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Questions and Answers
What are risks for pulmonary embolism?
What are risks for pulmonary embolism?
What are the indicators of STEMI on ECG?
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?
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?
What are emergency reperfusion options?
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What are the symptoms of RV infarct?
What are the symptoms of RV infarct?
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What is the workup after EKG for STEMI?
What is the workup after EKG for STEMI?
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What is the diagnosis for normal ECG with elevated cardiac enzymes?
What is the diagnosis for normal ECG with elevated cardiac enzymes?
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What are the three cardiac enzymes?
What are the three cardiac enzymes?
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What is included in NSTEMI acute treatment?
What is included in NSTEMI acute treatment?
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What is the first treatment option for STEMI?
What is the first treatment option for STEMI?
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What medications should be included in NSTEMI discharge prescriptions?
What medications should be included in NSTEMI discharge prescriptions?
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What leads to a diagnosis of unstable angina?
What leads to a diagnosis of unstable angina?
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What to avoid before an exercise EKG?
What to avoid before an exercise EKG?
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What are contraindications to exercise stress tests?
What are contraindications to exercise stress tests?
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What medications are used for a chemical stress test?
What medications are used for a chemical stress test?
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What needs to be avoided before MUGA?
What needs to be avoided before MUGA?
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What is the acute treatment for unstable angina?
What is the acute treatment for unstable angina?
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What is the most common cause of death post-MI?
What is the most common cause of death post-MI?
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What murmur is associated with papillary muscle rupture post-MI?
What murmur is associated with papillary muscle rupture post-MI?
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What causes acute severe hypotension post-MI?
What causes acute severe hypotension post-MI?
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What indicates a 'step up' in oxygen from RA to RV post-MI?
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?
What is indicated by persistent ST elevation one month later post-MI?
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What does 'Cannon A-waves' indicate?
What does 'Cannon A-waves' indicate?
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What is Dressler's syndrome?
What is Dressler's syndrome?
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What characterizes pericarditis in a young, healthy patient?
What characterizes pericarditis in a young, healthy patient?
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What condition presents with chest pain that worsens with palpation?
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?
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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