PCI)?

Antiplatelet therapies

What is done 6 months post catheterization to lower adverse events?

PCI, thats why it is the preferred method (especially for prolonged symptom patients)

Which one has reduced cardiovascular rates, Lytics or PCI?

True

T or F. PCI is an early invasive approach for NSTEMI

Thrombolytics (Lytics)

Fibrinolytics =

1) Tx time < 6-12 hrs of sxs onset; at least 1mm of S-T elevation in at least 2 contiguous leads.

2) Angioplasty/stent is not available.

3) Can't relieve pain w/ meds

What are the indications for Lytics?

Streptokinase

What is the cheapest "Lytic"?

Tenecteplase

What"Lytic" is easiest to use?

Alteplase (tPA)
Reteplase (rtPA)

What are other "Lytics"?

The choice of which fibrinolytic to be used is most likely based on the institution.

So how do I know which "Lytic" to use?

Facilitated PCI

This is described as:


1) Planned initial pharmacologic tx followed by PCI

2) ASSENT-4 PCI Trial

Rescue PCI

This is described as:

1) After failed lytic therapy (Because I should see a reperfusion rhythm after pushing "Lytics"

2) Special populations

Within 48 hours

How soon is "early" when it comes to NSTEMI Reperfusion?

Aspirin

What Anitplatelet do we use?

ASAP

When do we give the aspirin?

> 162

What doses cause immediate, nearly complete inhibition of thromboxane A2?

NO!

Can I use enteric coated Aspirin?

There is strong evidence of allergy or active Peptic Ulcer Diease

I should usually never hold ASA, but when should I hold it?

Clopidogrel (Plavix)

What is an alternative to ASA?

It is associated with a higher risk of bleeding

What is the problem with Clopidogrel (Plavix)?

Glycoprotein IIb/IIIa Inhibitors

What is Indicated for patients undergoing PCI?

Rapid reversal of platelet inhibition after cessation of infusion

What is the limitation of Glycoprotein IIb/IIIa Inhibitors?

Offers an advantage during Percutaneous Coronary Intervention (PCI) when bleeding complications occur

-Discuss their use when consulting cardiology.
The cardiologist may want you to start prior to movement into the cath lab.

What is the advantage that Glycoprotein IIb/IIIa Inhibitors has?

1) Unfractionated Heparin (UFH)

2) Low Molecular Weight (LMWH) "LOVENOX"

What are the antithrombins that we use?

Unfractionated Heparin (UFH)

This antithrombin is described as the following:

- Unpredictable anticoagulant response due to the mixture of varying molecular weights
- Requires close monitoring and dose adjustment
*Indicated for AMI*
- Used instead of LMWH in pending CABG cases

Low Molecular Weight (LMWH) "LOVENOX"

This antithrombin is described as the following:

- Greater bioavailability that achieves a more reliable anticoagulant effect

- Can be administered in a fixed SQ dose for a stable therapeutic response

*Preferable in STEMI & Lytics NOT STEMI & PCI*

*Preferable to UFH in UA/NSTEMI*

Low Molecular Weight (LMWH) "LOVENOX"

STEMI & Lytics, then use

NO!

Low Molecular Weight (LMWH) "LOVENOX" in STEMI and PCI?

Low Molecular Weight (LMWH) "LOVENOX"

Low Molecular Weight (LMWH) "LOVENOX" or Unfractionated Heparin (UFH) in Unstable Angina/NSTEMI?

1) Nitrates

2) Beta-blockers

3) ACE-I

4) Magnesium

5) Ca++ Channel Blockers

What meds can we use to limit the size of the infarct?

Nitrates

This drug does the following:

- Vasodilatation effect

- Decreases ventricular filling pressures and afterload

- Decreases cardiac work and myocardial O2 demand

Be very careful in the inferior wall MI! (Because right sided Acute MI patients are volume depleted and we can bottom

Can I give a patient that has an Inferior MI Nitro?

NO. Use it IV for first 24-48 hrs in AMI and titrate to B/P NOT to pain relief.

Is Nitro titrated to pain relief?

If patient does not respond to sublingual nitroglycerin tablets.

When would I use IV in in UA/NSTEMI ?

Beta Blockers

This is an
Anti-arrhythmic
Anit-hypertensive, and
Anti-ischemic
- Diminish myocardial O2 demand by decreasing the heart rate, systemic arterial pressure, and myocardial contractility.

ALL STEMI/NSTEMI patients

**Who gets Beta Blockers (unless Contra-indicated within 24 hrs of onset of Acute MI?

Metoprolol (Lopressor®)

What is the typical Beta Blocker used?

1) Heart rate < 60 BPM

2) SBP < 100 mmHg

What are the relative contraindications for the use of Beta Blockers?

1) Asthmatics

2) Insulin dependent DM

3) Severe COPDers

*Non-cardioselective agents can block beta-2 subunit receptors resulting in vasoconstriction, bronchospasm, and hypoglycemia. Be cautious with use in:

ACE-I

This does the following:

1) Reduce L ventricular dysfunction

2) Slow development of CHF during AMI

Within the first 24 hours

When are STEMI patients started on ACE-I?

with persistent hypertension after NTG and B-blockers

When are UA/NSTEMI patients given ACE-I?

Magnesium

This does the following:

1) Vasodilatation and antiplatelet activity

2) Protects myocytes from Ca++ influx during reperfusion

Given only if hypomagnesemia with Torsades type v-tach with prolonged QT interval

When is Magnesium given?

CCB

This drug is defined as the following:

1) Antianginal, vasodilatory and antihypertensive

2) Studies show no reduced mortality rate and harmful in some cases of AMI

Extremely limited use in patients with AMI.

Whats the bottom line with CCB?

Morphine (does not decrease morbidity and mortality)

This does the following:

1) Decreases anxiety

2) ***Decreases pain

3) Decreases B/P

Start at 2-5mg and titrate

What is the dose of morphine?

NO:

-Does not increase mortality

- May be protective

Most patients with Acute MI have dysrhythmias, are Bradydysrhythmias
significant?

1) Seek out a treatable etiology-pain, anxiety, fever, hypovolemia.

2) Generally not an issue initially, but has a poor prognosis late in the MI.

What about Tachydysrhythmias?

True

T or F. 15 to 20% of AMI will have a certain degree of heart failure (CHF)

Cardiogenic Shock

What is the most common cause of acute MI related deaths in the hospital?

Careful fluid resuscitation and inotropic medications

What does cardiogenic shock require?

1) Elderly
2) Female
3) Previous MI
4) CHF
5) Diabetes

What are the risk factors for cardiogenic shock?

1) Free wall rupture (10% of AMI fatalities)

2) Interventricular septal rupture

3) Papillary muscle rupture

What are the mechanical complications of acute MI?

NO!!!! Give them Aspirin

Can I give a patient Ibuprofen for Pericarditis?

Rectal Bleeding

*** LOL, What is a contraindication for Fibrinolytic use?

2-5mg IV q 5-15 prn pain

Morphine dose =

2-4 liters Nasal Canula for EVERYBODY

Oxygen dose =

0.4 mg SL q 5 min x 3 prn pain

Or

10 ug/min IV titrated to B/P

Nitroglycerin dose =

160-325 mg PO

Aspirin dose =

Clopidogrel 300 mg

Alternate to Aspirin

- 5mg IV q 5 min up to 15 mg
Or
- 50 mg PO q 12 hrs

*Stop if pulse drops to 60 or SBP reaches 100

*Contraindications: Asthmatics, Insulin dependent DM, Severe COPDers

Metropolol dose =

- Cardiology
- Internal Medicine if no Cardiology

STEMI goes to

Internal Medicine-may end up in Cardiology

NSTEMI goes to

Internal Medicine

Angina goes to

Don't send anyone home without a rule out!

Bottom line for disposition is:

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