STEMI Treatment Quiz

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Questions and Answers

Which medication should not be administered to a patient with STEMI who has a known recent ischemic stroke?

Fibrinolytics (correct)

Sublingual nitroglycerin

Anticoagulation with unfractionated heparin

Aspirin

What is the preferred approach for patients with STEMI when primary PCI is not available within 120 minutes of medical contact?

Administration of anticoagulation only

Intranasal oxygen if saturation is low

Fibrinolytic therapy (correct)

Immediate administration of aspirin

Which of the following is a contraindication for the use of fibrinolytics in STEMI treatment?

Systolic blood pressure over 180 mmHg

Prior intracranial hemorrhage (correct)

Active menses

Recent nebulized bronchodilator treatment

Which anti-platelet medication should be administered to all patients with STEMI without contraindications within 24 hours of hospital arrival?

Aspirin Signup and view all the answers

Which of the following medications is classified as a fibrinolytic?

Alteplase Signup and view all the answers

What is the primary concern related to the use of fibrinolytics in patients with a history of significant closed head trauma within 3 months?

Intracranial hemorrhage Signup and view all the answers

In which situation would fibrinolytic therapy be indicated?

Patient presents with STEMI within 12 hours of chest discomfort and has 1-mm STE Signup and view all the answers

What should be the first-line treatment for a STEMI patient if they are capable of receiving it within the recommended time frame?

Primary PCI Signup and view all the answers

What is the recommended duration for dual antiplatelet therapy following PCI?

12 months Signup and view all the answers

Which of the following is considered a preferred antiplatelet agent in the initial management of NSTE-ACS?

Ticagrelor Signup and view all the answers

Which of the following medications is NOT indicated for continued management in patients with normal left ventricular function after myocardial infarction?

Calcium Channel Blockers Signup and view all the answers

Which agents are to be used for administering nitrates in patients with NSTE-ACS?

SL NTG followed by IV NTG Signup and view all the answers

What is the primary goal of secondary prevention following myocardial infarction?

Control modifiable risk factors Signup and view all the answers

Which of the following should be continued indefinitely in patients with left ventricular ejection fraction (LVEF) of 40% or less?

β-blockers Signup and view all the answers

In cases where β-blockers are contraindicated, which of the following may be used for patients with ongoing ischemia?

Amlodipine Signup and view all the answers

What is the role of short-acting SL NTG or lingual NTG spray following a myocardial infarction?

As needed for anginal relief Signup and view all the answers

What is the recommended dosage of non-enteric-coated aspirin for patients not previously taking aspirin?

162-325 mg regardless of reperfusion strategy Signup and view all the answers

What are common adverse drug reactions of oral nitrates?

Tachycardia and hypotension Signup and view all the answers

Which of the following is a common adverse reaction (ADR) associated with Clopidogrel?

Hypersensitivity Signup and view all the answers

Why should non-steroidal anti-inflammatory drugs (NSAIDs) and COX inhibitors be discontinued at the time of STEMI?

They increase the risk of death and reinfarction Signup and view all the answers

Which calcium channel blocker should be avoided due to its potential to cause reflex sympathetic activation?

Nifedipine Signup and view all the answers

Which of the following P2Y12 inhibitors can be given as an initial 300-mg loading dose in adults younger than 75 years receiving fibrinolytics?

Clopidogrel Signup and view all the answers

In patients with NSTE-ACS, which therapy should NEVER be administered?

Fibrinolytic therapy Signup and view all the answers

What is a significant contraindication for administering Glycoprotein IIb/IIIa receptor inhibitors?

History of hemorrhagic stroke Signup and view all the answers

What is the recommended course of action for high-risk patients in NSTE-ACS?

Early angiography and possible GPI administration Signup and view all the answers

What should be administered to all patients with NSTE-ACS in the emergency department if there are no contraindications?

Intranasal oxygen and SL NTG Signup and view all the answers

Which anticoagulant is preferred for patients undergoing primary PCI?

Bivalirudin Signup and view all the answers

What is the maximum infusion rate of Abciximab during PCI?

10 mcg/min Signup and view all the answers

Aspirin reduces the risk of death or myocardial infarction by approximately what percentage in patients with NSTE-ACS?

50% Signup and view all the answers

What is the primary role of a P2Y12 inhibitor in patients with NSTE-ACS?

To reduce the risk of ischemic events when combined with aspirin Signup and view all the answers

Which of the following statements about Aspirin and ADP inhibitors is accurate?

ADP inhibitors are recommended in conjunction with Aspirin for all STEMI patients. Signup and view all the answers

When should oral beta-blockers be initiated in patients without cardiogenic shock?

Within the first 24 hours Signup and view all the answers

Which condition is associated with PSVT due to reentrant mechanisms?

Sinoatrial node reentry Signup and view all the answers

What characterizes monomorphic ventricular tachycardia?

Wide QRS with regular rhythm Signup and view all the answers

Which of the following can lead to torsades de pointes?

Hypokalemia Signup and view all the answers

What is the primary mechanism associated with atrial fibrillation and atrial flutter?

Reentry mechanisms Signup and view all the answers

What distinguishes sustained ventricular tachycardia from nonsustained ventricular tachycardia?

Requires intervention to restore rhythm Signup and view all the answers

Which arrhythmia is characterized by a rapid but irregular ventricular response and a lack of visible P waves?

Atrial fibrillation Signup and view all the answers

Which condition is NOT typically associated with premature ventricular complexes (PVCs)?

Normal heart function Signup and view all the answers

What is the typical range of atrial beats per minute in atrial flutter?

270–330 beats/min Signup and view all the answers

Which of the following arrhythmias typically does not require drug therapy?

Sinus tachycardia Signup and view all the answers

What are the typical ventricular rates observed in atrial fibrillation?

120–180 beats/min Signup and view all the answers

Which laboratory evaluation is likely beneficial in diagnosing arrhythmias?

ECG interpretation Signup and view all the answers

What characterizes supraventricular arrhythmias?

They can occur in the atria. Signup and view all the answers

Which of the following arrhythmias can present with a regular ventricular response and a pattern of alternating conduction ratios?

Atrial flutter Signup and view all the answers

Study Notes

Acute Coronary Syndrome (ACS)

ACS encompasses syndromes associated with acute myocardial ischemia, arising from an imbalance between myocardial oxygen demand and supply.
Classification is based on electrocardiographic (ECG) changes:
- ST-segment elevation myocardial infarction (STEMI):
  - Characterized by ST-segment elevation in at least two contiguous leads on the 12-lead ECG.
- Non-ST-segment-elevation acute coronary syndrome (NSTE-ACS):
  - Includes:
    - Non-ST-segment-elevation myocardial infarction (NSTEMI):
      - Characterized by ST-segment depression or T-wave inversion, possibly with elevated cardiac biomarkers.
    - Unstable angina (UA):
      - Characterized by chest pain or discomfort, and may or may not have elevated cardiac biomarkers.

Learning Outcomes (Acute Coronary Syndrome)

Explain the pathophysiology of ACS.
Identify factors inducing and potentiating ACS.
Discuss the clinical presentation, diagnosis, and laboratory evaluation of ACS.
Evaluate therapeutic outcomes of ACS treatment.

Coronary Artery Structure

The artery wall consists of several layers:
- Tunica intima: innermost layer, contains endothelium and elastic membrane
- Tunica media: middle layer, composed of smooth muscle and elastic fibers
- Tunica adventitia: outermost layer, composed of connective tissue

Pathophysiology of ACS

Endothelial dysfunction, inflammation, and fatty streak formation contribute to atherosclerotic plaque development.
Plaque rupture leads to collagen and tissue factor exposure, thus inducing platelet adhesion and activation.
Platelet activation promotes the release of adenosine diphosphate (ADP) and thromboxane A2, which results in vasoconstriction.
Platelet aggregation through fibrinogen bridges occurs.
Exposure of blood to the thrombogenic lipid core and endothelium activates the extrinsic coagulation cascade and forms a fibrin clot.

Learning Outcomes (Arrhythmia)

Explain the pathophysiology of arrhythmias.
Identify factors inducing and potentiating arrhythmias
Discuss clinical presentation, diagnosis, and laboratory evaluation of arrhythmias.
Evaluate therapeutic outcomes for arrhythmia treatment

Arrhythmia

Arrhythmia is the irregular heartbeat abnormality, including:
- Ventricular arrhythmias: occur in the lower chambers (ventricles) of the heart.
- Supraventricular arrhythmias: occur in the upper chambers (atria) of the heart.

Atrial Fibrillation (AF)

Extremely rapid (400–600 beats/min) and disorganized atrial activation.
Irregular ventricular rate, often not visible P waves in the ECG.

Atrial Flutter

Rapid (270–330 beats/min) but regular atrial activation.
Regular ventricular response pattern (often 2:1, 3:1, or 4:1 conduction).

Paroxysmal Supraventricular Tachycardia (PSVT)

Caused by re-entry mechanisms, including AV nodal re-entry, AV re-entry incorporating an anomalous AV path, sinoatrial (SA) nodal re-entry, and intra-atrial re-entry..
Characterized by a regular, narrow complex tachycardia.

Ventricular Tachycardia (VT)

Three or more repetitive ventricular premature complexes (PVCs) at a rate above 100 beats per minute.
Can be monomorphic (consistent QRS) or polymorphic (varying QRS morphology), with torsades de pointes as a specific polymorphic form.

Ventricular Proarrhythmia

Development of new or worsening ventricular arrhythmias due to antiarrhythmic agents.
Torsades de pointes (TdP) is a rapid, polymorphic VT associated with delayed ventricular repolarization.

Ventricular Fibrillation (VF)

Chaotic irregular deflections without identifiable P-QRS-T waves.
Usually associated with no cardiac output and sudden cardiac arrest in patients with left ventricular dysfunction or coronary artery disease.

Cardiac Arrest

Cessation of cardiac mechanical activity, confirmed by the absence of signs of circulation (e.g., pulse, responsiveness, and breathing).

Pathophysiology of Cardiac Arrest

Two primary causes:
- Primary: arterial blood is typically fully oxygenated.
- Secondary: occurs from respiratory failure as a result of absent or inadequate ventilation.
- Coronary artery disease as a possible underlying contributor in adults.

Clinical Presentation of Cardiac Arrest

Cardiac arrest may be preceded by symptoms like anxiety, shortness of breath, chest pain, nausea, vomiting, and diaphoresis.
After arrest, patients are unresponsive, apneic, and hypotensive, lacking a detectable pulse.

Diagnosis of Cardiac Arrest

Clinical manifestations consistent with cardiac arrest.
Vital signs (heart rate, respirations) confirm the diagnosis
ECG identifies the rhythm, guiding the determination of drug therapy.

Treatment of Cardiac Arrest

CPR; Return of Spontaneous Circulation (ROSC) with early ventilation.
Immediately address precipitating cause(s) of arrest..
Optimize tissue oxygenation and prevent subsequent episodes.

Chain of Survival Approach

Out-of-hospital arrests:
- Recognition and activation of the emergency response system.
- Immediate high-quality CPR.
- Rapid defibrillation.
- Basic and advanced emergency medical services.
- Advanced life support and post-arrest care.
In-hospital arrests: same as above, with added surveillance and prevention steps.

Treatment of Ventricular Fibrillation and Pulseless Ventricular Tachycardia

Administer electrical defibrillation (360 J monophasic or 120-200 J biphasic).
Restart CPR until rhythm analysis, then repeat defibrillation or consider pharmacologic therapy.
Establish airway and IV access when feasible.
Provide 100% oxygen.

Pharmacologic Therapy (Cardiac Arrest)

Epinephrine: first-line treatment.
Amiodarone: second-line treatment if epinephrine ineffective or unavailable.
Lidocaine: alternative to amiodarone

Treatment of Pulseless Electrical Activity (PEA) and Asystole

- CPR, airway control, and IV access.
- Avoid defibrillation in asystole.
- Transcutaneous pacing if available.

Acid-Base Management (Cardiac Arrest)

Acidosis typically occurs due to decreased blood flow or inadequate ventilation.
Sodium bicarbonate is sometimes used in special circumstances (e.g., preexisting metabolic acidosis, hyperkalemia, TCA overdose).

Postresuscitation Care

Ensure adequate airway and oxygenation.
Evaluate for myocardial infarction (MI) and consider revascularization.
Therapeutic hypothermia (32-36°C) is usually used.
Monitor for and address complications, including electrolyte imbalances, infections, and dysrhythmias.
Gradually rewarm the patient at a controlled rate.

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Description

Test your knowledge on the treatment protocols for STEMI, including medication administration and contraindications. This quiz covers critical scenarios in which fibrinolytics may be used, as well as the management approaches when primary PCI is unavailable. It's essential for healthcare professionals involved in cardiology and emergency medicine.