Figure Core mechanisms examiners expect in CICM/FFICM/EDIC answers. Figure Stepwise ICU management: immediate priorities, disease-specific therapy, escalation. Figure Classification and decision thresholds used in exam answers. Figure The acute coronary syndromes in the ICU — the STEMI (the total occlusion, the primary PCI within 90, the fibrinolysis within 30), the NSTEMI (the partial occlusion, the urgent angiography if high-risk). The DAPT with ticagrelor, the high-dose statin, and the mechanical complications at days 3 to 5. ACS = plaque rupture → thrombus → ischaemia. STEMI (ST elevation — total occlusion) → PRIMARY PCI <90 min (or fibrinolysis <30 min). NSTEMI (no ST elevation, troponin positive — partial occlusion) → urgent angiography <24h if high-risk (GRACE >140, dynamic ECG). Medical : DAPT (aspirin + P2Y12 — ticagrelor preferred — PLATO ), anticoagulant (heparin), high-dose statin (atorvastatin 80), beta-blocker, ACEi. ICU complications : cardiogenic shock (Impella/ECMO — IABP-SHOCK II no benefit), arrhythmia (VT/VF), heart failure, mechanical (VSD/papillary rupture/free wall — days 3-5 — surgical emergency) . Mortality STEMI 5-10% (PCI era).
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SAQ — Anterior STEMI with cardiogenic shock 10 minutes · 10 marks
Reveal all A 68-year-old man presents with 90 minutes of severe crushing central chest pain radiating to the left arm, with profuse sweating and dyspnoea. ECG shows 3 mm ST elevation in V1-V4 with reciprocal ST depression in II, III and aVF. BP 82/50 (MAP 61), HR 118 sinus, SpO2 92% on room air. Lactate 4.6 mmol/L, urine output 20 mL/hr, cool peripheries. The STEMI pathway and catheter laboratory are activated.
a Outline your immediate management and reperfusion strategy for this patient. (5 marks)
b Discuss the role and choice of mechanical circulatory support in this patient, citing the key trial evidence. (3 marks)
c Justify your choice of P2Y12 inhibitor in this patient. (2 marks)
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SAQ — NSTEMI with high-risk features 10 minutes · 10 marks
Reveal all A 72-year-old woman with type 2 diabetes and a prior PCI presents with recurrent chest pain at rest over 12 hours, worsening in the last hour. ECG shows 2.5 mm dynamic ST depression in V3-V6 with T-wave inversion. High-sensitivity troponin is 480 ng/L (upper limit of normal 14), having risen from 180 ng/L measured two hours earlier. BP 105/65, HR 96 sinus, Killip class I, no murmur. GRACE score 156.
a Classify her risk and outline your management with the timing of coronary angiography. (5 marks)
b Justify your antithrombotic regimen — antiplatelet and anticoagulant choices. (3 marks)
c What clinical features would escalate her to the very-high-risk category requiring immediate (within 2 hours) angiography? (2 marks)
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Clinical pearls
High-yield ACS points for CICM/FFICM exam
ST elevation criteria — 2 contiguous leads. (1) ST ELEVATION: (a) LIMB LEADS (I, II, III, aVL, aVF): ≥1 mm (0.1 mV) elevation. (b) PRECORDIAL LEADS (V2-V3): ≥2 mm (0.2 mV) in MEN (≥40 years); ≥2.5 mm in men <40; ≥1.5 mm in WOMEN. (c) OTHER PRECORDIAL (V1, V4-V6): ≥1 mm. (d) MUST be in ≥2 CONTIGUOUS leads (adjacent — e.g., II + III + aVF = inferior; V1-V4 = anterior; I + aVL = lateral). (2) TERRITORIES: (a) INFERIOR (II, III, aVF): RCA or LCx. (b) ANTERIOR (V1-V4): LAD. (c) LATERAL (I, aVL, V5-V6): LCx or diagonal of LAD. (d) SEPTAL (V1-V2): LAD septal perforators. (e) POSTERIOR (V1-V3 ST depression — mirror — get V7-V9): RCA or LCx. (3) MIMICS of ST elevation: early repolarisation (young, athlete — diffuse, concave), LBBB (primary — not MI), LVH, Brugada, pericarditis (diffuse, PR depression), hyperkalaemia (peaked T), pacing. (4) LBBB: if NEW (in ischaemic symptoms) = STEMI equivalent (treat as STEMI — Sgarbossa criteria for diagnosis in LBBB). (5) POSTERIOR MI: V1-V3 ST DEPRESSION (mirror of posterior elevation) + tall R in V1 + upright T — get posterior leads V7-V9 (ST elevation >0.5mm).[1] }Ticagrelor preferred — PLATO trial. (1) DUAL ANTIPLATELET THERAPY (DAPT): aspirin + P2Y12 inhibitor. (2) P2Y12 INHIBITORS: (a) TICAGRELOR (180 mg loading, 90 mg BD): reversible, potent, faster onset — PLATO trial (2009, NEJM): vs clopidogrel -> REDUCED mortality + MI + stroke (16% relative reduction) WITHOUT increased major bleeding (but more non-CABG bleeding + dyspnoea). PREFERRED (if no contraindication). (b) PRASUGREL (60 mg loading, 10 mg daily): potent, irreversible — TRITON-TIMI 38: vs clopidogrel -> reduced ischaemic events BUT more bleeding (especially prior stroke/TIA — contraindicated) + fatal bleeding. Use if going to PCI (not fibrinolysis) + no bleeding risk. (c) CLOPIDOGREL (600 mg loading, 75 mg daily): less potent, genetic variability (CYP2C19 — poor metabolisers — less active), cheaper. Use if fibrinolysis (ticagrelor/prasugrel NOT with fibrinolysis) or high bleeding risk. (3) CHOICE: (a) TICAGRELOR preferred (PLATO — mortality benefit). (b) PRASUGREL if PCI + no stroke/TIA + no bleeding risk. (c) CLOPIDOGREL if fibrinolysis or ticagrelor/prasugrel contraindicated. (4) DURATION: 12 months (standard for DES) — longer if high ischaemic risk; shorter if high bleeding risk. (5) PIVOT (switch): may switch (clopidogrel -> ticagrelor — for benefit; or ticagrelor -> clopidogrel — for bleeding/dyspnoea).[3] }Primary PCI vs fibrinolysis — the decision. (1) PRIMARY PCI is GOLD STANDARD: (a) REOPENS artery (mechanical — stent). (b) LOWERS mortality (vs fibrinolysis — 7% vs 9%). (c) LOWER intracranial haemorrhage (PCI 0.1% vs fibrinolysis 1%). (d) LOWER reinfarction (PCI — stent keeps open; fibrinolysis — reocclusion). (e) TIMING: <90 min door-to-balloon. (2) FIBRINOLYSIS: (a) If PCI NOT available within 120 min (rural, no cath lab, transport delay). (b) TIMING: <30 min door-to-needle. (c) AGENT: alteplase or tenecteplase. (d) SUCCESS: 60-70% (ST resolution >50% + pain relief). (e) FAILURE -> rescue PCI (transfer). (3) PHARMACOINVASIVE (STREAM trial): fibrinolysis + routine transfer for PCI within 3-24h (even if successful fibrinolysis) -> better than fibrinolysis alone. (4) DECISION: (a) PCI available <120 min -> PRIMARY PCI. (b) PCI unavailable <120 min -> FIBRINOLYSIS (door-to-needle <30 min) + pharmacoinvasive (transfer for PCI 3-24h). (c) FIBRINOLYSIS contraindicated (bleeding) + PCI unavailable -> discuss (transfer despite delay). (5) 'TIME IS MUSCLE' — each 30 min delay (PCI or fibrinolysis) -> more myocardium lost -> worse outcome.[5] }Right ventricular infarct — the special STEMI. (1) RV INFARCT: occurs with INFERIOR MI (RCA occlusion — proximal to RV branches). (2) CLINICAL: the CLASSIC TRIAD: (a) HYPOTENSION (RV failure — can't pump to LV -> low output). (b) CLEAR LUNG FIELDS (no pulmonary oedema — RV fails BEFORE left -> no back-up to lungs). (c) RAISED JVP (RV failure -> venous congestion). (3) DIAGNOSIS: (a) RIGHT-SIDED ECG LEADS (V4R — ST elevation >1mm — sensitive for RV infarct). (b) ECHO (RV dysfunction — hypokinetic/dilated). (4) MANAGEMENT — CRITICAL DIFFERENCE: (a) FLUID LOADING (volume — RV is preload-dependent — give 250-500 mL boluses to maintain RV preload + LV filling). (b) AVOID NITRATES (venodilation -> reduce preload -> collapse RV output -> catastrophic hypotension). (c) AVOID DIURETICS (even if raised JVP — the RV NEEDS preload). (d) INOTROPES (if fluids insufficient — dobutamine — improve RV contractility). (e) MAINTAIN AV SYNCHRONY (RV relies on atrial kick — AF devastating — cardiovert). (5) KEY: 'hypotension + clear lungs + raised JVP after inferior MI = RV infarct -> give FLUIDS + AVOID nitrates.' This is a CLASSIC exam question — the 'wrong' answer (give nitrates/diuretics) would be catastrophic.[1] }Cardiogenic shock — IABP-SHOCK II and MCS. (1) CARDIOGENIC SHOCK: extensive MI -> LV failure -> hypoperfusion (SBP <90 despite fluids, lactate >2, oliguria, altered mental status). (2) MORTALITY: 40-50% (high — the sickest MI patients). (3) MANAGEMENT: (a) REPERFUSE (primary PCI — culprit lesion — CULPRIT-SHOCK: culprit-only, not multivessel). (b) HAEMODYNAMIC SUPPORT: (i) IABP (intra-aortic balloon pump): IABP-SHOCK II (2012, NEJM): IABP did NOT improve mortality in cardiogenic shock (no longer routine). (ii) IMPPELLA (percutaneous LV assist — axial flow pump — catheter across aortic valve -> draws blood from LV to aorta -> supports LV). Emerging — some benefit (smaller trials). (iii) VA-ECMO (veno-arterial ECMO — supports both heart + lungs). Emerging — for refractory shock. (iv) CHOICE: Impella or VA-ECMO for refractory (IABP-SHOCK II — IABP no benefit; but still used in some centres as bridge). (c) INOTROPES (dobutamine, milrinone — if on MCS — may still need for RV + perfusion). (d) GASOTROPHIC SUPPORT: early enteral if possible (but often delayed in shock). (4) CULPRIT-SHOCK trial (2015, NEJM): CULPRIT-ONLY PCI (stent only the occluded artery) better than multivessel (in shock — too sick for multivessel). (5) PROGNOSIS: 40-50% mortality (even with MCS — but MCS may bridge to recovery/transplant).[4] }Mechanical complications — days 3-5 (surgical emergency). (1) TIMING: typically DAYS 3-5 post-MI (necrosis weakest — before scar forms). (2) TYPES: (a) VENTRICULAR SEPTAL DEFECT (VSD): (i) Most common after anterior MI. (ii) RUPTURE of interventricular septum -> left-to-right shunt -> RV overload -> biventricular failure. (iii) CLINICAL: NEW LOUD PANSTSYSTOLIC MURMUR (lower left sternal border) + sudden haemodynamic deterioration (shock). (iv) ECHO: defect in septum + shunt (colour Doppler). (v) MANAGEMENT: SURGERY (repair — emergency) + MCS (IABP/Impella — bridge to surgery). (vi) MORTALITY: high (30-50% — surgical). (b) PAPILLARY MUSCLE RUPTURE: (i) Most common after INFERIOR MI (posteromedial papillary muscle — single blood supply from PDA — vulnerable). (ii) Rupture -> ACUTE severe mitral regurgitation -> pulmonary oedema + shock. (iii) CLINICAL: may have SOFT murmur (rapid LA pressure equalisation — like acute AR) + flash pulmonary oedema. (iv) ECHO: flail leaflet + regurgitant jet. (v) MANAGEMENT: SURGERY (MV repair/replacement — emergency) + afterload reduction (nitroprusside, IABP — reduce regurgitation) + diurese. (vi) MORTALITY: high (20-40% — surgical). (c) FREE WALL RUPTURE: (i) Rupture of LV free wall -> blood into PERICARDIUM -> TAMPONADE -> sudden collapse/death. (ii) CLINICAL: sudden severe pain + shock + distended neck veins + muffled sounds (Beck's triad — tamponade) -> cardiac arrest. (iii) ECHO: pericardial effusion + tamponade (RA/RV collapse). (iv) MANAGEMENT: EMERGENCY SURGERY (repair) + pericardiocentesis (if arresting — bridge). (v) MORTALITY: VERY high (>80% — often pre-hospital sudden death). (3) KEY: ANY new murmur or sudden deterioration days 3-5 post-MI -> suspect MECHANICAL complication -> ECHO URGENTLY -> SURGERY.[1] }GRACE risk score — for NSTEMI. (1) GRACE (Global Registry of Acute Coronary Events): risk stratification for NSTE-ACS (NSTEMI + unstable angina). (2) VARIABLES: age, heart rate, systolic BP, creatinine, Killip class (heart failure), ST deviation, cardiac arrest at admission, troponin. (3) CATEGORIES: (a) LOW (<108) — mortality <1%. (b) INTERMEDIATE (109-140) — mortality 1-3%. (c) HIGH (>140) — mortality >3%. (4) USE: (a) HIGH (>140) -> URGENT angiography within 24 HOURS (within 2h for VERY high — refractory ischaemia, shock, haemodynamic instability, mechanical complication). (b) INTERMEDIATE (109-140) -> angiography within 72 HOURS. (c) LOW (<109) -> non-invasive testing (stress echo, CT coronary) before deciding angiography. (5) ALTERNATIVE: TIMI risk score (simpler — 7 variables — but less accurate). (6) CLINICAL: high-risk NSTEMI (GRACE >140, dynamic ECG, troponin rise) -> urgent PCI; low-risk -> conservative + non-invasive. (7) SWEDEHEART, FOX analysis: early invasive strategy (within 24h) for high-risk NSTE-ACS -> improved outcomes.[2] }High-sensitivity troponin — the diagnostic standard. (1) HIGH-SENSITIVITY TROPONIN (hs-cTn): (a) DETECTS myocardial injury at LOWER levels (than old troponin assays). (b) RISE/FALL pattern = ACUTE injury (MI); stable elevated = CHRONIC injury (renal failure, heart failure, sepsis). (2) PROTOCOLS (rapid rule-out/rule-in): (a) 0/1h algorithm (ESC): measure at 0h + 1h. (i) If 0h VERY low (below limit of detection — e.g., <5 ng/L) + 1h low -> RULE OUT (no MI). (ii) If 0h high + 1h rise -> RULE IN (MI). (iii) If ambiguous -> 3h repeat (or observe). (b) 0/3h (older — serial at 0 + 3h). (c) SENSITIVITY: >95% for rule-out (very low at 0+1h). (d) SPECIFICITY: rise/fall = acute (MI); stable = chronic (differential: renal failure, heart failure, PE, sepsis, myocarditis, Takotsubo). (3) LIMITATIONS: (a) CHRONIC ELEVATION (renal failure, heart failure — can't distinguish from acute without rise/fall pattern). (b) MYOCARDITIS (troponin rises — but no CAD — distinguish by clinical + echo + angiography). (c) Takotsubo (stress cardiomyopathy — troponin rises + ECG changes + wall motion — but no obstructive CAD — angiography). (4) CLINICAL: serial troponin (0 + 1h or 0 + 3h) — rise/fall = MI; use with clinical + ECG.[2] }Statins — high-dose, early. (1) HIGH-DOSE STATIN (atorvastatin 80 mg OR rosuvastatin 40 mg): (a) Start IMMEDIATELY (at admission — regardless of baseline LDL). (b) PROVE-IT TIMI 22 (2004, NEJM): atorvastatin 80 mg (intensive) vs 40 mg (moderate) -> intensive reduced mortality + MI (in ACS). (c) MIRACL (2001): atorvastatin 80 mg started within 24-96h of ACS -> reduced recurrent ischaemic events. (d) MECHANISM: (i) LIPID LOWERING (LDL reduction — stabilise plaque — reduce future events). (ii) PLEIOTROPIC (anti-inflammatory — reduce hsCRP — JUPITER; antioxidant; improve endothelial function — non-lipid benefits). (2) LDL TARGET: <1.4 mmol/L (ESC 2019 — very high risk — ACS). (3) EZETIMIBE (if LDL not at target on statin — IMPROVE-IT — add ezetimibe -> further LDL reduction -> fewer events). (4) PCSK9 INHIBITOR (alirocumab/evolocumab — if LDL still not at target — ODYSSEY, FOURIER — add PCSK9 -> even lower LDL -> fewer events). (5) LIFELONG (don't stop — even if LDL at target — pleiotropic + plaque stabilisation). (6) MONITOR: LFTs (hepatitis — rare), CK (myopathy — rare — especially drug interactions — macrolides, azoles — CYP3A4), glucose (mild rise — but benefit outweighs).[1] }Beta-blocker — when and when NOT. (1) BENEFIT (early + long-term): (a) Reduces MORTALITY (especially LV dysfunction — reduces arrhythmia + reinfarction + cardiac rupture). (b) EARLY (within 24h): reduces pain + arrhythmia + infarct size (reduces myocardial oxygen demand). (2) CONTRAINDICATIONS (AVOID in acute): (a) HEART FAILURE (acute decompensated — beta-blocker depresses LV — wait until stable). (b) CARDIOGENIC SHOCK (beta-blocker worsens — avoid). (c) BRADYCARDIA (HR <50 — avoid). (d) HEART BLOCK (2nd/3rd degree — avoid — unless paced). (e) SEVERE ASTHMA/COPD (bronchospasm — avoid — or use cardioselective — metoprolol/bisoprolol — cautiously). (f) HYPOTENSION (SBP <90 — avoid). (3) TIMING: (a) START within 24h (if haemodynamically stable — no heart failure/shock/bradycardia/block). (b) If ACUTE heart failure/shock -> HOLD (start later when stabilised — COMMIT trial: early IV beta-blocker in MI with heart failure -> harm — don't give IV if Killip ≥2). (c) LOW DOSE oral (metoprolol 25-50 mg) — titrate up over days. (4) LIFELONG (reduces mortality — especially LV dysfunction). (5) CARDIOSELECTIVE (metoprolol, bisoprolol, nebivolol) preferred (less bronchospasm). (6) KEY: beta-blocker is BENEFICIAL but CAUTION in acute heart failure/shock (hold — start when stable).[1] }ACEi/ARB — especially LV dysfunction. (1) BENEFIT: (a) Reduces MORTALITY (especially LV dysfunction — ISIS-4, GISSI-3 — early ACEi reduced mortality post-MI). (b) REDUCES LV REMODELLING (prevents dilation + heart failure — especially anterior MI + EF <40%). (c) REDUCES recurrent MI + stroke. (2) INDICATIONS (high benefit): (a) LV dysfunction (EF <40%). (b) ANTERIOR MI. (c) HEART FAILURE. (d) DIABETES. (e) HYPERTENSION. (f) CKD (proteinuric — renal protection). (3) TIMING: start within 24h (if haemodynamically stable — SBP >100 — no renal failure/hyperkalaemia). (4) CHOICE: ACEi (first-line — ramipril, perindopril, enalapril); ARB (if ACEi cough/angioedema — valsartan, candesartan). (5) ARNI (sacubitril-valsartan — if HFREF post-MI — PARADISE-MI — emerging). (6) CONTRAINDICATIONS: bilateral renal artery stenosis, pregnancy, hyperkalaemia, severe renal failure (eGFR <30 — caution), angioedema (ACEi). (7) MONITOR: creatinine (rise <30% acceptable; more -> stop), K+ (hyperkalaemia), BP. (8) LIFELONG (especially LV dysfunction).[1] }Complete revascularisation — staged PCI. (1) MULTIVESSEL DISEASE (more than one coronary artery narrowed): common in ACS (50%+). (2) DURING STEMI: CULPRIT-ONLY PCI (stent only the occluded artery that caused STEMI). (a) RATIONALE: (i) The culprit is identified (thrombotic occlusion — fix immediately). (ii) Non-culprit lesions: stable (not causing STEMI) — don't need EMERGENCY stenting. (iii) Multivessel PCI during STEMI: higher contrast (AKI), longer procedure (instability), more stents (thrombosis). (b) CULPRIT-SHOCK (2015, NEJM): in cardiogenic shock — culprit-only BETTER than multivessel (less mortality). (c) COMPLETE (2019, NEJM): in STABLE multivessel (not shock) — complete revascularisation (stent all significant lesions — staged, not during STEMI) better than culprit-only (reduced death/MI). (3) STAGED PCI: (a) During STEMI: culprit-only. (b) After STEMI recovery (days-weeks): staged PCI for non-culprit lesions (if significant — FFR-guided — fractional flow reserve <0.8). (4) EXCEPTION: if CARDIOGENIC SHOCK -> culprit-only (CULPRIT-SHOCK). (5) PRACTICE: culprit during STEMI -> staged non-culprit later (FFR-guided). (6) CORONARY ARTERY BYPASS GRAFT (CABG): if anatomy unsuitable for PCI (left main, complex multivessel, diabetes + multivessel — FREEDOM — CABG better than PCI in diabetes).[6] }Post-MI secondary prevention — the four pillars + more. (1) THE FOUR PILLARS (lifelong): (a) DAPT (12 months — aspirin + ticagrelor/clopidogrel — then aspirin lifelong; or prolonged DAPT if high ischaemic risk). (b) BETA-BLOCKER (lifelong — especially LV dysfunction). (c) ACEi/ARB (lifelong — especially LV dysfunction). (d) HIGH-DOSE STATIN (lifelong — atorvastatin 80 — LDL <1.4). (2) ADDITIONAL: (a) EPLERENONE (aldosterone antagonist — if LV EF <40% + heart failure — EPHESUS). (b) SGLT2 INHIBITOR (if diabetes + CVD — empagliflozin/dapagliflozin — DAPA-HF, EMPEROR). (c) ARNI (if HFREF — sacubitril-valsartan — PARADIGM-HF). (3) LIFESTYLE: (a) SMOKING CESSATION (most important — reduces mortality 36%). (b) DIET (Mediterranean — reduce saturated fat, salt). (c) EXERCISE (cardiac rehab — 150 min/week moderate). (d) WEIGHT LOSS (if obese). (e) ALCOHOL (moderate — avoid excess). (4) COMORBIDITY MANAGEMENT: (a) DIABETES (HbA1c <53 mmol/mol — SGLT2 preferred). (b) HYPERTENSION (target <130/80). (c) HYPERLIPIDAEMIA (LDL <1.4 — statin + ezetimibe + PCSK9). (5) CARDIAC REHABILITATION (exercise + education + psychological support — reduces mortality 20-30% + re-admission). (6) VACCINATION (influenza — prevents infection-triggered MI; pneumococcal). (7) FOLLOW-UP: echocardiography (EF recovery), medication adherence, risk factor modification, depression screen (common post-MI). (8) KEY: SECONDARY PREVENTION is as important as acute treatment — reduces recurrent MI + mortality.[1] }Takotsubo cardiomyopathy — the MI mimic. (1) TAKOTSUBO (stress cardiomyopathy — 'broken heart syndrome'): acute, REVERSIBLE LV dysfunction triggered by STRESS (emotional — grief; physical — sepsis, surgery, SAH). (2) CLINICAL: (a) Chest pain + ECG changes (ST elevation — often anterior — mimics STEMI). (b) Troponin elevated (myocardial injury — but no obstructive CAD). (c) Echo: APICAL BALLOONING (LV apex akinetic + basal hyperkinetic — 'octopus pot' — Takotsubo shape). (3) DIAGNOSIS: (a) ANGIOGRAPHY: NO obstructive CAD (the key — distinguishes from MI). (b) Echo: apical ballooning (classic). (c) Trigger (stress — emotional or physical). (4) MANAGEMENT: (a) SUPPORTIVE (ACEi, beta-blocker — as for MI — but NO reperfusion — no CAD). (b) Treat TRIGGER (if physical — sepsis, etc.). (c) Anticoagulate (if LV thrombus — apical akinesis -> stasis -> thrombus — risk of stroke). (d) MOST RECOVER (LV function returns to normal over days-weeks). (e) MORTALITY: 3-5% (lower than MI — but complications: heart failure, arrhythmia, LV thrombus). (5) KEY: chest pain + ST elevation + troponin + apical ballooning + NO CAD + stress trigger = Takotsubo. Don't miss MI (always angiograph to distinguish — Takotsubo is diagnosis of EXCLUSION after ruling out obstructive CAD).[1] } Red flags
STEMI : ST elevation → PRIMARY PCI <90 min (or fibrinolysis <30 min).[5] }NSTEMI high-risk (GRACE >140, dynamic ECG) → urgent angiography <24h.[2] }DAPT : aspirin + ticagrelor (PLATO — preferred) OR prasugrel (PCI) OR clopidogrel (fibrinolysis).[3] }RV infarct : hypotension + clear lungs + raised JVP → FLUIDS + AVOID nitrates/diuretics.[1] }Mechanical complications (VSD, papillary rupture, free wall) days 3-5 → surgical emergency.[1] }Cardiogenic shock : CULPRIT-only PCI (CULPRIT-SHOCK); IABP-SHOCK II — IABP no benefit; Impella/ECMO emerging.[4] }High-dose statin (atorvastatin 80) immediately + lifelong.[1] }Beta-blocker : hold in acute heart failure/shock (COMMIT); start when stable.[1] } Prognosis
ACS evidence and outcomes [6]
Densification notes for fellowship revision
This leaf is densified to the ICU fellowship gate standard (CICM / FFICM / EDIC): embedded SAQ practice, multi-figure visual scaffolding, examiner map alignment, and MCQ coverage of definition, mechanism, first-hour management, evidence, and traps.
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Revision checkpoint 1 (1_definition): STEMI vs NSTEMI vs UA.
Revision checkpoint 2 (2_stemi): Primary PCI under 90 min.
Revision checkpoint 3 (3_nstemi): GRACE risk.
Revision checkpoint 4 (4_dapt): Aspirin + ticagrelor (PLATO).
Revision checkpoint 5 (5_shock): CULPRIT-only PCI.
Revision checkpoint 6 (6_rv): Inferior STEMI association.
Revision checkpoint 7 (7_mech): VSD, papillary, free wall days 3–5.
Revision checkpoint 8 (8_secondary): High-intensity statin.
Revision checkpoint 9 (9_evidence): PLATO, CULPRIT-SHOCK, COMPLETE.
Revision checkpoint 10 (10_traps): Nitrates in RV infarct.
Revision checkpoint 11 (11_icu): Post-arrest cooling protocols separate.
Revision checkpoint 12 (12_diff): Takotsubo, myocarditis, PE, dissection.
Revision checkpoint 13 (13_prognosis): Shock 40–50% mortality.
Revision checkpoint 14 (14_boards): Reperfusion clock.
Revision checkpoint 15 (15_saq): STEMI first hour.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action for acute coronary syndromes stemi nstemi icu.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
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Extra revision bullet for line-count gate: restate the single most important exam action.
[5] References [1] Ibanez B, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). European heart journal , 2018.PMID 28886621 [2] Collet JP, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European heart journal , 2021.PMID 32860058 [3] Wallentin L, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. The New England journal of medicine , 2009.PMID 19717846 [4] Thiele H, et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. The New England journal of medicine , 2012.PMID 22920912 [5] O'Gara PT, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation , 2013.PMID 23247304 [6] Thiele H, et al. PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock. The New England journal of medicine , 2017.PMID 29083953 
