> [!Key Points] > **criteria for reperfussion therapy**: concerning symptoms + ECG (1mm STE in contiguous leads or posterior STEMI or ~~presumed new LBBB~~ or LBBB/PPM with [[STEMI equivalents|sgarbossa]]) > - 2013 ACC/AHA removed new LBBB as indication for cath lab or thrombolytics see also: [[GTN]], [[Unstable angina]], [[ECG]], [[STEMI ECG patterns]], [[Chest pain]], - [Heart foundation ACS guideline 2025](https://www.heartfoundation.org.au/for-professionals/acs-guideline) - [Devonthink link](x-devonthink-item://943750C1-A66C-4BDB-8619-5655C54B9191) - [Australian clinical guidelines for management of Acute Coronary Syndromes (powerpoint)](x-devonthink-item://1C4FE8DC-AB60-4AF9-9150-0801545351F5) -- outdated as of 2025 - [National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016.](bookends://sonnysoftware.com/ref/DL/200959) -- outdated as of 2025 - [Braunwald - VT in IHD -- ECG location of VT](x-devonthink-item://18E3C9C6-F903-460A-9B39-E4A2B50B5AA6?page=20) > [!quote] ACS Definition > ACS encompass both acute myocardial infarction (AMI) and [[Unstable angina]] (UA). ACS may also be classified as ST-segment elevation ACS (STEACS) and non- ST-segment elevation ACS (NSTEACS). > > This guideline adopts the term acute coronary occlusion myocardial infarction (ACOMI) which may present as ST-segment elevation myocardial infarction (STEMI) or STEMI equivalents. The term ACOMI is adopted to highlight STEMI equivalents, which are often under recognised or missed in emergency settings. > \- [2025 ACS Guideline](x-devonthink-item://943750C1-A66C-4BDB-8619-5655C54B9191?page=9), page 3 # Path of ACS Atherosclerosis → exposes endothelium → platelets and fibrin attach ## causes - plaque rupture - inflammation - trauma and vessel damage - clotting disorders - dissection - drugs eg cocaine with vasospasm # ECG > note, see [[ECG]] section! classic changes in AMI: - ST elevation (early -- minutes to hours) - hyperacute T waves (early -- minutes) - ST depression -- could be ischaemia, reciprocal change, or posterior MI - Q waves -- usually late ## STEMI ## STEMI mimics - pericarditis - [benign early repolerisation](bear://x-callback-url/open-note?id=CC3F4026-F9FD-41D6-9C3D-7F0E8F1DCF3F-3058-0000021ACC2B4F19) ## ST depression - usually not for thrombolytics, unless V1-V3 with STD and consideration of [[#posterior]] STEMI ## STEMI equivolents [[STEMI mimics]] ## Sgarbossa criteria [[STEMI equivalents#Sgarbossa examples]] # Cardiac vessel supply ## LAD - supplies anterior wall - some of the septum - V1-V4 STE Complications: - CHF - valves - arrhythmias ![[Pasted image 20230514212640.png| STE V1-V5, LAD infarct]] ## Circumflex - branch of LAD - supplies lateral portion of heart - I, aVL, V5-V6 STE ## Right coronary artery - supplies inferiorly and posteriorly - right side of heart, inferior wall - II, III, aVF can get hypotensive and bradycardic (supplies AV node) if lesion is more proximal, then very fluid dependent ## posterior infarct - can also be from RCA - STD in v1-v3 # Early MI complications - Arrhythmia (fast or slow) - shock -- loss of muscle - shock -- valve dysfunction - Congestive heart failure |good prognosis | bad prognosis| |---|---| |Mobitz I|Mobitz II (often wide complex; suggests septal involvement)| |Narrow complex bradycardias| CHF| |PVC| persistent tachycardia| |Non-sustained VT| New LBBB| ||failure of reperfusion| # MI complications by location |location| Leads | complications| prognosis| |---|---|---| ---| |**inferior**| II, III, aVF | AV blocks, fluid-responsive hypotension| good; not much myocardium involved| |**anterior**| v2-v5 | CHF, shock, wide-complex bradycardia| BAD| |**right ventricle**| STE in III > II, STE in V1 > V2, STD in V2 and not V1 | hypotension. associated with inferior MI| OK to bad| | **posterior** | | often missed | BAD| ![[Pasted image 20230420022216.png]] ## inferior > STE - II, III, aVF > node blood supply: > sinus: **RCA** 60%; circumflex 40% > AV node: RCA 90%; circumflex 10% - **blocks** - tend to be narrow complex - Hypotension - ==good prognosis== as not much myocardium involved - classic Mobitz type I - even a narrow complex 3rd deg AV block has a decent prognosis; took out AV node but not too much lower - sinus bradycardia from high vagal tone - **papillary muscle rupture** ![[Pasted image 20230514222736.png| inferior MI with Mobitz I narrow complex. can treat with usual MI care]] ## right ventricular inferior MI's evil twin > inferior where STE in III > II, STE in V1 > V2, STD in V2 and not V1 > - STE in V1 and STD in V2 is highly **specific** for RV infarction - hypotension -- treat with IV fluids - Associated with inferior MI - ==beware of using GTN== --> severe hypotension - Kussmauls sign, elevated prominent jugular venous pressure and hypotension are all signs of RV infarction. - **Kussmaul sign** is a paradoxical rise in jugular venous pressure (JVP) on inspiration, or a failure in the appropriate fall of the JVP with inspiration. ### example 1 ![[Pasted image 20230514223434.png]] STE in v1, STE in III > II. ![[Pasted image 20230514223504.png]] ^ confirmed with V4R electrode position ### example 2 ![[Pasted image 20230514223530.png]] ^ STE III > II, isoelectric ST in v1, STD v2, STE in V4R lead ### example 3 Chest pain, BP 60/35. what is best initial therapy? ![[Pasted image 20230514223833.png]] ^ inferior STE with III >II, STE in V1 and STD V2. **treat with IVF** (not epinephrine or pressors) ## anterior-septal > V2-V5 - poor prognosis - LV - CHF/shock -- lots of myocardium involved - Shock - Bad bradyarrhythmias because affecting comduction pathway - septum and conduction pathway die and LOTS of heart muscle is gone - tend to be WIDE complex that is NOT responsive to atropine - structural problems - myocardial rupture -- tx fluid and surgery - septum rupture, acute VSD -- tx: reduce afterload, surgey > MI + new Murmur + CHF/shock = consult cardiac surgeon ![[Pasted image 20230514225125.png]] ## posterior - often missed # General Treatment of MI - Early defibrillation if indicated - Aspirin -- 25% reduction in death! - +/-[[GTN|nitrates]] -- reduce pain, increase blood flow, maybe reduce mortality (see comment below) - ONLY give beta blockers PO if really hypertensive or tachycardic - do NOT give beta blockers if any CHF - ACE-I in first 24 hours - Supplemental O2 *only* if O2 sats on RA < 90%. In patients receiving O2 therapy, SpO2 should not exceed 96% (strong recommendation with moderate > [[GTN]] is not a *treatment* and does NOT improve prognosis (see ISIS-4 and GISSI-3 studies), but can help improve symptoms. My personal practice is to use it with extreme prejudice in ED due to: > 1. Hypotension in any patient > 2. Risk of [[STEMI ECG patterns#right ventricular|RV infarct]] in patients with equivocal inferior STEMI > 3. Often language barrier may preclude clarity about whether they are taking a contraindicated medication such as phosphodiasterase 5 inhibitor (eg viagra/sildenafil). ![[Pasted image 20250510224607.png]] ## ACS with multivessel disease without cardiogenic shock see: [2025 guideline](https://www.heartfoundation.org.au/for-professionals/acs-guideline?tab=3#Treatment%20for%20ACS%20with%20multivessel%20disease%20without%20cardiogenic%20shock) # Risk stratification ![[Pasted image 20240726213634.png]] # thrombolysis see: [Dunn - thrombolytic therapy in ACS](x-devonthink-item://1667438D-1517-41FD-B7D1-62E76471D349), [[TPA|thrombolysis]] **tenectolase** ## indications for thyrombolysis > - STE (persistent STE ≥1mm in 2 contiguous limb leads, persistent STE ≥ 2mm in 2 contiguous chest leads, [[STEMI equivalents|sgarbossa]] LBBB > - Chest pain > 30 minutes, <12 hours > - no PCI available within 90 minutes > - no contraindications ### ECG criteria for thrombolysis - ST elevation >1mm in 2 contiguous leads - LBBB with sgarbossa criteria - New LBBB with CP is still an indication - you should be able to read MI in RBBB - can be subtle; ANY STE especially v1 v2 is abnormal **Not indicated for:** ST depression (except if posterior) or good history alone ### Sgarbossa criteria 1. concordant STE 2. excessive discordance >5mm STE 3. concordant STD ## tenecteplase dose guide ![[Pasted image 20230514201955.png]] ## Contraindications to thrombolysis: absolute - active bleeding - ischemic stroke last 3 months - cerebral haemorrhage at anytime - closed head injury in prior 3 months - known intracerebral tumor/AVM, etc - suspected aortic dissection > **Summary of contraindications** > - Badness in head > - other bleeding risks ![[Pasted image 20230514202125.png]] ## Complications of thrombolysis - intracranial bleeding (>50% mortality) - 1/70 - 1/100 - RF: old age, HTN, female, black, HTN - major bleeding (~5%) ## Post-thrombolysis - hopefully reduced pain - ST segment lowering by ~70% - T wave inversion within 4 hours is highly specific for reperfusion - Reperfussion arrhythmia - Also look out for **accelerated idoventricular rhythm** -- looks like slow VT; it is a perfusing rhythm, do NOT treat with antiarrhythmics - usually lasts very short period, a few times and a few minutes - if VT, then WOULD treat ### AIVR - ==do not give sodium channel blocker== -- can suppress rhythm and cause asystole - not VT if rate <120 ![[Pasted image 20230515225404.png|AIVR]] # PCI ## PCI indications - STEMI within [12 hours](x-devonthink-item://1C8D118F-382C-4964-A580-CF1530A06BF9?page=24&start=333&length=67&search=For%20patients%20with%20STEMI%20presenting%0Awithin%2012%20hours%20of%20symptom%20onset) of onset - shock with STEMI - contraindications to thrombolysis - failed thrombolysis - NSTEACS with very high risk criteria (ongoing ischaemia, haemodynamic compromise, arrhythmias, mechanmical complications of MI, acute heart failure, recurrent dynamic or widespread ST-segment and/or T wave changes on ECG) → [immediate PCI within two hours](x-devonthink-item://1C8D118F-382C-4964-A580-CF1530A06BF9?page=29) # Chest pain with cocaine - Generally low risk - if ECG negative, trop rule out; can usually go home DDx: - ACS - vasospasm - pneumothorax - pneumomediastinum If they have a ST elevation, also give: - benzos - calcium channel blockers - possibly treat as STEMI # Related Questions ## ACS - [x] 1Q: [Acute coronary syndrome](x-devonthink-item://310EEEDE-D794-4365-8865-5B3DD1C20510?page=8) -- [Answer](x-devonthink-item://6D5125AD-DE4D-435B-8D13-6EA35DB8E785?page=10) -- [prop](x-devonthink-item://D0A460D5-938B-4002-A684-EFD9189B08C1?page=4) - [x] 2Q: [Chest pain](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=21) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=21) - [x] 3Q: [Acute Coronary Syndrome](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=57) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=28) - [x] 4Q: [Chest pain](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=7) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=2) - [x] 5Q: [Abnormal ECG](x-devonthink-item://FE3157C2-07B3-43F2-9ECE-AFACE1355E13?page=26) -- [Answer](x-devonthink-item://DDC959EB-0C1E-448A-8380-C397BF734322?page=12) -- [prop](x-devonthink-item://4042F313-756E-469B-BB0C-4CD9D1E5225F?page=4) - [ ] 6Q: [STEMI](x-devonthink-item://C1DDA3AB-2DA2-4922-A8A6-F597AB7E2558?page=3) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=12) -- [prop](x-devonthink-item://B864660E-6598-4555-ACA9-B87F41ED4C3A?page=8) - [ ] 7Q: [Chest Pain](x-devonthink-item://5ADC62A1-9798-4399-BE79-68C375E8D9BF?page=8) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=22) -- [prop](x-devonthink-item://308BBEF4-A83E-4972-8F63-9249898FC8E8?page=14) - [ ] 8Q: [Chest Pain and Abnormal ECG](x-devonthink-item://7061D1B4-0AB9-4963-B3B0-23BDD975B2CD?page=7) -- [Answer](x-devonthink-item://3F30C77E-E23E-4200-89FE-48A41618E0C2?page=5) ## acute coronary syndrome - [ ] 9Q: [Acute coronary syndrome](x-devonthink-item://5B3989BE-73BA-4EB6-8D42-758DAA229A56?page=2) -- [Answer](x-devonthink-item://F6B57015-DA53-404D-804A-55DCA60971A6?page=0) -- [prop](x-devonthink-item://C5EFC1EA-802B-49BC-824D-CFF7C6FFDBD8?page=1) - [x] DUPLICATE Q: [Acute coronary syndrome](x-devonthink-item://310EEEDE-D794-4365-8865-5B3DD1C20510?page=8) -- [Answer](x-devonthink-item://6D5125AD-DE4D-435B-8D13-6EA35DB8E785?page=10) - [x] DUPLICATE Q: [Chest pain](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=7) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=2) - [ ] 10Q: [Acute Coronary Syndrome](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=30) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=14) -- [prop](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=74) - [ ] 11Q: [Acute Coronary Syndrome](x-devonthink-item://40193B7A-D362-4C39-9D2A-2D112B58104B?page=6) -- [Answer](x-devonthink-item://AADB7978-B533-4E12-B6E4-E994C0B685FF?page=5) -- [prop](x-devonthink-item://F8FBC1E8-52B3-47B9-8EBB-5CB6F3F81EBC?page=4) - [x] DUPLICATE Q: [Chest Pain and Abnormal ECG](x-devonthink-item://7061D1B4-0AB9-4963-B3B0-23BDD975B2CD?page=7) -- [Answer](x-devonthink-item://3F30C77E-E23E-4200-89FE-48A41618E0C2?page=5) - [ ] 12Q: [Epigastric Pain with ECG Changes](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=9) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=7) -- [prop](x-devonthink-item://2A1F4A99-92AE-4C8E-B325-AE448BD46AC6?page=3) ## dissection - [ ] 26Q: [Aortic dissection](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=7) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=10) -- [prop](x-devonthink-item://D0A460D5-938B-4002-A684-EFD9189B08C1?page=11) ## ecg - [ ] 27Q: [Management of post arrest patient](x-devonthink-item://09493372-578D-4C97-972A-EEC617B38B53?page=5) -- [Answer](x-devonthink-item://A0D348CE-FCD4-4ECD-BE21-6CA73F6DE8CD?page=3) - [ ] 29Q: [Chest pain and unusual ECG](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=48) -- [Answer](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=50) - [ ] 31Q: [Pericarditis](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=6) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=6) -- [prop](x-devonthink-item://68EA6F60-334D-4A94-8327-78286C5F1AED?page=3) - [ ] 32Q: [Post Arrest Arrhythmia and Retrieval](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=23) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=23) -- [prop](x-devonthink-item://68EA6F60-334D-4A94-8327-78286C5F1AED?page=10) - [x] 34Q: [ST Elevation and Negative Troponin](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=41) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=41) -- [prop](x-devonthink-item://68EA6F60-334D-4A94-8327-78286C5F1AED?page=10) - [x] DUPLICATE Q: [Abnormal ECG of unwell elderly man](x-devonthink-item://CA0CC973-6102-4C33-AB59-A43A87724DF0?page=16) -- [Answer](x-devonthink-item://9F437E5A-02D4-43FC-B795-5386EDE954F3?page=14) - [x] DUPLICATE Q: [Presyncope of Young Person During Exertion](x-devonthink-item://8AAAF35C-CCF4-4157-9551-5B05727AA0CD?page=17) -- [Answer](x-devonthink-item://FDFBA3A1-6207-4204-AB6D-7483D80C5B5C?page=18) - [x] DUPLICATE Q: [Acute coronary syndrome](x-devonthink-item://5B3989BE-73BA-4EB6-8D42-758DAA229A56?page=2) -- [Answer](x-devonthink-item://F6B57015-DA53-404D-804A-55DCA60971A6?page=0) - [ ] 38Q: [Hypokalaemia](x-devonthink-item://2F267333-5FEC-47E5-83D1-CC05B23EB91A?page=19) -- [Answer](x-devonthink-item://C6CAC39D-CAE8-4F76-9C45-689A0464D936?page=14) -- [prop](x-devonthink-item://C5EFC1EA-802B-49BC-824D-CFF7C6FFDBD8?page=4) - [ ] 39Q: [Aortic dissection](x-devonthink-item://B257662E-D069-4044-AF7A-736487B5CA99?page=2) -- [Answer](x-devonthink-item://1658DB69-4D34-47EF-9495-B6B43E0BE3BE?page=1) -- [prop](x-devonthink-item://51B63B5B-D684-4BF3-8B62-95FCA5EF7503?page=2) - [ ] 40Q: [Brugada syndrome](x-devonthink-item://80040649-2DDB-4266-9A7C-4DE4E6DD4AE6?page=3) -- [Answer](x-devonthink-item://C96EDD2F-137A-43E5-80EE-5F42C5971D55?page=4) -- [prop](x-devonthink-item://51B63B5B-D684-4BF3-8B62-95FCA5EF7503?page=8) - [ ] 41Q: [Overdose](x-devonthink-item://310EEEDE-D794-4365-8865-5B3DD1C20510?page=5) -- [Answer](x-devonthink-item://6D5125AD-DE4D-435B-8D13-6EA35DB8E785?page=6) -- [prop](x-devonthink-item://D0A460D5-938B-4002-A684-EFD9189B08C1?page=3) - [x] DUPLICATE Q: [Acute coronary syndrome](x-devonthink-item://310EEEDE-D794-4365-8865-5B3DD1C20510?page=8) -- [Answer](x-devonthink-item://6D5125AD-DE4D-435B-8D13-6EA35DB8E785?page=10) - [x] DUPLICATE Q: [Chest pain](x-devonthink-item://F0498813-9350-484C-AD5B-6FF7C3AE9015?page=21) -- [Answer](x-devonthink-item://A491A3F6-FD6D-492F-BCBE-7F7BAE101EDF?page=21) - [x] DUPLICATE Q: [Acute Coronary Syndrome](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=57) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=28) - [x] DUPLICATE Q: [Arrhythmia](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=35) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=12) - [x] DUPLICATE Q: [Abnormal ECG](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=69) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=26) - [ ] 46Q: [Cardiogenic Syncope](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=15) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=6) -- [prop](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=69) - [x] DUPLICATE Q: [Acute Coronary Syndrome](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=30) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=14) - [x] DUPLICATE Q: [Abnormal ECG](x-devonthink-item://FE3157C2-07B3-43F2-9ECE-AFACE1355E13?page=26) -- [Answer](x-devonthink-item://DDC959EB-0C1E-448A-8380-C397BF734322?page=12) - [ ] 50Q: [Chest pain and LBBB](x-devonthink-item://1442A590-B32E-40BE-9C29-6401A71DC2DC?page=15) -- [Answer](x-devonthink-item://0C9617AB-8E16-4A75-ADF0-AB06FA726B0A?page=6) -- [prop](x-devonthink-item://D5D52721-F021-4ABC-B6EA-727BF54DF6B9?page=4) - [ ] 52Q: [ST Elevation](x-devonthink-item://84CE632D-3DD4-4F41-A900-23F41BE57287?page=6) -- [Answer](x-devonthink-item://D25C2F83-6C30-4F45-8B5B-6E7E57BD24A3?page=22) -- [prop](x-devonthink-item://0F9688C6-AA10-45DA-BFF4-9BBBFC201582?page=15) - [ ] 53Q: [Broad Complex Tachycardia](x-devonthink-item://A8F2D7A0-9A26-4012-AF42-19D640D674B4?page=18) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=9) -- [prop](x-devonthink-item://B864660E-6598-4555-ACA9-B87F41ED4C3A?page=5) - [x] DUPLICATE Q: [STEMI](x-devonthink-item://C1DDA3AB-2DA2-4922-A8A6-F597AB7E2558?page=3) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=12) - [x] 55Q: [Post Arrest ECG](x-devonthink-item://C4CCEB12-61D5-4308-AA41-5078F3D96CC0?page=13) -- [Answer](x-devonthink-item://75D8E35B-EE77-4D1B-A665-438451C976AE?page=18) -- [prop](x-devonthink-item://E34679F3-102F-4E16-AF81-9D679412EDAC?page=11) - [x] DUPLICATE Q: [Chest Pain](x-devonthink-item://5ADC62A1-9798-4399-BE79-68C375E8D9BF?page=8) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=22) - [x] DUPLICATE Q: [Acute Coronary Syndrome](x-devonthink-item://40193B7A-D362-4C39-9D2A-2D112B58104B?page=6) -- [Answer](x-devonthink-item://AADB7978-B533-4E12-B6E4-E994C0B685FF?page=5) - [ ] 64Q: [Adult Cardiac Arrest](x-devonthink-item://2CAEF14B-356F-45F8-834C-4766A58A56A9?page=16) -- [Answer](x-devonthink-item://98D17FA0-225B-4E94-B21C-4E36D5C76A7C?page=22) -- [prop](x-devonthink-item://093F49C6-2E32-460E-9C00-3E9F15CD417E?page=10) - [x] 66Q: [Chest Pain and Abnormal ECG](x-devonthink-item://09CFA1A7-00F1-4151-979E-8F3984924D54?page=3) -- [Answer](x-devonthink-item://CF5E9C2B-42F9-4F9C-AC29-877E20134927?page=3) - [ ] 67Q: [Arrhythmia and Chest Pain](x-devonthink-item://09CFA1A7-00F1-4151-979E-8F3984924D54?page=17) -- [Answer](x-devonthink-item://CF5E9C2B-42F9-4F9C-AC29-877E20134927?page=11) - [x] DUPLICATE Q: [Adult with Palpitations](x-devonthink-item://09CFA1A7-00F1-4151-979E-8F3984924D54?page=30) -- [Answer](x-devonthink-item://CF5E9C2B-42F9-4F9C-AC29-877E20134927?page=20) - [x] DUPLICATE Q: [Chest Pain and Abnormal ECG](x-devonthink-item://7061D1B4-0AB9-4963-B3B0-23BDD975B2CD?page=7) -- [Answer](x-devonthink-item://3F30C77E-E23E-4200-89FE-48A41618E0C2?page=5) - [x] DUPLICATE Q: [Syncope with Abnormal ECG](x-devonthink-item://7061D1B4-0AB9-4963-B3B0-23BDD975B2CD?page=20) -- [Answer](x-devonthink-item://3F30C77E-E23E-4200-89FE-48A41618E0C2?page=13) - [x] DUPLICATE Q: [Hypotensive SVT Patient](x-devonthink-item://1EA9311E-0B9E-49F7-8D6E-4C4187A838C4?page=29) -- [Answer](x-devonthink-item://B1CB2E8F-5D04-49EE-8274-043871389D28?page=19) - [x] DUPLICATE Q: [Epigastric Pain with ECG Changes](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=9) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=7) - [ ] 72Q: [Collapse with Abnormal Rhythm Strip](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=46) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=31) -- [prop](x-devonthink-item://2A1F4A99-92AE-4C8E-B325-AE448BD46AC6?page=10) - [ ] 73Q: [Arrhythmia with Pacemaker](x-devonthink-item://7495767E-7B93-4C14-A35D-AFEF8CF7D0B8?page=6) -- [Answer](x-devonthink-item://01E87078-FF7E-4661-BAEF-58FAE1C99A04?page=4) -- [prop](x-devonthink-item://B892F073-9AD2-46E4-98D6-B0574CAA73A3?page=7) - [x] DUPLICATE Q: [ECG for Lightheadedness](x-devonthink-item://CDB16617-3785-40E5-B8BE-5668D2D7A3E7?page=6) -- [Answer](x-devonthink-item://A6CA01E8-9551-45E7-8617-441BE3DBB5D7?page=5) - [ ] 74Q: [Nightclub Pills and Cardiac Ills](x-devonthink-item://6092BF31-E542-4019-8E17-0C628DD3B0F1?page=11) -- [Answer](x-devonthink-item://E15CEB64-C6A5-4A7D-84B4-E7D1DC667B0E?page=7) -- [prop](x-devonthink-item://B3E266DE-B0B2-4F19-9986-B7C6FD455008?page=2) - [ ] 75Q: [Unwell Post CABG](x-devonthink-item://EB2A381E-D8D3-4236-B51F-2DF81CE08885?page=17) -- [Answer](x-devonthink-item://8455B512-D9BD-4314-927B-D3208619EE2A?page=16) -- [prop](x-devonthink-item://B3E266DE-B0B2-4F19-9986-B7C6FD455008?page=4) ## sgarbossa - [x] DUPLICATE Q: [Chest pain](x-devonthink-item://7FCD3940-4BB4-45FE-86A6-E5707E82D5B5?page=7) -- [Answer](x-devonthink-item://3263A68A-96A6-43EC-985B-43260C3509BF?page=2) - [x] DUPLICATE Q: [Chest pain and LBBB](x-devonthink-item://1442A590-B32E-40BE-9C29-6401A71DC2DC?page=15) -- [Answer](x-devonthink-item://0C9617AB-8E16-4A75-ADF0-AB06FA726B0A?page=6) - [x] DUPLICATE Q: [Chest Pain and Abnormal ECG](x-devonthink-item://7061D1B4-0AB9-4963-B3B0-23BDD975B2CD?page=7) -- [Answer](x-devonthink-item://3F30C77E-E23E-4200-89FE-48A41618E0C2?page=5) ## st elevation - [x] DUPLICATE Q: [ST Elevation and Negative Troponin](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=41) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=41) - [x] DUPLICATE Q: [ST Elevation](x-devonthink-item://84CE632D-3DD4-4F41-A900-23F41BE57287?page=6) -- [Answer](x-devonthink-item://D25C2F83-6C30-4F45-8B5B-6E7E57BD24A3?page=22) ## stemi - [x] DUPLICATE Q: [Post Arrest Arrhythmia and Retrieval](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=23) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=23) - [x] DUPLICATE Q: [Acute coronary syndrome](x-devonthink-item://310EEEDE-D794-4365-8865-5B3DD1C20510?page=8) -- [Answer](x-devonthink-item://6D5125AD-DE4D-435B-8D13-6EA35DB8E785?page=10) - [x] DUPLICATE Q: [Acute Coronary Syndrome](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=57) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=28) - [x] DUPLICATE Q: [Acute Coronary Syndrome](x-devonthink-item://834C484F-DDAA-4819-8DF0-84AE5E70DA1D?page=30) -- [Answer](x-devonthink-item://D46998FE-62E2-4A3A-860D-C32C94B86E42?page=14) - [x] DUPLICATE Q: [Abnormal ECG](x-devonthink-item://FE3157C2-07B3-43F2-9ECE-AFACE1355E13?page=26) -- [Answer](x-devonthink-item://DDC959EB-0C1E-448A-8380-C397BF734322?page=12) - [x] DUPLICATE Q: [Chest pain and LBBB](x-devonthink-item://1442A590-B32E-40BE-9C29-6401A71DC2DC?page=15) -- [Answer](x-devonthink-item://0C9617AB-8E16-4A75-ADF0-AB06FA726B0A?page=6) - [x] DUPLICATE Q: [STEMI](x-devonthink-item://C1DDA3AB-2DA2-4922-A8A6-F597AB7E2558?page=3) -- [Answer](x-devonthink-item://A10DE51E-92FA-42D1-8AA0-7AE68C2FA743?page=12) - [x] DUPLICATE Q: [Chest Pain](x-devonthink-item://5ADC62A1-9798-4399-BE79-68C375E8D9BF?page=8) -- [Answer](x-devonthink-item://6F751245-A36C-447A-8AE7-599AD5871C71?page=22) - [x] DUPLICATE Q: [Adult Cardiac Arrest](x-devonthink-item://2CAEF14B-356F-45F8-834C-4766A58A56A9?page=16) -- [Answer](x-devonthink-item://98D17FA0-225B-4E94-B21C-4E36D5C76A7C?page=22) - [x] DUPLICATE Q: [Epigastric Pain with ECG Changes](x-devonthink-item://73409C77-B2FA-4E0A-AEB3-5EB284457F0C?page=9) -- [Answer](x-devonthink-item://5A848952-80E3-4184-B553-368412A69917?page=7)