Cardio

Chest pain: EKG > Cardiac enzymes (3x q8h)

o Myoglobin for reinfarct; also CK
STEMi positive EKG is (1) ST elevation (2 mm) or (2) LBBB (wide, flat QRS)
o Later signs T wave inversion
o Old infarct (permanent) Q waves
Cardiac enzymes
o Troponin I most sensitive; rises in 3-5h, nml by 7-10d
o CKMB rises in 4-8h, nml by 72h; also can detect reinfarct after 72h
o Myoglobin first to rise (2h) , first to drop (nml by 24h), therefore most
sensitive for reinfarction
Treatment: MONA (ASA/Clopidogrel), BB
Coronary Angiogram determines necessity for intervention
o Stent (PCI) pre;ferred
o Bypass if (1) left main disease (2) 3 vessel-disease or (3) 2 vesseldisease in diabetic
Discharge meds
o ASA
o Clopidogrel for 9-12m if Stented
o BB
o ACE-I if CHF or LV Dysfxn
o Statin (prevent future disease)
o Nitrates (chest pain)
Any new angina is deemed Unstable Angina if theres no ST-elevation and normal
cardiac enzymes x3
o Next test: Stress test (Exercise EKG)
Avoid BB and CCB,
c/i: old LBBB, baseline ST-elevation, Digoxin do Exercise Echo
instead
o in Stress/Exercise test cant be performed, do Chemical Stress Test
(Dobutamine or Adenosine)
o MUGA (nuclear medicine test) shows perfusion
Avoid caffeine and theophylline
o Positive if chest pain is reproduced, ST-depression or hyptension occur do
Coronary Angiogram
Post-MI complications
o MCCOD arrhythmia (V. fib worst)
o New systolic murmer 5-7d s/p MI AR secondary to papillary mm rupture
o Acute severe hypotension vent free wall rupture
o Step Up in O2 conc in RA more than RV septal wall rupture
o Persistent ST-elevation 1 month later with systolic MR murmer Ventricular
Wall aneurysm
o Cannon A-waves (in JVP, bounding) AV-dissociation, either V. fib or 3rd
degree heart block
o 5-10w later, pleuritic chest pain, low grade temp Dressler Syn (autoimmune
pericarditis; Rx: NSAIDs and ASA)
o Diffuse ST-elevation a/w pericarditis; worsens with inspiration, friction rub,
pain alleviates w/ leaning forward