Risk Factors and Prevention
This lifestyle habit is the single most important modifiable risk factor for ACS.
What is smoking?
Typical Patient Presentation
Chest pain or discomfort
• Often described as pressure, tightness, squeezing, or heaviness
• Located retrosternally, may radiate to the left arm, neck, jaw, or back
• May occur at rest or with exertion and last >10 minutes
Shortness of breath
• Especially in elderly or those with heart failure
Diaphoresis
• Profuse sweating due to sympathetic activation
Nausea and/or vomiting
Palpitations or lightheadedness
A patient suffering myocardial ischemia (without infarction) may demonstrate which EKG findings?
ST depressions or T wave inversions.
ST elevation is indicative of true myocardial infarction.
Dosage of aspirin given in ACS
162-325mg (moderate-to-high dose)
This diagnostic procedure is considered appropriate for patients with suspected acute coronary syndrome and high-risk features.
What is a Left heart catheterization
This lipid abnormality is a well-known risk factor for atherosclerosis and MI.
What is high LDL cholesterol?
Difference between unstable angina, NSTEMI and STEMI.
ST-Elevation Myocardial Infarction (STEMI): Caused by complete coronary artery occlusion, characterized by persistent ST-segment elevation on ECG and elevated cardiac troponins, indicating full-thickness myocardial necrosis.
Non-ST-Elevation Myocardial Infarction (NSTEMI): Caused by partial or transient occlusion, with no ST elevation but positive troponins, indicating subendocardial infarction.
Unstable Angina: Also caused by partial occlusion or plaque instability, with no ST elevation and normal troponins, as there is ischemia without infarction.
What leads on an EKG correspond to the inferior, lateral and anteroseptal coronary distributions?
Inferior- II, III, aVF
Lateral- I, aVL, V5, V6
Anterior/ Septal- V1-V4
Typical anticoagulant used in acute coronary syndrome
Unfractionated heparin (drip)
Can also use bivalirudin
This is the most common arterial access site for left heart catheterization.
What is the femoral artery
Elevated levels of this lab, often inherited, are an independent risk factor for premature atherosclerotic cardiovascular disease.
What is lipoprotein(a)?
This structured clinical tool helps evaluate chest pain in the emergency setting by scoring History, ECG, Age, Risk factors, and Troponin to predict the likelihood of major cardiac events.
HEART score
What non-ACS cause of chest pain may also present with ST elevations on EKG?
And how is the distribution of those elevations different than in a STEMI?
Pericarditis
Classically presents with diffuse ST elevations and PR depressions.
ST elevations are not confined to one coronary territory.
Type of infarction that should NOT receive nitrates.
Right ventricular
Triad: distended neck veins, clear lung sounds, hypotension.
What coronary variant, present in up to 30% of people, arises between the LAD and LCX arteries?
What is the ramus intermedius artery?
This genetic condition causes markedly elevated LDL from a young age and leads to premature coronary artery disease.
What is familial hypercholesterolemia?
Type I vs Type II MI
Type 1 Myocardial Infarction:
Caused by a primary coronary artery event, typically atherosclerotic plaque rupture, ulceration, or erosion leading to intraluminal thrombus formation and acute coronary obstruction.
→ Often associated with ACS presentations such as STEMI or NSTEMI.
→ Troponins elevated
Type 2 Myocardial Infarction:
Caused by a mismatch between myocardial oxygen supply and demand without acute plaque rupture.
→ Common triggers include severe anemia, hypoxia, tachyarrhythmias, hypotension, or sepsis.
→ Troponins elevated, but usually in the context of another acute illness and not due to primary coronary thrombosis.
Which specific wave on an EKG is indicative of a prior myocardial infarct?
Q Wave
A negative deflection preceding the R wave which often indicates prior myocardial infarction/ necrosis.
Duration of DAPT after PCI for ACS
twelve months
if drug eluting stent is placed in stable ischemic heart disease (not ACS presenting), six months DAPT is recommended
What test can be done if severity of left main coronary stenosis is indeterminate.
What is fractional flow reserve (FFR) measurement?
This inflammatory marker is sometimes elevated in patients at increased cardiovascular risk, even with normal lipids.
What is C-reactive protein (CRP)?
Apart from Troponin, what other biomarker can be used to diagnose ACS? Also, when is it appropriate to order?
CK-MB can be helpful when assessing for reinfarction or new myocardial injury shortly after a recent MI, and when diagnosing periprocedural myocardial infarction, where its faster elimination kinetics can be advantageous.
However, for routine diagnosis of ACS, CK-MB is not recommended when hs-cin assays are available.
What is the eponymous name for EKG findings of biphasic or deeply inverted T waves in leads V2-V3, classically associated with critical LAD stenosis.
Wellen's Sign/ Syndrome
Classically found on EKGs after recent chest pain once the pain has resolved.
Should prompt coronary angiography rather than stress testing.
What medication should be considered in patients with ACS when a PCI cannot be performed within 120 minutes?
Fibrinolytic therapy - tenecteplase, alteplase, repteplase, streptokinase
*If without absolute contraindications (active bleeding, prior intracranial bleed, head trauma or ischemic stroke in the past 3 months, intracranial malignancy, head/spine surgery in last 2 months)
In patients with a mechanical aortic valve who need a LHC, this alternative approach is preferred over the traditional route
What is a transseptal approach