Medicine Marrow Pg No 427-436 (ECG)
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Questions and Answers

What is the expected ECG finding in AVR during proximal LCA occlusion?

  • T wave inversion
  • Normal
  • ST elevation (correct)
  • ST depression

    • Immediate PCI is necessary to prevent 100% mortality in cases of proximal LCA occlusion.

    True

    Name two complications that can occur due to left ventricle involvement in AWMI.

    V-tach and V-fib

    If a patient experiences sudden cardiac death due to AWMI, it may be due to involvement of the _____ ventricle.

    <p>left</p> Signup and view all the answers

    Match the following complications with their descriptions:

    <p>V-tach = A rapid heartbeat originating from the ventricles Cardiac rupture = A life-threatening complication of myocardial infarction Infra-hisian blocks = Conduction disturbances below the His bundle Septal rupture = A complication involving the partition between heart chambers</p> Signup and view all the answers

    What is the primary goal when dealing with a myocardial infarction?

    <p>Save the artery</p> Signup and view all the answers

    The first 6 hours after the onset of chest pain are referred to as the golden hours.

    <p>True</p> Signup and view all the answers

    What is the term used for the procedure that aims to open blocked arteries in myocardial infarction cases?

    <p>Percutaneous coronary intervention (PCI)</p> Signup and view all the answers

    After _____ hours, only 1/6th of the myocardium remains viable.

    <p>6</p> Signup and view all the answers

    Which chest pain descriptor has the highest positive likelihood ratio?

    <p>Radiation to the right arm or shoulder</p> Signup and view all the answers

    Match the outcomes of myocardial infarction intervention with their descriptions:

    <p>A-B = No benefit A-C = Benefit B-C = Benefit E-D = Harm</p> Signup and view all the answers

    A patient experiencing chest pain that goes away after 20 minutes is guaranteed to be safe.

    <p>False</p> Signup and view all the answers

    What are two angina equivalents?

    <p>Dyspnea and fatigue</p> Signup and view all the answers

    The one-month mortality rate after _____ is 5%.

    <p>reperfusion</p> Signup and view all the answers

    Match the management strategies with their corresponding mortality rates:

    <p>Pre-CCU = 30% mortality rate CCU = 15% mortality rate Reperfusion = 5% mortality rate</p> Signup and view all the answers

    Which of the following conditions can lead to elevated levels of Cardiac Troponin? (Select all that apply)

    <p>Myocarditis</p> Signup and view all the answers

    NSTEMI is characterized by a normal enzyme level.

    <p>False</p> Signup and view all the answers

    What is the required Cardiac Troponin T/I value to indicate myocardial injury?

    <p>≥ 1 value above the 99th percentile with acute rise and fall</p> Signup and view all the answers

    If a patient has a _____ reaction with elevated Cardiac Troponin levels, they may be diagnosed with myocardial infarction.

    <p>steep increase</p> Signup and view all the answers

    Match the following myocardial conditions with their respective Cardiac Troponin elevation patterns:

    <p>Myocarditis = Moderate increase and gradual return to normal CHF = Low to moderate increase, then stable Myocardial Infarction = Steep increase, then slower decrease back to normal</p> Signup and view all the answers

    Which lead shows ST elevation in a Right Coronary Artery (RCA) occlusion?

    <p>Lead III</p> Signup and view all the answers

    The Left Anterior Descending Artery (LAD) primarily supplies the lateral wall of the heart.

    <p>False</p> Signup and view all the answers

    What is the significance of ST elevation in lead II being greater than lead III in LCX occlusion?

    <p>It indicates occlusion of the Left Circumflex Artery (LCX) with lateral wall involvement.</p> Signup and view all the answers

    The __________ phenomenon occurs when the Right Coronary Artery (RCA) supplies all regions.

    <p>wrap around</p> Signup and view all the answers

    Match the artery with the area it primarily supplies:

    <p>LCA = Left anterior interventricular sulcus LCX = Lateral wall LAD = Anterior wall RCA = Inferior wall</p> Signup and view all the answers

    Which leads show ST elevation in an antero-septal high lateral myocardial infarction (MI)?

    <p>I, aVL</p> Signup and view all the answers

    In an anteroseptal MI, ST elevation is observed in leads V1 and V2.

    <p>True</p> Signup and view all the answers

    Where does the course of the anterior descending artery terminate?

    <p>Anastomosis with PDA</p> Signup and view all the answers

    The anatomical landmark of S2 is located __________ D1.

    <p>before</p> Signup and view all the answers

    Match the types of myocardial infarctions with their corresponding ST elevation leads:

    <p>Antero-septal high lateral MI = V2, V3, V4, I, aVL Anteroseptal MI = V1, V2 Anterolateral MI = Occlusion between S2 and D1 ST elevation in V5, V6 = Wrap around phenomenon</p> Signup and view all the answers

    What defines significant ST depression in an ECG reading?

    <p>ST depression associated with certain clinical features</p> Signup and view all the answers

    NSTEMI is characterized by the presence of typical chest pain in all patients.

    <p>False</p> Signup and view all the answers

    What age group is commonly affected by NSTEMI?

    <p>40-50 years</p> Signup and view all the answers

    In patients with NSTEMI, __________ is a common feature observed in the ECG readings.

    <p>ST depression</p> Signup and view all the answers

    Match the following NSTEMI characteristics with their descriptions:

    <p>Rest angina &gt; 20 minutes = A prolonged chest pain indicating ischemia New onset severe angina = A sudden and intense chest pain Crescendo pattern of angina = Increasing severity of angina over time Typical chest pain in diabetes = Often absent in diabetic patients</p> Signup and view all the answers

    Which of the following is NOT a determinant of salvageable myocardium?

    <p>Thrombolysis</p> Signup and view all the answers

    The mode of reperfusion is considered more important than reopening the artery in treating STEMI.

    <p>False</p> Signup and view all the answers

    What is the target time for wire crossing after diagnosis in a STEMI patient when the time is less than 60 minutes?

    <p>90 minutes</p> Signup and view all the answers

    In STEMI, if the diagnosis to wire crossing time is 60 minutes or more, thrombolysis must be performed within _____ minutes.

    <p>10</p> Signup and view all the answers

    Match the following approaches with their descriptions:

    <p>Pharmacoinvasive approach = Prevents recurrence of thrombus formation Thrombolysis = Treatment option administered within 10 minutes First medical contact personnel = Responsible for taking and interpreting ECG Wire crossing = Target time of less than 90 minutes if diagnosis time is under 60 minutes</p> Signup and view all the answers

    What is the most common cause of Type 1 myocardial infarction?

    <p>Athero-thrombotic occlusion</p> Signup and view all the answers

    Development of pathological Q waves is considered a symptom of myocardial ischemia.

    <p>True</p> Signup and view all the answers

    What type of myocardial infarction is characterized by sudden cardiac death?

    <p>Type 3</p> Signup and view all the answers

    New _____ changes can indicate myocardial ischemia.

    <p>ECG</p> Signup and view all the answers

    Match the type of myocardial infarction with its description:

    <p>Type 1 = Athero-thrombotic occlusion Type 2 = Demand/Supply mismatch Type 4 = Post percutaneous coronary intervention Type 5 = Post coronary artery bypass graft</p> Signup and view all the answers

    Which of the following is NOT a potential cause of Type 2 myocardial infarction?

    <p>Plaque rupture</p> Signup and view all the answers

    What does an elevated level of cardiac troponin indicate when it exceeds the 99th percentile URL?

    <p>Acute myocardial infarction or acute myocardial injury</p> Signup and view all the answers

    Ultrasensitive troponin assays can detect enzyme levels as low as 0.5 ng/mL.

    <p>False</p> Signup and view all the answers

    What is a criteria for diagnosing reinfarction?

    <p>Two troponin values greater than a 20% increase</p> Signup and view all the answers

    Plaque rupture is more common in women than in men.

    <p>False</p> Signup and view all the answers

    What are the two primary underlying pathologies of culprit coronary lesions?

    <p>Plaque rupture and plaque erosion</p> Signup and view all the answers

    The condition characterized by a thin cap and a necrotic lipid core greater than 40% is known as ______.

    <p>vulnerable plaque</p> Signup and view all the answers

    Match the following myocardial conditions to their characteristics:

    <p>Hibernating Myocardium = Chronic Setting, Viable tissue Stunned Myocardium = Acute Setting, Restore perfusion for few hours</p> Signup and view all the answers

    Which of these characteristics are associated with vulnerable plaques? (Select all that apply)

    <p>Thin cap</p> Signup and view all the answers

    CPK-MB plays a significant role in diagnosing myocardial infarction.

    <p>False</p> Signup and view all the answers

    What is the relationship between hibernating myocardium and perfusion?

    <p>Hibernating myocardium has decreased function due to low perfusion.</p> Signup and view all the answers

    Study Notes

    Proximal Left Coronary Artery (LCA) Occlusion

    • Proximal LCA occlusion leads to ST elevation in the AVR lead and ST depression in all other leads.
    • Without treatment, mortality is 100%.
    • Treatment involves immediate percutaneous coronary intervention (PCI).

    Acute Coronary Syndrome (ACS) - Coronary Circulation

    • The provided image likely shows an ECG tracing.
    • The ECG pattern indicates proximal LCA occlusion.

    Complications of Acute Wide Myocardial Infarction (AWMI)

    • Left ventricular (LV) involvement can cause ventricular tachycardia (V-tach), ventricular fibrillation (V-fib), and sudden cardiac death.
    • Mechanical complications include external cardiac rupture and septal rupture.
    • Infra-hisian blocks can occur.

    Chest Pain Characteristics

    • Radiation of chest pain to the right arm or shoulder has a positive likelihood ratio of 4.7.
    • Radiation to both arms or shoulders has a positive likelihood ratio of 4.1.
    • Chest pain associated with exertion has a positive likelihood ratio of 2.4.
    • Radiation to the left arm has a positive likelihood ratio of 2.3.
    • Chest pain associated with diaphoresis has a positive likelihood ratio of 2.0.
    • Chest pain associated with nausea or vomiting has a positive likelihood ratio of 1.9.
    • Chest pain worse than previous angina or similar to a previous myocardial infarction (MI) has a positive likelihood ratio of 1.8.
    • Chest pain described as pressure has a positive likelihood ratio of 1.3.

    Angina Equivalents

    • Dyspnea, fatigue, diaphoresis, and atypical site pain can be equivalents of angina.

    Management of Chest Pain

    • Pre-Coronary Care Unit (CCU): Morphine for sedation. 1-month mortality rate: 30%.
    • CCU: Beta-blockers, defibrillator. 1-month mortality rate: 15%.
    • Reperfusion (Since 1975): Thrombolysis, percutaneous intervention. 1-month mortality rate: 5%.

    ST Elevation Myocardial Infarction (STEMI)/ST-Elevation Acute Coronary Syndrome (STE-ACS)

    Salient Features

    • The provided image shows diagrams illustrating the progression of myocardial infarction at different time points.
    • The diagrams highlight the affected arteries: Left anterior descending artery (LAD), Right coronary artery (RCA), and Left circumflex artery (LCX).

    Progression of Myocardial Damage

    • The first 6 hours are considered the "golden hours".
    • After 6 hours of chest pain onset, only 1/6th of the myocardium remains viable.

    Mortality Reduction

    • A graph showing the rapid decline in survival rate after time zero highlights the critical importance of timely treatment.

    Potential Outcomes

    • Outcomes are categorized into benefit (A-C, B-C) and harm (E-D).

    Extent of Salvage

    • A graphic demonstrates the importance of rapid artery opening through PCI or lysis.
    • The x-axis represents time in hours, and the y-axis represents the extent of salvage.

    Reperfusion (PCI)

    • Myocardium can be salvaged before 6 hours of coronary artery occlusion.
    • After 6 hours, PCI can reduce pain, prevent electrical complications, and prevent mechanical complications.

    Diagnosis: ECG Changes

    • ST Elevation: Leads II, III, AVF
    • Reciprocal Change: Leads V1, V2, V3
    • RCA: ST elevation in lead III > lead II, ST depression in AVL > AVR
    • Proximal: ST depression in V1 discordant to V2, V3
    • Wrap around phenomenon: RCA supplies all regions

    Note: LCX Occlusion

    • Left ventricle wall motion abnormalities (LWM1) + Posterior wall motion abnormalities (PWM1)
    • ST elevation in lead II > lead III
    • In left-dominant circulation, if LCX supplies the lateral wall, LWM1 may be present.

    Papillary Muscle Rupture → 2° MR

    • Occurs post-LWM1 PCI with congestive heart failure (CCF).
    • Presents with LV S3, absence of murmur.
    • Ejection fraction (EF): Good.
    • Normal or near-normal ECG.

    Left Coronary Circulation

    Left Coronary Artery (LCA)

    Left Circumflex Artery (LCX)

    • Branches: D (high lateral wall), S (septal wall), Da (anterior wall), D3 (lateral wall), D (diagonal), S (septal)

    Left Anterior Descending Artery (LAD)

    • Site: Left anterior interventricular sulcus
    • ECG Leads:
      • Anterior: V1, V2, V3 (LAD)
      • Lateral: V5, V6 (LAD/LCX)
      • High Lateral: I, AVL (LAD/LCX)
      • Septal: V1 >> V2 (LAD)
      • Apical: V4

    ECG Interpretation

    • Antero-septal high lateral MI: V2, V3, V4 ST elevation (LAD), I, AVL ST elevation (before D1), wrap around phenomenon (V2, V3, V4 ST elevation above Da, V1 no elevation below S2, V5, V6 ST elevation wrap around)
    • Anteroseptal MI: V1, V2 ST elevation (above S2), I, AVL ST depression (between D1 and S2)
    • Anterolateral MI: Anatomical S2 before D1, Occlusion between S2 and D1

    Diagnosis: ECG Changes

    • Diagnosis: Reinfarction (within 28 days)
    • Reinfarction: Two troponin values immediately and 3-6 hours later that are greater than a 20% increase.

    Underlying Pathologies of Culprit Coronary Lesion

    • Plaque Rupture: 60-70% (most common), men, associated with elevated cholesterol
    • Plaque Erosion: 30-40%, female, young, associated with smoking

    Characteristics of Vulnerable Plaques

    • Thin cap, necrotic lipid core (greater than 40%), increased macrophage infiltration, decreased smooth muscle cell content, spotty calcification

    Hibernating and Stunned Myocardium

    • Hibernating Myocardium: Chronic setting, viable tissue (MRI should be done for evaluation), decreased function due to low perfusion.
    • Stunned Myocardium: Acute setting, seen post-ischemia, viable tissue, restore perfusion for few hours.

    Diagnosis

    • ECG: Used to diagnose reinfarction.

    ACS - Evaluation & Management

    Definition

    • Universal definition of MI (2018): Obsolete terms: fixed plaque, rupture, fibrin-rich thrombus, platelet-rich thrombus. Critical occlusion, incomplete occlusion.
    • STEMI/STE-ACS --> NSTE-ACS
    • Normal enzyme: Unstable angina
    • Raised enzyme: NSTEMI

    a. Myocardial Injury

    • Cardiac Troponin T/I: ≥ 1 value above 99th percentile with acute rise and fall.
    • Other causes of ↑ troponin level:
      • Cardiac: Myocarditis, Takotsubo cardiomyopathy, defibrillator shocks, increased oxygen demand (tachyarrhythmia), decreased oxygen supply (spasm, embolism, dissection).
      • Non-Cardiac: Sepsis, subarachnoid hemorrhage, chronic kidney disease, critically ill patients, pulmonary embolism.

    Current Universal Definition - ACS/Acute MI:

    Myocardial injury + ½ clinical evidence of myocardial ischemia.

    Types and Clinical Features

    • Type 1: Athero-thrombotic occlusion (most common)
    • Type 2: Demand/supply mismatch (ICU patients, Severe anemia)
    • Type 3: Sudden cardiac death
    • Type 4: Post percutaneous coronary intervention
    • Type 5: Post coronary artery bypass graft

    Ultrasensitive Troponin Assays

    • Can detect enzyme elevation levels as low as 0.0ng/mL.

    TYPE I MI

    • Possible triggers: Atherosclerosis + thrombosis, plaque rupture, plaque erosion.

    TYPE 2 MI

    • Possible causes: Oxygen supply and Demand imbalance, severe hypertension, sustained tachyarrhythmia.

    TYPE 3 MI

    • Possible causes: Oxygen supply and demand imbalance, acute heart failure, myocarditis.

    Chronic MI

    • Possible causes: Structural heart disease, chronic kidney disease.

    Determinants of Salvageable Myocardium

    • Collaterals, myocardial oxygen demand, ischemic preconditioning.

    Target Time in STEMI (European Society of Cardiology)

    • Chest pain → First medical contact (FMC) (should be < 10 min)
    • Diagnosis → Availability of 24-hour PCI center
    • YES (Diagnosis to Wire Crossing Time < 60 min): Wire crossing done within 90 min (+ 30 min for patient transfer)
    • NO (Diagnosis to Wire Crossing Time >= 60 min): Thrombolysis within 10 min (Tenecteplase or Reteplase), transfer patient to PCI center, check for ST resolution after 60-90 min (successful > 70% resolve, unsuccessful < 70% resolve (Rescue PCI / Emergency PCI))
    • Pharmacoinvasive approach: Successful thrombolysis within 2-24 hours, prevents recurrence of thrombus formation.
    • First medical contact personnel: Medical/Paramedic staff, take & interpret ECG, can use defibrillator.

    b. Clinical evidence of myocardial ischemia.

    • Symptoms
    • New ECG changes.
    • Development of pathological Q waves.
    • Imaging evidence (New RWMA).
    • Angiography evidence (Coronary thrombus).

    Localization

    • Before D1, between D1 and S2, below S2.

    Course

    • Enters the Posterior interventricular sulcus.
    • Terminates at anastomosis with PDA.
    • Wrap around phenomenon: Inferior wall.

    ECG

    • Deterinants of salvageable myocardium: Collaterals, Myocardial oxygen demand, Ischemic preconditioning.
    • Note: Reopening the artery is more important than the mode of reperfusion.

    ECG Wave Form Descriptions

    • ECG traces, labeled with different leads (e.g., I, II, III, aVR, aVL, aVF, V1-V6), showing ST depression, appear as waves and deflections on a grid.

    NSTEMI (Non-ST-Elevation Myocardial Infarction)

    • Features: Rest angina lasting more than 20 minutes, new onset severe angina, crescendo pattern of angina, ST depression and T wave inversion, elevated cardiac troponins.
    • Clinical presentation: Age group 40-50 years (50-60 years in other regions), predominance of females over males in patients from locations outside India, vague symptoms in females are a common presentation, absence of typical chest pain in patients with diabetes.
    • TIMI score: Used to determine mortality risk in NSTEMI cases.

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    Description

    This quiz tests your knowledge on proximal left coronary artery occlusion, its complications, and the characteristics of associated chest pain. Understand the implications of acute coronary syndrome and the importance of timely intervention.

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