Podcast
Questions and Answers
What is the primary goal in the management of STEMI?
What is the primary goal in the management of STEMI?
What characterizes a Type 4 myocardial infarction (MI)?
What characterizes a Type 4 myocardial infarction (MI)?
Which of the following is NOT included in the immediate management of acute chest pain?
Which of the following is NOT included in the immediate management of acute chest pain?
What differentiates primary PCI from fibrinolytic therapy?
What differentiates primary PCI from fibrinolytic therapy?
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Which of the following is an indication for fibrinolytic therapy in STEMI?
Which of the following is an indication for fibrinolytic therapy in STEMI?
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Which lab test is essential to perform within the immediate management of acute chest pain?
Which lab test is essential to perform within the immediate management of acute chest pain?
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What does a new left bundle branch block (LBBB) indicate in a patient with suspected STEMI?
What does a new left bundle branch block (LBBB) indicate in a patient with suspected STEMI?
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Which of the following conditions does NOT contribute to changes in myocardial oxygen supply and demand?
Which of the following conditions does NOT contribute to changes in myocardial oxygen supply and demand?
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What is the main cause of acute coronary syndrome?
What is the main cause of acute coronary syndrome?
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Which ECG change is most associated with ST Elevation Myocardial Infarction (STEMI)?
Which ECG change is most associated with ST Elevation Myocardial Infarction (STEMI)?
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Which condition is characterized by angina at rest without evidence of myocardial necrosis?
Which condition is characterized by angina at rest without evidence of myocardial necrosis?
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What is NOT a criterion for diagnosing Myocardial Infarction?
What is NOT a criterion for diagnosing Myocardial Infarction?
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What distinguishes Type 1 Myocardial Infarction from Type 2?
What distinguishes Type 1 Myocardial Infarction from Type 2?
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Which symptom is commonly associated with both STEMI and NSTEMI?
Which symptom is commonly associated with both STEMI and NSTEMI?
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Which of the following indicates a significant blockage in a coronary artery?
Which of the following indicates a significant blockage in a coronary artery?
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What imaging evidence is required for the diagnosis of Myocardial Infarction?
What imaging evidence is required for the diagnosis of Myocardial Infarction?
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Study Notes
Acute Coronary Syndrome
- Acute coronary syndrome (ACS) encompasses symptoms and clinical findings with acute myocardial ischemia.
- Usually precipitated by acute thrombosis induced by a ruptured and eroded atherosclerotic coronary plaque (unstable plaque).
- Spectrum includes ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI).
- STEMI (complete blockage of artery): Specific ECG changes (significant ST-segment elevation in two contiguous leads), often severe.
- NSTEMI (partial blockage of artery): Nonspecific ECG changes (ST-segment depression, T-wave inversion, or no changes). Symptoms similar to STEMI, may be less severe. Unstable angina (UA) is a type of NSTEMI with symptoms like new onset angina, worsening angina, or angina at rest, but no evidence of myocardial necrosis.
- Myocardial infarction is defined as a rise or fall in cardiac biomarkers plus one of the following: symptoms of ischemia, development of pathologic Q waves on ECG, new or presumed new ST changes, or identification of intracoronary thrombus.
Myocardial Infarction
- Classification includes different types:
- Type 1 MI: pathologic process in coronary artery wall (plaque rupture, tearing)
- Type 2 MI: imbalance between oxygen supply and demand (spasm, anemia, arrhythmias).
- Type 3 MI: MI resulting in death due to lack of cardiac enzyme availability
- Type 4 MI: MI due to PCI/stent thrombosis
- Type 5 MI: MI associated with CABG.
Approach to Acute Chest Pain
- Differential diagnoses: acute coronary syndrome, aortic dissection, pulmonary embolism, pneumothorax, pericarditis/cardiac tamponade/myocarditis, esophageal spasm, mediastinitis, respiratory tract infections/pleuritis, asthma exacerbations, musculoskeletal causes (costochondritis, contusions, muscle strains), anxiety.
Immediate Management
- Monitor vital signs (including blood pressure in both arms).
- Oxygen if SpO2 < 90%.
- Establish intravenous access.
- ECG within 10 minutes of contact with medical services
- Obtain history and physical examination
- Conduct CBC, electrolytes, BUN, creatinine, troponin, and CK test.
- Obtain chest x-ray (CXR).
STEMI Management
- Primary goal is to restore coronary blood flow as soon as possible by either:
- Primary PCI (percutaneous coronary intervention): Mechanical revascularization, preferred if first medical contact to balloon inflation time is under 90-120 minutes.
- Fibrinolytic therapy (e.g., alteplase, tenecteplase): Pharmacological revascularization, indicated if time to balloon inflation is longer
- Factors affecting choice of treatment include patient characteristics and clinical presentation.
- Consideration of risk factors in medication and procedural treatment.
Medical Therapy
- Antiplatelet agents (e.g., ASA, clopidogrel, prasugrel, ticagrelor): Prevent further clot formation
- Anticoagulation (e.g., heparin, bivalirudin): Reduce clot formation, particularly in PCI patients
- Beta-blockers: Help to manage heart rate and blood pressure.
- Statins: Reduce elevated cholesterol levels
- ACE inhibitors/ARBs: Helpful in patients with reduced left ventricular ejection fraction (<40%).
Causes of Elevated Troponin
- Cardiac muscle damage releases troponin into the bloodstream.
- Elevated troponin levels may signify critical illness, respiratory failure, sepsis.
NSTEMI
- The TIMI (Thrombolysis in Myocardial Infarction) risk score helps assess risk of adverse outcomes.
- Patients can benefit from early invasive management (coronary angiography and revascularization) or intensive medical therapy.
Surgical Revascularization (CABG)
- A procedure used to bypass blocked or narrowed coronary arteries using harvested blood vessels.
- The decision to utilize this approach is individualized based on patient factors.
Take Home Messages
- Acute coronary syndromes involve the mechanism of myocardial ischemia.
- Management of STEMI focuses on opening the occluded artery (medications and intervention).
- Unstable angina and NSTEMI management: initial stabilization followed by risk stratification for early intervention or conservative therapy.
- In Type II MI (supply-demand mismatch), the underlying cause is targeted to improve outcomes.
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Description
This quiz covers the key concepts of Acute Coronary Syndrome (ACS), including its causes, symptoms, and classifications such as STEMI and NSTEMI. Understand how these conditions manifest in terms of ECG changes and myocardial infarction. Test your knowledge on this critical topic in cardiovascular medicine.
