Questions and Answers
What are risks for pulmonary embolism?
What are the indicators of STEMI on ECG?
2mm ST elevation, T wave inversion after 6hrs, Q waves last forever, new LBBB
What leads are associated with localized infarcts?
V1-4 for anterior (LAD), I aVL V4-6 for lateral (Circumflex), II III aVF for inferior (RCA), V4 on right side ECG for RV (RCA)
What are emergency reperfusion options?
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What are the symptoms of RV infarct?
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What is the workup after EKG for STEMI?
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What is the diagnosis for normal ECG with elevated cardiac enzymes?
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What are the three cardiac enzymes?
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What is included in NSTEMI acute treatment?
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What is the first treatment option for STEMI?
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What medications should be included in NSTEMI discharge prescriptions?
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What leads to a diagnosis of unstable angina?
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What to avoid before an exercise EKG?
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What are contraindications to exercise stress tests?
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What medications are used for a chemical stress test?
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What needs to be avoided before MUGA?
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What is the acute treatment for unstable angina?
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What is the most common cause of death post-MI?
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What murmur is associated with papillary muscle rupture post-MI?
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What causes acute severe hypotension post-MI?
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What indicates a 'step up' in oxygen from RA to RV post-MI?
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What is indicated by persistent ST elevation one month later post-MI?
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What does 'Cannon A-waves' indicate?
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What is Dressler's syndrome?
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What characterizes pericarditis in a young, healthy patient?
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What condition presents with chest pain that worsens with palpation?
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What characterizes chest pain with a vague history of viral infection?
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Study Notes
Risks for Pulmonary Embolism (PE)
- Increased risk after surgery, long car rides, or conditions leading to hypercoagulability (e.g., cancer, nephrotic syndrome).
STEMI Indicators on ECG
- 2mm ST elevation observed immediately.
- T wave inversions appear within 6 hours and can last for years.
- Q waves remain permanently.
- New left bundle branch block (LBBB) with wide, flat QRS complexes can indicate STEMI.
Localized Infarcts and Related ECG Leads
- Anterior infarct associated with the Left Anterior Descending artery (LAD), diagnosed with leads V1-V4.
- Lateral infarct tied to the Circumflex artery, seen in leads I, aVL, V4-V6.
- Inferior infarct linked to the Right Coronary Artery (RCA) with leads II, III, aVF.
- Right Ventricular (RV) infarct noted with RCA, leads V4 on right side ECG.
Emergency Reperfusion Options
- Options include catheterization in the cath lab and thrombolytics, effective within 6 hours.
- Contraindications include active bleeding, history of hemorrhagic stroke, and recent closed head trauma.
Right Ventricular (RV) Infarct Presentation
- Symptoms include low blood pressure, tachycardia, clear lung sounds, and jugular venous distention (JVD).
- Absence of pulsus paradoxus.
- Treatment involves vigorous fluid resuscitation to increase preload; nitroglycerin is contraindicated.
STEMI Workup After ECG
- Confirmation through cardiac enzyme testing.
Normal ECG with Elevated Cardiac Enzymes
- Diagnosis of NSTEMI (Non-ST Elevation Myocardial Infarction).
- Repeat enzyme tests every 8 hours for 3 cycles to observe trends.
Cardiac Enzyme Markers
- Myoglobin: Rises first, peaks at 2 hours, normal by 24 hours.
- CK-MB: Rises 4-8 hours, peaks at 24 hours, normal by 72 hours.
- Troponin I: Rises 3-5 hours, peaks at 24-48 hours, normal by 7-10 days.
NSTEMI Acute Treatment
- Immediate management includes morphine, oxygen, nitrates, and ASA/clopidogrel.
- Coronary angiography should be performed within 48 hours.
Primary Treatment for STEMI and NSTEMI
- First-line treatment involves percutaneous coronary intervention (PCI) with stenting.
- CABG indicated in cases such as significant left main disease, multivessel disease, or persistent symptoms despite treatment.
NSTEMI Discharge Medications
- Post-discharge regimen includes beta-blockers (e.g., Metoprolol), ACE inhibitors for CHF or LV dysfunction, statins, and heparin during hospitalization.
Criteria for Unstable Angina
- Diagnosis confirmed with three normal cardiac enzyme tests; if both are negative, it indicates unstable angina.
Unstable Angina Workup Process
- Tests include exercise ECG, exercise echocardiogram, chemical stress tests (adenosine/dobutamine), and MUGA scan for heart perfusion.
- Positive results warrant coronary angiography.
Pre-Exercise ECG Preparations
- Avoid beta-blockers and calcium channel blockers (CCB) prior to stress testing.
Contraindications for Exercise Stress Testing
- Includes old LBBB, baseline ST elevation, and patients on digoxin.
Medications for Chemical Stress Testing
- Utilizes dobutamine, adenosine, and thallium-dipyridamole to enhance coronary blood flow during testing.
Pre-MUGA Considerations
- Caffeine and theophylline should be avoided before undergoing a MUGA scan.
Acute Treatment for Unstable Angina
- Immediate management involves beta-blockers, nitrates, and aspirin (ASA).
Post-MI Complications Overview
- Arrhythmias, particularly ventricular fibrillation (VF), are the most common cause of death after a myocardial infarction.
Post-MI Complications: Papillary Muscle Rupture
- Manifests 5-7 days post-MI as a holosystolic murmur indicative of mitral regurgitation radiating to the axilla.
Severe Hypotension After MI
- Acute hypotension can arise from ventricular free wall rupture, indicating a critical condition.
"Step Up" in Oxygen Saturation
- Observed in ventricular septal rupture when there is a higher oxygen concentration in the right atrium compared to the right ventricle.
Persistent ST Elevation Post-MI
- Around one month later, may indicate a ventricular wall aneurysm accompanied by systolic mitral regurgitation murmur.
Cannon A-Waves and JVP Findings
- Associated with AV dissociation, potentially due to ventricular fibrillation or third-degree heart block.
Delayed Pleuritic Chest Pain Post-MI
- Occurring 5-10 weeks later may suggest Dressler's syndrome, an autoimmune form of pericarditis, treatable with NSAIDs and ASA.
Pericarditis in Young Patients
- Symptoms include chest pain exacerbated by inspiration, relieved by leaning forward, often displaying diffuse ST elevation on ECG; treated with NSAIDs.
Costochondritis Presentation
- Characterized by chest pain that worsens upon palpation, common in young, healthy individuals.
Vague Chest Pain with Viral History
- Indication of potential myocarditis or other viral-related cardiac conditions requiring further evaluation.
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