DIP Episode 477 - The Clutch Acute Coronary Syndromes Podcast

Welcome, my name is Devine. This is episode 477 of the Divine Intervention Podcasts. Into this podcast we're going to be discussing acute coronary syndromes. In fact, I'm going to title this the Clotch Acute Coronary Syndrome Podcast. Acute coronary syndromes are pretty high yield for pretty much every USMD exam. There may be no sun crannies of things that they could test. So these are things you certainly want to make sure you know and thoroughly and properly understand. So let's start off with a question. So what if they give you a question about 61-year-old male? And they tell you that he was golfing and then suddenly had significant pain in his chest. And during that episode he had to stop for a bit. But that you know after a few hours the chest pain receded. And they ask you what is the most appropriate and the tell you that he came to the emergency room when you asked what is the most appropriate next step in management. Well the most appropriate next step in management is to get two things. It's to get an EKG and get the appropriate serum biomarkers. Get an EKG and get the appropriate serum biomarkers. So with that opening let's go ahead and jump into acute coronary syndromes. And we're going to delve deep into this and kind of break down some things with this case and how he can help you on your exams. But again I would encourage you please really pay attention to this podcast. This stuff is not low yield by any stretch.

So the thing is if you notice a set of this case with a guy, but a woman can also have MI symptoms obviously MI skin and acute coronary syndromes can certainly happen in women. But the critical thing to keep in mind is in women especially in elder women or people that have diabetes, they may have symptoms that are a little weird. Sometimes they may not have the classically described chest pain. Sometimes he may feel like really bad acute digestion or you may notice that they have a lot of vomiting. And also remember diabetics since they have neuropathy sometimes they may not even feel that pain. They may just have like weird symptoms. So just be careful you may even see things that appear to be abdominal symptoms in a person that has diabetes or an elderly lady. And it may still be an MI that's why it's very important. Pay attention to the suddenness of those symptoms. And if you notice from the original case I said that all the next thing you should be doing is to get an ekeg and serum biomarkers. So what's the serum biomarker? Well obviously it's going to be a troponic. The reason that those are the first two things you get is that it pretty much helps you distinguish the three acute coronary syndromes. So we know that there's unstable angina. We know that there's an end stemming and we know that there's a stemming. I think the smart thing to do is to talk about this thing in a logical progression. So people that have unstable angina. In fact here's the thing.

The way I think about this is for these acute coronary syndromes for the first one we discuss one thing is normal, the other is abnormal. For the second thing we discuss one thing is normal, the other is abnormal. For the third thing we discuss everything the two things are abnormal again these two things being the ekeg and serum biomarkers. So starting off we don't stable angina. Starting off we don't stable angina. What's abnormal? Well the thing that's abnormal is the ekeg. The ekeg may be abnormal although it may also be completely fine. So you may see them have some STD impressions on ekeg. They can have T-wave inversions. I'm going to tell you that right now. But the critical thing to keep in mind is that the acute biomarkers are going to be normal. The troponins will not be elevated. But for an end stemming on the flip side, these people, the biomarkers will be positive. The biomarkers will be positive. So you're going to notice that they're going to have elevated troponins. Now I remember I said that one thing may be normal. And yes the ekeg may be completely normal. I'm going to tell you this right now. People that have end stemming, the ekeg may be completely normal although although the ekeg may also be abnormal. The critical thing to keep in mind though is that the ST segment will not be elevated. There will not be any ST elevation. So again the mcst depressions, the mcct wave inversions.

So the only absolute for unstable langinitis, your cardiac biomarkers will be normal. Your ekeg actually may be completely normal or it may just have some abnormalities. For end stemming is the only absolute that your biomarkers, the troponins will be elevated. The ekeg may be completely normal or it may have some abnormalities. So this or is kind of like wishy-washy-washy-washy. That's why again I say that the... I say one thing is normal, one thing is abnormal. The one abnormal thing is the absolute. The normal thing may also be abnormal. Just something you want to keep at the back of your mind. But for stemming, things are different. In a stemming you're going to have ST elevations and elevated biomarkers. So your biomarkers will be elevated, your troponins will be elevated. You're going to have ST elevations. And again remember, it's not only ST elevations that tell us that you have an MI. A new left bondo branch block is a stemming equivalent. So if a person has like an elevated ST segment, if they have a new left bondo branch block, those things are pretty much classified as being equal on exempt. And the thing is you may ask yourself, why is that a person suddenly just gets thrown into an acute coronary syndrome? Well here's the thing. You can have it from one of two situations. So many times you're going to have it because your coronary blood fluids disrupt it in some way.

So you essentially have like an atherosclerotic plaque, interruptures, and then it acutely occludes your coronary vessels. Or you can also have these problems when the metabolic requirements of your heart exceed the supply for it. I just got to think of it this way during the pandemic. The requirements for N95s essentially exceeded the supply, at least initially. So people that are having issues in healthcare systems and even personal issues of that sort. If your coronary arteries are so occluded that they can only supply like 10% of the normal amount of blood flow. As long as your heart is just living on that 10%, it's not a big deal. But when your heart, let's say you start exercising or you start doing some kind of physical activity, and your heart's need exceeds the available supply, that's a problem. It's just kind of like with life, right? If for example you're earning some dollars a month and your lifestyle expenses are just those dollars, then you're fine. You won't have any issues, you won't feel any pitch. But when you're in need, let's say your life expenses go up, you know, because of inflation or whatever. But you're still getting the exact same pay, then that's going to cause a problem, right? That's going to cause a problem. Just something you want to keep at the back of your mind, right? So let's then talk about how to manage these things, right? So let's talk about you know unstable engineer or an instant, right?

So the thing is management of unstable engineer and endstaming honestly for some people is a little challenging. But honestly, let me teach you a role that I think is going to make your life very simple. Again, I'm teaching you these roles for the USMLE level, right? If you were going deeper and deeper, let's say you were a resident or whatever, taking some of these resident board exams. Honestly, these roles still help. Again, what am I about to describe? Me sound a little bit atypical, okay? Me sound a little bit atypical. But I promise you is what you're supposed to use on the exams just in general, right? Because many people in cardiology, they are prone to memorizing all these scores and scores and scores and scores to make themselves look smart. And don't get me wrong, you're doing those scores if you're working in the clinical sphere. But again, these podcasts, I'm going to obviously mount a disclaimer, making this for testing purposes and not making this for clinical medicine, okay? So please just throw that disclaimer out there, right? But honestly, what do I like to teach here with unstable engineer and endstaming? Just look at the factors that are present, look at the factors that are present. What do I mean by factors? Basically, there's a lot of bad things going on in a person that has unstable engineer or an endstaming. You should go ahead and take them to the cath lab. That should be your next step. That should, you should go ahead and say, you know what?

Let's go to the cath lab and get a coronary angiography, right? Go ahead and get coronary angiography. So what are these factors? Well, and again, the thing is, many people are prone to also memorizing lists of things. But the thing that makes sense here is to just ask intuitively ask yourself, does this thing seem pretty bad? If it seems pretty bad, then maybe going to angiography is not a horrible idea, right? So say, for example, you notice the person is very high-potensive. You know, they're very hemodynamicly unstable, right? Or you notice that man, this person has got a lot of therapy, you know, a lot of nitrates and whatnot for their chest pain and they're not getting better, right? Or you notice that man, they develop like a mechanical complication in the heart, right? A mechanical complication in the heart. Or you notice that they have like a very sustained arrhythmia, like a sustained bad ventricular arrhythmia, right? Or you notice that they have heart failure symptoms when you're unstable, you know, an endstaming. It makes sense. It makes sense to go ahead and proceed to angiography. For those people, you're not going to be messing around with a stress test or any of that crap. Just go ahead and proceed to angiography. Go ahead, many of those people are going to go ahead and put a staining there in your heart. But if people have fewer factors, if people have fewer factors, right? So let's say that all they have is pretty much just that unstable, an endstaming.

And you don't really have much of anything beyond that, honestly. Just go ahead and do a stress test, right? Go ahead for those people and consider a stress test. Before they leave the hospital, so people that come in with unstable angiography and endstaming, they need to be admitted to the hospital. That can be a USMD question right there. They need to be admitted to the hospital. But after they are admitted, right? After they are admitted, go ahead and do some kind of stress test. Go ahead and do some kind of stress test. If that stress test does not show significant ischemia, then you know, just put them on medical therapies and send them home, follow them closely. But if the stress test shows very significant ischemia, then those people should also again go to the cathlaub. So again, let me summarize this. For unstable angiography and endstaming, there are two things that will get you to the cathlaub. The first thing that will get you to the cathlaub is if you have unstable angiography and endstaming, you just have very many significant factors, right? Like your hypotensive, your heart failure, right? You have a mechanical complication in the heart, you have a sustained ventricular rhythmia, right? We've tried so many drugs and we're getting better. Those are the cathlaub. That's easy. Alternatively, if your person that does not have many factors, you have many factors, right? Then for those people, go ahead and admit them to the hospital. Do a stress test, right?

If that stress test does not show significant ischemia, put them on just medical therapies. But if the stress test shows significant ischemia, put them on just the cathlaub. So people may have memorized, oh, tini scores, tini scores, tini scores. Honestly, you're wasting your time memorizing tini scores. We like to stratify people that have unstable angina or endstamies with tini scores. If your tini score is 0-2, your lower isch, if it's 3-7, your higher isch. And that's fine. You know, the higher isch people, they go to the cathlaub. The lower isch people, you're going to do this second thing I said of doing stress testing and whatnot. But again, memorizing those tini scores, honestly, it's a huge waste of time for the exam. Maybe you can say, okay, let me just memorize the score and what it means, right? So like 0-2 is the person that you're going to be doing this stress test and all that stuff I talked about. 3-7, you're going to go straight to the cathlaub with. But again, memorizing all the different components of the score, honestly, you're monumentally wasting your time. So you may then say, oh, okay, why you said that these people should get some drugs. So let me tell you this, everyone that has unstable angina or an endstamie needs drugs, needs drugs. I'm going to say that again. And then what that has unstable angina or an endstamie needs drugs. You need to be on some drugs chronically.

Okay, but in general, I'll just say, even in the acute phase, they do get these drugs. So what are the drugs that these people should certainly get? Basically, here's the thing. I like to remember this with two, you need to give them two antipletlite drugs, a bit of blocker, a nitrate, a starting and hepper. Okay, so two antipletlite drugs, the two antipletlite drugs are going to be aspirin and groupilogrel, a bit of blocker, a starting, a nitrate and hepper. That's it. That's it. That's it. So when they go to the cath lab or you just stress this and whatever, you're supposed to get all these drugs. You're literally supposed to get all these drugs. You're supposed to get all these drugs. Okay, so now the next thing I want to talk about, or at least talk about the big bad stemming. Right? The big bad stemming. Right? ST elevation myocardial infarction. So what's the big bad stem with stemming? So again, like I said, your biomarkers are going to be elevated. You're going to have EKG findings of either ST elevations or a new left wonder branch block. And obviously for person has a stemming, you certainly want to go ahead and take them to the cath lab. Right? But again, there are some time frame things you kind of need to know here. There are some time free things you kind of need to know here. So here's the thing. I will say in general, there are three time frames that you need to know here. There are three time frames you want to know here.

I'm going to discuss the most important. I'm going to discuss, I'm going to go from most important to least important. So what's the most important? The first most important time frame you want to know is this concept of the door to balloon time, the door to balloon time. Right? So if for example you get to a hospital, literally from when you shop at the hospital, from when you shop at the hospital, or the first time that a healthcare worker sees you, you're like, oh, I think I'm having a hard attack. To when that stent is being placed in your heart should be less than 90 minutes. Should be 90 minutes or less or 90 minutes is included. Just in case the USL is decides to stop playing these funky games with you guys. Right? So the 90 minutes is included. So 90 minutes or less, that's the door to balloon time. From when you have first contact as a patient that has an MI and print that you never be a person that has an MI, you know, God willing. But basically from the first time you contact a healthcare worker, you have MI symptoms, to when that stent is being placed in your heart. 90 minutes or less is the clinical guideline. That can easily be a healthcare system stingy test on the exams. Right? So that's the first time to know, right? That's the door to the balloon time. But let's say for example, the place that a healthcare worker first sees you is a place where, oh, there's no tough lab.

So the first time you literally, so this is the second time frame I'm discussing, you know, the healthcare worker sees you, you have MI symptoms. But that place, that location, that location matters. The location where this series of place where there is no tough lab, you didn't need to ask yourself a question. Is it more than two hours? Will it take us two hours or less? So 120 minutes is included. Will it take us two hours or less to get to the tough lab and have a stent placed? If you'll take you two hours or less, go to the tough lab. But if it's going to take you more than two hours, so if it's going to take you like 121 minutes or more, go ahead and do TPA. Go ahead and give those people TPA. Okay? Go ahead and give those people TPA. Okay? Go ahead and give those people TPA. Now, the third time line, this one is ultra low yield. Probably will never be tested on your USM in exams. But here's the thing. This is from when the patient starts having symptoms. So again, let me just summarize the first time frame I talked about is your first contact with a healthcare worker at a location where a cardiac cath is possible. Use 90 minutes or less. Second timeline was, if from your first contact with a healthcare worker, you had a location where a cardiac cath is not available, obviously you want to be transferred if it's 120 minutes or less. If it's 121 minutes or more, go ahead and do TPA. But the third timeline, super super low yield is 12 hours.

What does this 12 hour hour, hours, go note? Basically, what this means is if you have had MIS symptoms. So notice, this 12 hours doesn't deal with when you first contacted a healthcare worker. Now, just from when your MIS symptoms started, if you've had like, you know, MIS symptoms for less than 12 hours, less than 12 hours, we really should try to get you to the cath lab. If you've had it for less than 12 hours, so it's not like a stroke where, oh man, if it's more than 4.5 hours, sorry man, no more TPA. If when your symptoms started, so notice I didn't see when you contacted a healthcare worker first. When your symptoms started, it's like 12 hours or less. We should still consider a cath lab. Remember, we're going to do cabbage, a query everybody has graphed. When a person has multiple vessels that are messed up, so let's say for example, you have three or more query vessels that are screwed up with an MIS, or you have, or you have an MIS with your left main query artery. In those circumstances, you're going to consider a cabbage, a query artery bypass graphed. Okay, a query artery bypass graphed. Let me tell you this. Another indication for cabbage, that's kind of weird, what's kind of important is, if for example, the tell you in the question that, oh, this person getting percutaneous query intervention, it's just not really going to be possible. For those people, you really want to consider cabbage. Honestly, you really want to consider cabbage.

You really want to consider cabbage. So say for example, these people have developed some kind of really nasty mechanical complication of an MIS. You really, really want to consider cabbage, a query artery bypass graphed in those people. Again, that's the thing with this topic. This topic is pretty detailed. But again, all the stuff I'm telling you is pretty high yield. Okay, let me tell you this. All the stuff I'm telling you is pretty, it's pretty, pretty high yield. Okay, all the stuff I'm telling you is pretty high yield. Another scenario you're even getting on your exams is, oh, this person gets TPA. Well, the person's myocardial is Schemia, does not improve. If you're Schemia, does not improve with TPA. What's going to be your next best step on your exam? Go to the cath lab. That person should go ahead and get percutaneous corner intervention. And again, in general, we're going to prefer a cath lab. If you have, again, many bad factors. Let's say you have like hard failure, you have got an engine shock from your, from your MI, go ahead and proceed to a cath lab. Again, many of these things are scenario based. Many of these things are scenario based. Now, one thing I'm going to say is, again, TPA, again, I'm already giving the situation where you give TPA.

Again, if, from the first time you contact a healthcare worker, if you have a location that does not support a cath lab, and it takes 121 minutes or more for you to go to a cath lab place, then go ahead and consider TPA. And the thing is, you know, our friends at the USMEL is the love, love, love to test these TPA contraindications. So, say for example, a person is actively bleeding, or they have a higher risk for bleeding. So, let's say they've had like really big surgery, like really big gastrointestinal surgery, or really big thoracic surgery, or really big vascular surgery recently. Obviously, you shouldn't give those people a, you shouldn't give those people TPA if not they're going to bleed out and they're going to have a really, really big problem. And also, if your blood pressure is crazy high, right? If your blood pressure is crazy high, so let's say, your systolic blood pressure is like more than 180 millimeters of mercury, or your gastrointial blood pressure is more than 110 millimeters of mercury, you certainly should not be doing a TPA, right? So, you should not be doing a TPA. You know, if you're able to somehow magically bring those people's blood pressure down, be low, those thresholds, then yeah, you can go ahead and do TPA. But again, if your blood pressure is really, really high, if you, if you give people TPA, those will come bleed out and die. You don't, you don't want that, you don't want that.

Okay, so now, again, let's kind of talk about the drugs that you need to be taking. If you have a quick, acute coronary syndrome, right? If you have an M line, right? So you got a stemming. What kinds of drugs should you be taking? Basically, let's talk about the drugs you have to be on. You have to be on, right? So you got to be on aspirin. aspirin is a big one, right? And you're going to get it in the acute phase. You're going to be on it indefinitely. That's the truth. The second one is, again, another anti-pletraug. Usually we like clopidogrel, right? But really, you can use any P2 Y12 inhibitor. Remember, P2 Y12 is a fancy MBME name for ADP receptor, right? So an ADP receptor antagonist. So something like clopidogrel, that's like the big one we love, right? But other things like Prostogrel, type clopidine or type cagrallor, right? So clopidogrel, Prostogrel, type clopidine, type cagrallor, type cagrallor, TIC, HGRE, LOR. Those can certainly be used, right? You're going to get it in the acute phase, right? But in addition to that, you're going to take it for a year after you've had the M line. You're going to take it for a year after you've had the M line. The third thing that you need to be on a beta blocker, you've got to be on a beta blocker, okay? Those beta blockers, again, you're going to take it in the acute phase. Although the thing is, it's not something you have to get the moment you get to the hospital.

But usually within the first day, within the first 24 hours of you having an M line, you've got to get a beta blocker. And then after that, you're going to take it indefinitely, right? You're going to take it indefinitely. And then heprin. You know, heprin is another thing you should also get. Heprin is something you should get the moment you get to the hospital, okay? You don't want me to get to the hospital. You don't want me to get to the hospital. You absolutely should get that, okay? But you don't have to take the heprin indefinitely. And then kind of like beta blockers undergroup you also get is an ACE inhibitor, right? An ACE inhibitor, an ACE inhibitor. You're going to get an ACE inhibitor. Again, you don't have to get the moment you get to the hospital. But within the first 24 hours of you showing up at the hospital, you absolutely positively should get an ACE inhibitor. And the thing is that ACE inhibitor is not something that you have to continue indefinitely. Well, there are some people that should continue indefinitely. And honestly, the people that should continue indefinitely are people that normally probably need ACE inhibitors. Like for example, if for example, the person's the person has diabetes, you got diabetes, right? You should probably be on an ACE inhibitor long term, right? Because it's renal protective. If you have hypertension, you have chronic kidney disease, right?

Well, you see you have heart failure because remember, ACE inhibitors do improve survival in heart failure. Then just be on this ACE inhibitors indefinitely. So it's not every one that needs is inhibitors indefinitely. It's just people that have some indication for it. Okay, but everyone though, in the first 24 hours after they have the M.I. Yeah, within that first 24 hour window. So within, not outside within, did you get the ACE inhibitor? And then you should continue indefinitely if they have a need for it, right? You can also use ARBS, right? If you can use ACE inhibitors and dry cough, whatever. Right? And then nitrates, right? Again, nitrates are largely for chest pain, right? The largely for chest pain. Well, remember, you avoid nitrates when you have an RC infart, right? A 2, 3 EVF infart, right? And then statins, right? Statins, the moment you get to the hospital, we want to try to give you statins. Even if your LDL is normal, it doesn't matter. You're going to get a statin. Right? Once you have a, a curinary syndrome, it's an atherosclerotic cardiovascular disease. You're going to get a statin, a high intensity statin, something like a 2-ver statin or a silver statin. Although this whole business of high intensity, medium intensity, low intensity, kind of a waste of time for the USMELIS trying to memorize that to be honest with you, right? So the person should be on a statin and they're going to be on it indefinitely. They're going to be on it indefinitely. Okay?

They're going to be on it indefinitely. Okay? Now, one thing I'm going to say. One thing I'm going to say is if, for example, they give you that, wow, this person's ejection fraction, you know, the MIR was so bad, the ejection fraction is like 40% or lower, right? You notice that they have like heart failure symptoms and whatnot. Then you need to consider an auto-steroid antagonist in those people. That's just for completeness sake, but honestly that point is pretty, pretty low yield. I would not stress too much about that if I were you. Okay? I would not stress too much if I were, if I were you about that. Okay? I would not stress too much if I were you. I would not stress too much if I were you. Now, let me just say something. So I said you can use TPA for a staining. Please, please, please, please. Never pick TPA if you have any order kind of acute coronary syndrome. So never pick TPA for stable angina as you answer on an example. You'll be wrong. Never pick TPA for an end staining as the treatment on an example. You'll be wrong. TPA is only used for staining. Okay? The researchers are just too high. Right? So we're not going to be giving that for willingly for any for just any any person. Okay? So just be be careful there. I think that's something you kind of want to keep in mind for your exams. Right? And the thing is again, there are many bad things that can happen with an M.I. Right?

You know, you know, you know, you can see people die suddenly within the first 24 hours. Well, what's the most common cause of death in the first 24 hours after an M.I. It's going to be V-fib, right? It's going to be V-fib. It's going to be V-fib. It's going to be V-fib. And other classic one is you may see a person, you know, suddenly they become very unstable. And then you hear the murmur of mature regurg. Right? You hear the murmur of mature regurg. You hear the murmur of mature regurg. That person has ruptured the papillary muscles. Right? They have a papillary muscle rupture. And some ventricle this the cordy tendony rupture. Or you see again, the presence suddenly the compensate, you know, crackles in the lungs, all these problems. And you hear the murmur of VSD. You hear that VSD murmur. They want to think about an interventricular septal rupture. What do you think about an interventricular septal rupture? Okay? You want to think about an interventricular septal rupture. Or let's say you see like cardiac tamponad that develops suddenly. Again, all these things are suddenly symptoms. Suddenly symptoms, right? You see the person, the developer, cardiac tamponad suddenly will develop like a postless electrical arrest. When you see these things, honestly, if I were you, I would think about a ventricular free-wall rupture. A ventricular free-wall rupture. Okay? And if you're asking you, what's your next best step in diagnosis? Go ahead and get an echocardiogram.

That's the first thing you get when people develop these mechanical MI complications. Right? Another scenario you get on your exam is you get a question about a person, you know, they have an MI and you give them a nitrate and then boom, they have no pressure just tanks massively. Honestly, that's our roundabout way. Our friends at the USMT used love to test RCA infections, right? Cornery artery infections. Remember, these people are very pre-low dependence. Right? The nitrates are Vino dilators. Not a good idea. Not a good idea at all. Not a good idea at all for people that have RCA in parts. Okay? So if you see a person that, man, after they get like an nitrate, gee, these people just stop crushing and burning. Then don't give these people a... That's an RCA in fact that those people have right there. Many times we would have RCA in parts, we try to give them a little bit of fluid. Try to give them a little bit of fluid. Okay? We try to give them a little bit of fluid. And here's one thing I'm going to say. Just, again, I'm not just a few, I think, more scenario-based things that I may want to keep in mind. We love to test this on exams, but people that have had M Is or strokes, all of them should be screened for the pressure. All of them should be screened for the pressure. Right? Especially in MIP patients having that comorbid depression, actually it's a scenario like an increased risk of re-hospitalization, increased risk of death.

It's just something I want to keep on the back of your mind for, for your exams. Something I want to keep on the back of your mind for, for exams. And then, if you notice, if you notice that, what I want to say here, if you notice, there's not only M Is, there's not only STEM Is that cause STL innovations. I think that's one thing that people kind of erroneously think on, on exams. STEM Is are not the only causes of STL innovations actually. They mean other things that can cause STL innovations, like Prinsmetal and Gena, which we call a variant of these days, it can cause STL innovations. If a person has an aneurysm of the left interval, that can cause them to have STL innovations. If you see diffused STL innovations, that's very good ideas. Very good ideas can absolutely cause STL innovations. Even when you see an old lady that hears bad news and boom, she becomes more than stable. Tako Subo, like a stressing use cardiomyopathy. That honestly, honestly, that can also cause STL innovations. So just be careful. Just be careful of those things can certainly cause STL innovations. So I think I'm going to go ahead and pause here. This broadcast is kind of going along, but again, I promise you the stuff is floridly high up for the University of the exams. Again, I'd offer a few classes for step one, I have one in September and for step two and step three. Slash off exams, I have that in September as well.

I'll offer the course for step one is 25 hours long, the course for step two is 30 to 20 hours long. And then I have some courses that I'd like to step one over the windows step three. We have a two and a half hour MBA meetings, taking strategy scores, four hour by your stats class and five hour social sciences, quality improvement, ethics, healthcare systems, communications class. Again, many people have taken these classes and they've done extremely well with them and these classes are not lectures. Like 95% plus of these classes are entirely scenarios where there's a deep explanation of pathophase. So you can see things just in context, right? Many resources just present the point. No, you want to see scenarios. That's how you're really going to understand things, right? Because that's your exam is a bunch of scenarios basically. So you're going to see scenarios, you're going to get a very deep understanding of pathophysiology. And you're also going to get a very deep understanding of of of integration, right? How can this thing be tested in like multiple dimensions on the USM Lism? All these things over Zoom. If you're interested in many of these classes, just shoot me an email, I'll give you some more information. And then finally, I have I offer one or one tune for all the USML exams and also pre-clean call medical exams, 30-ish off exams.

And then I help with your application, you know, personal statements, rec letters, supplemental applications, mock interviews and stuff like that. And then finally, I have these podcasts on the major apps Apple, Google and Spotify. Actually, I guess not finally. And then I have these, I have this You Tube channel, Divine Intervention USM Ly podcast and videos. That's where I post the videos that I make. And then I also have a new website called Divine Intervention Lifelessence.com. Divine Intervention Lifelessence.com. It's a Bible based website, meaning if you're not a Christian, and I put two podcasts every week on some life lesson that's relevant to people. So I address a life lesson from a biblical perspective. We have, I think, almost 210 podcasts right now. This is actually an Apple podcast associated with that called Divine Intervention Lifelessence podcast. So thank you for joining me today. I will see you in a piece of 478. Have a wonderful rest of your day. God bless you. Bye for now. Thank you.

Obtain an EKG and appropriate serum biomarkers (troponins).

Troponins will be elevated, but there should be no ST segment elevation. The EKG may be normal or show abnormalities.

Elevated biomarkers AND ST segment elevations (or new LBBB).

Less than 90 minutes.

Active bleeding or high risk of bleeding, and severely elevated blood pressure (e.g., SBP > 180 mm Hg).

Aspirin, P2 Y12 inhibitor, Anticoagulant (Heparin), and Statin.

NSTEMI (Non-ST Elevation Myocardial Infarction).

Aspirin and a P2 Y12 inhibitor (e.g., Clopidogrel, Ticagrelor).

Proceed directly to the cath lab/angiography, regardless of risk scores.

High-intensity statin therapy should be started immediately upon arrival in the hospital, even if LDL levels are normal.

Systolic Blood Pressure (SBP) > 180 mm Hg or Gastrointestinal Blood Pressure (GIBP) > 110 mm Hg.

Ventricular fibrillation (V-fib).

NSTEMI (Non-ST Elevation Myocardial Infarction).

Aspirin and a P2 Y12 inhibitor (e.g., Clopidogrel, Ticagrelor).

Proceed directly to the cath lab/angiography, regardless of risk scores.

High-intensity statin therapy should be started immediately upon arrival in the hospital, even if LDL levels are normal.

Systolic Blood Pressure (SBP) > 180 mm Hg or Gastrointestinal Blood Pressure (GIBP) > 110 mm Hg.

Ventricular fibrillation (V-fib).