NR571 MIDTERM UPDATED ACTUAL Questions and CORRECT
Answers
Cardiac enzyme/marker interpretation (troponin, CK-MB, Troponin: Troponin is a protein in heart muscle cells that regulates muscular
BNP) contraction. When the heart muscle is damaged, as in a heart attack, troponin is
released into the bloodstream. Troponin levels can become elevated 3-4 hours
after a heart attack and can remain elevated for up to 14 days. Therefore, it is a
highly specific indicator of heart damage.
CK-MB (Creatine Kinase-MB): CK-MB is a form of creatine kinase found mostly in
the heart muscle. Levels in the blood can rise within a few hours of a heart attack
and generally peak within 24 hours. A high CK-MB level often indicates damage to
the heart. However, CK-MB is less specific for heart damage than troponin, as it
can also be elevated in conditions such as muscle injury, inflammation, or vigorous
exercise.
BNP (B-type Natriuretic Peptide): BNP is a hormone produced by the heart and
blood vessels. The level of BNP in the blood increases when the heart is working
hard and has more fluid than it should. High levels of BNP are often associated
with heart failure. This test is often used to differentiate between heart failure and
other conditions (like lung diseases) when a patient presents with shortness of
breath.
Additional Laboratory Tests
· Troponin every 8hr
· BNP to assess for heart failure
· CBC provides information needed for thrombolytic therapy (H/H and platelet
baseline)
· PTT, PT/INR to assess baseline coagulation status
· BMP to assess renal function and electrolytes
· TSH, magnesium, and phosphorus as imbalances can cause dysrhythmias
· echocardiogram to evaluate the ejection fraction and patency of heart valves
· coronary angiography
Differentials for angina
Unstable angina: acute cardiac chest pain that comes and goes without relation
to exertion along with ST segment depression or T-wave inversions. Cardiac
enzymes are normal
NSTEMI: elevated cardiac enzymes with acute cardiac chest pain or/and ECG
changes (ST segment depression or T-wave inversion)
STEMI: acute cardiac chest pain, ST segment elevations, and elevated cardiac
enzymes
Stable Angina: is a pattern of exacerbation with physical or emotional stress
caused by a supply–demand mismatch. It lasts several minutes and is relieved by
rest.
Variant/Prinzmetal: Occurs in the presence of arterial spasm and is unrelated to
CAD. More common in women.
,Risk factors for cardiac ischemia · Age > 55 years
· Family History of CAD
· Tobacco use
· Diabetes
· HTN
· Hyperlipidemia
· Vascular atherosclerosis
· Obesity
· Unhealthy diet
· Inactivity
· COVID-19
Appropriate diagnostic testing in PFO(Patent Foramen An echocardiogram can be done to diagnose a PFO. If the PFO is not easily seen,
Ovale) a cardiologist can perform a "bubble test." Saline solution (salt water) is injected
into the body as the cardiologist watches the heart on an ultrasound
(echocardiogram) monitor.
EKG interpretation in ACS/MI Inferior wall: II, III, & aVF--RCA & LCx
Intraventricular septum: V1-V2--LAD
Anterior wall: V3-V4--LAD, LCA
Lateral wall of the left atrium and septum: I, aVL, V5, & V6--LCx
Right atrium: aVR--RCA
Management of chest pain in CAD The 7 early treatment measures in ACS:
1. Oxygen
2. Nitroglycerine
3. Morphine
4. Beta-blocker
5. Aspirin
6. Clopidogrel
7. Anticoagulation
Admission vs discharge considerations in CAD/ACS Patients with NSTEMI, unstable angina, or STEMI will be discharged with DAPT for
at least 1 year. Continuation of DAPT versus aspirin-only beyond that is based on
the type of stent placed (if applicable) and cardiologist preference. High-intensity
statins will also be continued in ACS patients.
Additionally, ACS patients should also be discharged on a beta-blocker and a
high-intensity statin. Blood pressure should be optimized to a goal of 120/80
following JNC-VIII or AHA recommendations.
, Outpatient medication management S/P STEMI Treatment
· chewable ASA 325mg
· high dose atorvastatin or rosuvastatin
· Beta-blocker (avoid in cocaine-induced STEMI)
· Morphine (only for severe pain; use with caution)
· oxygen for SaO2 < 90%
· sublingual NTG x 3 tablets followed by NTG drip if pain not resolved
(contraindicated with RV infarct).
Return to light exercise should follow the cardiologist's recommendations and will
depend on the extent of the injury. Cardiac rehabilitation, which involves intense
CAD education and lifestyle management interventions, including weight
management, should be considered for all ACS patients.
Patients who use tobacco or illicit drugs should be advised to quit. Smoking
cessation education and treatment options provided to the patient should also be
well-documented
Differentials for atrial fibrillation cardiomyopathy
congestive heart failure,
heart disease
hyperthyroidism,
acute alcohol intoxication
myocardial infarction
pulmonary embolism
pericarditis
cardiac surgery
obesity,
hypertension,
diabetes mellitus
sleep disordered (OSA)
Answers
Cardiac enzyme/marker interpretation (troponin, CK-MB, Troponin: Troponin is a protein in heart muscle cells that regulates muscular
BNP) contraction. When the heart muscle is damaged, as in a heart attack, troponin is
released into the bloodstream. Troponin levels can become elevated 3-4 hours
after a heart attack and can remain elevated for up to 14 days. Therefore, it is a
highly specific indicator of heart damage.
CK-MB (Creatine Kinase-MB): CK-MB is a form of creatine kinase found mostly in
the heart muscle. Levels in the blood can rise within a few hours of a heart attack
and generally peak within 24 hours. A high CK-MB level often indicates damage to
the heart. However, CK-MB is less specific for heart damage than troponin, as it
can also be elevated in conditions such as muscle injury, inflammation, or vigorous
exercise.
BNP (B-type Natriuretic Peptide): BNP is a hormone produced by the heart and
blood vessels. The level of BNP in the blood increases when the heart is working
hard and has more fluid than it should. High levels of BNP are often associated
with heart failure. This test is often used to differentiate between heart failure and
other conditions (like lung diseases) when a patient presents with shortness of
breath.
Additional Laboratory Tests
· Troponin every 8hr
· BNP to assess for heart failure
· CBC provides information needed for thrombolytic therapy (H/H and platelet
baseline)
· PTT, PT/INR to assess baseline coagulation status
· BMP to assess renal function and electrolytes
· TSH, magnesium, and phosphorus as imbalances can cause dysrhythmias
· echocardiogram to evaluate the ejection fraction and patency of heart valves
· coronary angiography
Differentials for angina
Unstable angina: acute cardiac chest pain that comes and goes without relation
to exertion along with ST segment depression or T-wave inversions. Cardiac
enzymes are normal
NSTEMI: elevated cardiac enzymes with acute cardiac chest pain or/and ECG
changes (ST segment depression or T-wave inversion)
STEMI: acute cardiac chest pain, ST segment elevations, and elevated cardiac
enzymes
Stable Angina: is a pattern of exacerbation with physical or emotional stress
caused by a supply–demand mismatch. It lasts several minutes and is relieved by
rest.
Variant/Prinzmetal: Occurs in the presence of arterial spasm and is unrelated to
CAD. More common in women.
,Risk factors for cardiac ischemia · Age > 55 years
· Family History of CAD
· Tobacco use
· Diabetes
· HTN
· Hyperlipidemia
· Vascular atherosclerosis
· Obesity
· Unhealthy diet
· Inactivity
· COVID-19
Appropriate diagnostic testing in PFO(Patent Foramen An echocardiogram can be done to diagnose a PFO. If the PFO is not easily seen,
Ovale) a cardiologist can perform a "bubble test." Saline solution (salt water) is injected
into the body as the cardiologist watches the heart on an ultrasound
(echocardiogram) monitor.
EKG interpretation in ACS/MI Inferior wall: II, III, & aVF--RCA & LCx
Intraventricular septum: V1-V2--LAD
Anterior wall: V3-V4--LAD, LCA
Lateral wall of the left atrium and septum: I, aVL, V5, & V6--LCx
Right atrium: aVR--RCA
Management of chest pain in CAD The 7 early treatment measures in ACS:
1. Oxygen
2. Nitroglycerine
3. Morphine
4. Beta-blocker
5. Aspirin
6. Clopidogrel
7. Anticoagulation
Admission vs discharge considerations in CAD/ACS Patients with NSTEMI, unstable angina, or STEMI will be discharged with DAPT for
at least 1 year. Continuation of DAPT versus aspirin-only beyond that is based on
the type of stent placed (if applicable) and cardiologist preference. High-intensity
statins will also be continued in ACS patients.
Additionally, ACS patients should also be discharged on a beta-blocker and a
high-intensity statin. Blood pressure should be optimized to a goal of 120/80
following JNC-VIII or AHA recommendations.
, Outpatient medication management S/P STEMI Treatment
· chewable ASA 325mg
· high dose atorvastatin or rosuvastatin
· Beta-blocker (avoid in cocaine-induced STEMI)
· Morphine (only for severe pain; use with caution)
· oxygen for SaO2 < 90%
· sublingual NTG x 3 tablets followed by NTG drip if pain not resolved
(contraindicated with RV infarct).
Return to light exercise should follow the cardiologist's recommendations and will
depend on the extent of the injury. Cardiac rehabilitation, which involves intense
CAD education and lifestyle management interventions, including weight
management, should be considered for all ACS patients.
Patients who use tobacco or illicit drugs should be advised to quit. Smoking
cessation education and treatment options provided to the patient should also be
well-documented
Differentials for atrial fibrillation cardiomyopathy
congestive heart failure,
heart disease
hyperthyroidism,
acute alcohol intoxication
myocardial infarction
pulmonary embolism
pericarditis
cardiac surgery
obesity,
hypertension,
diabetes mellitus
sleep disordered (OSA)
