What groups are alternative presentations of MI most common?
Women, young, elderly
What might an S3 sound indicate?
left ventricular dysfunction
What might an S4 sound indicate?
decreased left ventricular compliance
(Note: this cannot occur in atrial fibrillation since it is caused by atria contraction driving blood into the ventricles and against an abnormal ventricular wall)
Why it it important to diagnose unstable angina?
10% of those with unstable angina will have an MI within 7 days
Angina as a symptom has what kind of duration?
It lasts no more than 30 minutes
Describe the 3 types of angina:
Stable
Prinzmetal’s
Unstable
Stable: -Can be frequent and still stable Prinzmetal's: -Vasospasm -associated w/ ST elevation -occurs at rest, often at night, rarely with exercise Unstable: -10% Will have MI in 7 days -Increasing duration, frequency, or intensity -Occurring with less and less activity
Let’s grade some anginas:
Real brief grades: 1,2,3,4
Grade 1: Ordinary activity produces no angina
Grade 2: Slight limitation of ordinary activity
Grade 3: Angina even occurs when walking
Grade 4: Can happen at rest, activity very limited
Specific criteria defining a heart attack:
Elevation of troponin and AT LEAST ONE of the following:
1) Symptoms of ischemia
2) Q wave development
3) New ST/T wave changes or new LBBB
4) Intracoronary thrombus
5) Loss of cardiac wall
Why does Dr. Adams say we can’t automatially discharge a patient with a normal EKG and troponin levels?
EKG can be normal in 1/3 of early MI’s
At 3 hours after an MI, troponin sensitivity is only 50%
(if normal for 6 hours, AMI can be excluded usually)
EKG reading in a STEMI?
-ST elevation in all leads (greater than 1 box)
but V2/V3 (greater than 2 boxes)
-If ST’s are depressed, can be posterior MI
EKG reading for NSTEMI?
Horizontal or downward ST depression is 2 contiguous leads
AND/OR
T wave inversion with prominent R wave or R/S ratio
How do you manage a patient with low risk ACS vs a patient with moderate/sever risk?
Low: aspirin, observation with repeate troponin every 6-12 hours
Mod/High: Nitroglycerin, heparin, repeat troponin every 6-12 hours
When should you use notroglycerin?
For angina, and selectively for MI (not good for RV infarct)
What medicines are usually not urgent, but important for mortality reduction in 1st 24 hours?
ACE inhibitors (for pts with CHF or low LV ejection) Beta-blockers