Clinical Presentation
Describe the location AND character of the pain experienced during a classic (i.e., non-atypical) STEMI.
Location: retrosternal, commonly radiating to the left chest, arm, shoulder, neck, jaw, and/or epigastrium
Character: Dull, squeezing pressure and/or tightness
Based on the following ECG, which coronary artery is most likely occluded?
ST elevations in leads V2, V3, V4 (all are anterior leads)...
Anterior MI...
Answer: LAD!
In a patient suffering from an acute MI, what is the main objective of treatment?
OPEN THE ARTERY! ("revascularization")
This can be accomplished via emergency angioplasty or thrombolysis.
Which of the following complications is most likely to occur in the first 4 days post-MI?
a. Free wall rupture
b. VSD (septal rupture)
c. Tamponade
d. Arrhythmia
e. Papillary muscle rupture
d. Arrhythmia
A certain emergency surgical procedure, often considered a last resort for severe MIs, involves creating new routes for blood flow to the heart muscle by bypassing blocked coronary arteries.
1. What is the name of this procedure?
2. What artery is most commonly used as a conduit to bypass the blocked coronary arteries?
1. CABG (coronary artery bypass grafting)
2. LIMA (left internal mammary artery)
What is the peak time of occurrence for a STEMI?
a. Morning
b. Noon
c. Late afternoon
d. Evening
a. Morning
Based on the following ECG, which of the following is LEAST likely to occur?
a. Posteromedial papillary muscle rupture
b. Right ventricular infarction
c. ST elevations in aVR
d. Sinus bradycardia and heart block
c. ST elevations in aVR
Inferior MI may result in:
- PM pap. m. rupture
- Right ventricular infarction (PDA is supplied by R. main in 90% of patients)
- Sinus bradycardia and heart block (vagal stimulation)
Which of the following is NOT typically part of the acute treatment plan for a STEMI?
a. Heparin
b. Hydrochlorothiazide
c. Aspirin
d. Nitroglycerin
e. Metoprolol
B. Hydrochlorothiazide
Fibrinous pericarditis is a NON-autoimmune form of pericarditis that can occur as a complication DAYS after an MI.
A different form of pericarditis can occur WEEKS after an MI as a result of an autoimmune process. What is the name of this syndrome?
Dressler's syndrome
In order to prevent a certain complication of stent placement, patients are typically given "dual antiplatelet therapy."
1. What is the name of this complication?
2. Fill in the blanks. "In dual platelet therapy, patients are typically given one year of [specific drug] plus a [specific class of drugs]."
Correctly answer all parts for credit. Be as specific as possible.
- Stent thrombosis
- Aspirin
- ADP receptor inhibitor (e.g., prasugrel, ticagrelor, or clopidogrel)
Atypical presentations of a STEMI are more likely to occur in which of the following groups? (Select all that apply)
- Elderly
- Patients with diabetes
- Women
All (women, elderly, and patients with diabetes)
Fact: "Silent MI" (i.e., MI without chest pain) is more common in patients with diabetes as a result of polyneuropathy.
The EKG of a patient with an acute MI reveals ST depressions in leads V1, V2, and V3 (with no other abnormalities). If you want to visualize ST elevations in this patient, what should you do?
Place posterior leads (e.g., V7, V8, V9) on the back of the patient.
Reason: This patient is having a posterior MI due to occlusion of the posterior descending artery (NOT the RCA or LCX).
This question has two parts. You must correctly answer both parts in order to win points.
Part 1: Define "door to ballon" time and "door to needle" time.
Part 2: What is the maximum amount of time that is acceptable for each?
Door-to-balloon time refers to the duration between a patient's arrival at the hospital and the initiation of percutaneous coronary intervention. It should be less < 90 minutes.
Door-to-needle time refers to the duration between a patient's arrival at the hospital and the administration of thrombolytic therapy. It should be < 30 minutes.
The technical name given to reduced movement of a region or whole of the heart muscle following an MI
Hypokinesis
Based on the following ECG, the patient most likely has an occlusion of which coronary artery?
LEFT MAIN CORONARY ARTERY
Reasoning:
- ST elevations in aVR (the "forgotten lead") accompanied by diffuse ST depressions
Which of the following best distinguishes between the cardinal symptoms and unspecific warning signs of ST-elevation myocardial infarction (STEMI)?
A) Cardinal symptoms typically include sudden onset chest pain or discomfort, whereas unspecific warning signs often manifest as generalized fatigue or nausea.
B) Cardinal symptoms usually involve radiating chest pain or pressure, while unspecific warning signs commonly present as localized numbness or tingling.
C) Cardinal symptoms often include shortness of breath or dizziness, while unspecific warning signs are characterized by severe chest pain lasting for more than 30 minutes.
D) Cardinal symptoms frequently involve sharp, stabbing chest pain exacerbated by breathing or movement, while unspecific warning signs often include sudden onset sweating or palpitations.
A) Cardinal symptoms typically include sudden onset chest pain or discomfort, whereas unspecific warning signs often manifest as generalized fatigue or nausea.
What is the most specific biomarker for myocardial necrosis?
Cardiac troponin (cTn)
("Troponin" is an acceptable answer.)
Fibrinolytic therapy.
Fibrinolytic therapy is often used to open the occluded artery when timely access to cardiac catheterization facilities is limited.
While ventricular aneurysm is more common in infarctions affecting the anterior wall, ventricular pseudoaneurysm is more often seen in infarctions affecting this wall
Inferior wall
(Note: In a ventricular pseudoaneurysm, the rupture is contained by pericardium/scar tissue.)
Let's talk about risk reduction. In patients with a history of MI, which of the following may be prescribed to prevent recurrence?
a. Aspirin
b. A statin
c. A beta blocker
d. Aspirin and a statin (NOT a beta blocker)
e. Aspirin, statins, and beta blockers
e. Aspirin, statins, and beta blockers have ALL been proven to be effective in preventing the recurrence of MI.
Which of the following types of chest pain are considered ATYPICAL symptoms of STEMI? (Select all that apply.)
a. Sharp chest pain
b. Squeezing chest pain
c. Burning chest pain
d. Pleuritic chest pain
e. No chest pain
a, c, d, e
Sharp, burning, and pleuritic chest pain are all atypical, as is the absence of chest pain.
This cardiac biomarker, largely replaced by troponin, can be helpful in evaluating re-infarction because of its short half-life.
CK-MB
When is oxygen used as an adjunctive therapy for MI?
Only in cases of severe dyspnea, cyanosis, or SpO2 < 90%.
(You final answer should be one of these answers but does not have to contain all three.)
Papillary muscle rupture and septal rupture are both complications that may occur 5-10 days after MI. Both produce murmurs. What feature do these murmurs share?
HOLOSYSTOLIC
Papillary muscle rupture - acute mitral regurgitation
Septal rupture - VSD
True or false? To improve their prognosis, patients with MI can be given a nitroglycerin, a drug that is contraindicated in patients an inferior wall infarct due to high risk for hypotension.
False
While nitroglycerin can be given to most patients with an MI for symptomatic relief of chest pain, it does not improve prognosis.