CCRN Cardio 2 Acute Coronary Syndrome

Question Answer
What are acute coronary syndromes? Unstable angina (UA)

ST-segment elevation myocardial infarction (STEMI)

non-ST-segment elevation myocardial infarction (NSTEMI)

ECG findings of Unstable angina (UA) may be normal or show non-specific ___ wave changes. T
Cardiac enzyme results will be ___________ with unstable angina (UA). Normal
What ACS would show an elevation in cardiac enzymes? STEMI and NSTEMI
It is important to obtain a _______ when there is chest pain. ECG
The results of an _____ differentiate between UA, NSTEMI, and STEMI. ECG
An ECG will be normal or show new onset ST-segment ____________ in NSTEMI. depression
A STEMI is identified by __________ ST-segment in 2 or more contiguous leads. elevation
Which 2 locations for an AMI may result in bradycardia? Inferior wall AMI and posterior wall AMI
The SA node is mostly perfused by the RCA (right coronary artery) and LCX (left circumflex artery) in most people and a loss of blood flow will result in _____________. bradycardia
The presence of a 1st degree heart block indicates ischemia at the level of the ___ node, mostly supplied by the RCA. AV
How is a 1st degree heart block identified on ECG? Prolonged PR interval
The initial diagnostic test obtained with onset of chest pain is ____. ECG
A 12-lead ECG is performed and interpreted within ___ minutes of arrival at the ED with chest pain. 10
If the initial ECG show ST-segment elevation in 2 or more contiguous leads, ___________ strategies are initiated. reperfusion
The differentiation between UA and NSTEMI is _________ ____________. cardiac enzymes
What ECG findings would indicate the need for a right-sided ECG (right precordial lead placement)? ST-segment elevation in leads II, III and a ventricular fibrillation (VF) .
ST elevation in II, III, and aVF would indicate _________ wall MI. inferior
Why would a right sided ECG be ordered with ST elevation in II, III, and aVF? Inferior wall MI may also involve the wall of the right ventricle (RV).
The best diagnostic for RV involvement is right precordial lead placement, looking for ST-segment changes in leads _____ and _____. V-R3, V-R4
Diagnosis of a ___________ wall MI may be done by looking for reciprocal changes in anterior leads. posterior
Posterior MI may be identified by tall __ waves and ST _________ in V1 and V2. This is a reciprocal change of ST-segment elevation and Q waves (or loss of R wave height). R, depression
Which leads are used to recognize lateral wall ischemia and infarction? I, aVL, V5, V6
Anterior wall MI is identified in leads ___, ___ or loss of ___ waves progression and involves the ____ (artery). V3, V4, R
Which artery is involved in anterior wall MI? LAD
Septal wall MI is recognized in which leads? V1-V2
Which artery is involved in septal wall MI's? LAD
Which leads are used to identify lateral wall MI's? I, aVL, V5, V6
Lateral wall MI's involve which artery? Left circumflex (LCX)
Inferior wall MI's are recognized in which leads? II, III, and aVF
Which artery is involved in inferior wall MI? Right coronary artery (RCA)
What ECG changes indicates acute injury? Elevated ST segment
ST segment elevations of at least ____ are considered significant. 1 mm
___ waves without ST-segment changes are indicative of a previous MI. Q
Q waves of ___ mm or more in depth, longer than _____ second duration, or greater than ______ of the height of the QRS are considered "significant" Q waves. 2



Significant Q waves indicate _______________ myocardial damage (infarction) and may develop within ______ to ______ of initial injury and can persist for life. irreversible

hours, days

______________ leads typically have small Q waves but are insignificant. Inferior
Which of the cardiac enzymes is the preferred biomarker for diagnosing and AMI? Troponin levels
___________ levels are more sensitive and specific to AMI than CPK-MB. Troponin
Cardiac contusions, myocarditis, CHF, CKD, and acute cardiomyopathy are other causes of elevated _________ levels. Troponin
How long after the onset of myocardial injury will an increase in cardiac enzymes occur? 4 – 6 hours
To rule out MI, cardiac enzymes are drawn every ___ hours x ___ hours. 8, 24
CPK-MB levels return to normal within ___ – ____ hours, while troponin levels stay elevated for up to ___ days. 36-40


Which cardiac protein elevates first? Myoglobin
The protein _________ is a sensitive marker for muscle damage, but not specific to myocardium. Myoglobin
Myoglobin elevates within __ hour of ischemia and returns to normal within ___ hours. 1, 24
Elevated __________ increases suspicion of AMI in patients presenting with anginal-type chest pain. Myoglobin
Name 2 emergency treatments for STEMI Emergency coronary balloon angioplasty with stenting and IV thrombolytic agent
The recommended treatment for STEMI is ______. PCI (percutaneous coronary intervention)
____________ therapy remains and important option for treatment in hospitals with _____ capabilities. Thrombolytic
IV thrombolytics are only indicated in ________. STEMI
What is the standard "door-to-balloon" time? Less than 90 minutes
For which types of ACS is PCI indicated? STEMI, NSTEMI, and UA
PCI is indicated if ischemic symptoms started less than ___ hours ago, clinical evidence of ongoing ischemia is between ___ – ___ hours after onset of symptoms, or if there is _________ shock/severe ___ regardless of time delay from onset. 12, 12-24, cardiogenic, HF
High-risk MI's have better outcomes with ____ therapy. PCI
High-risk MI's Elderly – Anterior wall STEMI – Serious ventricular arrhythmias – SBP < 100 – Signs of acute HF or low CO – Cardiogenic shock
Which drug therapy is recommended to support primary PCI? Anticoagulants and anti-platelet agents
When should aspirin (ASA) and thienopyridine (plavix, prasugrel, ticagrelor) should be administered? As soon as possible or at the time of PCI
____________ should not be administered to patients with a history of CVA or TIA. Prasugrel
What is the minimal time requirement for dual anti-platelet drug therapy in DES (drug-eluting stents)? 1 year
What is the recommended time requirement for dual anti-platelet drug therapy in BMS (bare metal stents)? 1 month (4-6 weeks)
When would a BMS be recommended over a DES? High risk of bleeding, predicted compliance issues, known need for surgical procedure
What are the clinical indications for fibrinolytic therapy? STEMI, hyperacute T wave, posterior infarction, and new onset LBBB
Hyperacute (tall, peaked) ___ waves develop at the onset of ____________. T, ischemia
Before starting fibrinolytic therapy to treat hyperacute T waves, rule out peaked T waves due to ______________. hyperkalemia
Fibrinolytic therapy should be given within ___ hours if PCI cannot be performed within _____ minutes. 12, 120
What is the recommended "door-to-needle" time when administering a fibrinolytic agent? 30 minutes or less
When would a fibrinolytic agent be administered to a STEMI patient beyond the 12 hour window (but not longer than ___ hours)? PCI not available and ongoing signs of ischemia, hemodynamic instability, or when a large area of heart is at risk, 24
SCENARIO: STEMI patient in cardiogenic shock/acute and severe HF, immediate _________ __ _________ _____ ____ _________, regardless of time of onset of symptoms. transfer to hospital with PCI capabilities
Which ACS patients would not be candidates for fibrinolytic therapy? UA, NSTEMI
Can a patient with a prior intracranial hemorrhage or known intracranial vascular lesion such as an aneurysm or AVM receive fibrinolytics? No
Can a patient with a brain tumor, TBI less than 3 months ago or suspected aortic dissection receive fibrinolytic therapy? No
Can a patient with active bleeding or a history of an ischemic stroke within the past 3 months receive fibrinolytics? No
A patient with NSTEMI or ST ___________(unless confirmed posterior MI) is not a candidate for thrombolytic therapy. depression
Following the administration of a fibrinolytic agent, what medications should be continued to prevent early reinfarction? ASA, Plavix, and an anticoagulant
At what dose and for how long should ASA be continued after thrombolytic therapy? 81-325mg, forever
How long should Plavix be continued after thrombolytic therapy? 14 days – 1 year
How long should an anticoagulant be continued after thrombolytic therapy? 48 hours – 8 days (or end of hospitalization)
What are the 4 signs of reperfusion following administration of fibrinolytics or PCI? Relief of chest pain – ST segment return to baseline – abrupt onset of ventricular arrhythmias – increased levels of cardiac enzymes (washout effect)
What are the most important signs of reperfusion following fibrinolytics or PCI? Relief of chest pain and ST-segment improvement by more than 50%
What is the most sensitive continuous monitor used to recognize MI or efficacy of treatment for STEMI? ST-segment monitoring
Lead ___ is the most reliable for identifying demand-related ischemia (ex: surgical patients). V5
What is the indication for a CABG in a patient with a STEMI? Coronary artery anatomy not amendable by PCI
What is the primary intervention for a RV infarction? Fluid bolus to produce adequate stroke volume
With LV infarction, what medications are indicated? Venodilators (nitrates, morphine)
What anticoagulant should be avoided in UA and NSTEMI? Vitamin K antagonists (Coumadin)
What 2 drugs administered after ACS have been found to reduce LV remodeling? Beta blockers and ACE inhibitors
How do beta blockers prevent remodeling of the LV after ACS? Blunt effects of SNS = reduce HR, BP and contractility
What medication would be contraindicated after ACS with cardiogenic shock/HF symptoms? Beta blockers
What medication is adminstered in the first 24 hours following an anterior wall MI with a ventricular EF < 40%? ACE Inhibitors
Why administer ACE inhibitors after AWMI? Arterial dilator, decreases LV afterload, lowers BP, prevents remodeling
High-intensity _______ therapy should be administered in all patients with STEMI, unless contraindicated. statin
What clinical situation would be contraindicated to administer an aldosterone blocker? Elevated Cr (2.5 mg/dL in men, 2.0 in women) and K+ (5.0 mEq/L)
What is the purpose of administering aldosterone blockers? Left Ventricular EF < 40% in acute MI or HF
Acute pulmonary edema following an inferior MI with new onset holosystolic murmur indicates which complication? Acute severe mitral regurgitation
Acute severe mitral regurgitation usually occurs within ___ hours of infarction but may occur up to ___-___ days later. 24, 3-5
Mitral regurgitation after MI is treated with _________ therapy, _____ counterpulsation, and _______; urgent __________ ________ of the valve is a Class I recommendation. inotropic, IABP, surgery; surgical repair
Mitral regurgitation causes a _______________ murmur.
(Look at the type of murmur given in the scenario)
Soft, Holosystolic
What is the recommended treatment of pericarditis after STEMI? ASA
What medications are contraindicated for pericarditis after STEMI? Glucocorticoids, NSAIDS
What type of AMI is most likely to result in the development of a LV mural thrombus and when is it most likely to occur? Anterior wall MI, within 10 days
Following ventricular septal rupture (VSR), what type of murmur does the patient suddenly develop? Loud, harsh holosystolic murmur
Symptoms of ventricular septal rupture (VSR). SOB, biventricular failure, chest pain, hypotension
When is VSR most likely to occur after AMI? Within 24 hours, then again at 3-5 days
Treatment of ventricular septal rupture are: vasodilators, inotropes, diuretics, IABP until defect can be repaired
What is the most common arrhythmia or cause of death in a LV free wall rupture? PEA
When would LV free wall rupture occur? Large, transmural infarctions
Clinical presentation of LV free wall rupture. Sudden, severe chest pain with abrupt hemodynamic collapse and PEA d/t the rapid development of pericardial tamponade
Complications of AMI Cardiogenic shock – Pericarditis – Post MI syndrome (Dressler's syndrome) – LV aneurysm – Papillary muscle rupture/mitral regurgitation – Arrhythmias – Ventricular free wall rupture – Cardiac tamponade – Ventricular septal rupture – LV mural thrombus