#3 Cardiac Flashcards
CAD
what med should you hold if pt has severe CAD?
note: presents w/ wide variety of Sxs
CAD
severe CAD –> hold clopidrogrel
Sxs (for reference)
- CP, SOB, DOE, dizzy, palp, leg swelling, wt gain
- syncope, shock, pulm congestion, rales
3 Types/Classification of ACS
3 Types/Classification of ACS
- STEMI
- NSTEMI
- Unstable Angina
Types/Classification of ACS
- which is a/w complete obstruction
- which is a/w intermittent occlusion/myocardial necrosis
- which is a/w occlusion that auto-reperfused
Types/Classification of ACS
- STEMI = complete obstruction
- NSTEMI = intermittent occlusion/myocardial necrosis
- Unstable Angina = occlusion that auto-reperfused
ACS: STEMI sides
- which side presents w/ epigastric pain, bradycardia, elevated JVP, inferior distribution, dont want to lay flat
- which side presents w/ HoTN, tachycardia, ant/lat distribution, SOB, rales
ACS: STEMI sides
- R side = epigastric pain, bradycardia, elevated JVP, inferior distribution, dont want to lay flat
- L side = HoTN, tachycardia, ant/lat distribution, SOB, rales
ACS: STEMI
- 2 things needed to make Dx
- What time frame are cardiac enzymes NOT definitive
ACS: STEMI
- Dx = clinical + EKG
- cardiac enzymes < 6 hr from Sx onset NOT definitive
ACS: STEMI and EKG
- what needs to be seen (and in how many leads) to make Dx
ACS: STEMI w/ EKG Dx
- ST elevation ( > .1mV/ 1mm) in 2 contiguous leads
Management for ACS (general)
4 things given if ACS suspected
Management for ACS (general)
- ACS suspected –> MONA
- Morphine
- O2
- NG
- ASA
Tx for STEMI (ACS)
- what med given immed
- what type of procedure for Tx (2 options)
- 3 meds given as post-care
Note: MC cause = plaque rupture
Tx for STEMI (ACS)
- Clopidrogrel given immed
- procedure for Tx
- cath lab (PCI)
- Fibrionolytics (if no cath lab w/in 90 min) - 3 meds given as post-care
- statin
- B-blocker
- ACE/ARB
Tx of STEMI: L vs R
- R = Pt w/ Inferior STEMI w/ RCA occlusion
- what to give immed
- what to avoid - L = Pt w/ ant or lat STEMI
- what do the need reduced (what med to give)
- what to avoid
Tx of STEMI: L vs R
- R = Pt w/ Inferior STEMI w/ RCA occlusion
- immed IVFs
- avoid Nitrates - L = Pt w/ ant or lat STEMI
- need afterload reduced –> give nitro
- avoid IVFs
(NOTE OPP OF R SIDED STEMI)
ACS: NSTEMI vs Unstable Angina Presentation
- what Sx do both have
- what do both have on EKG
- How do they differ in regards to labs
ACS: NSTEMI vs Unstable Angina Presentation
- common sx = Angina
- common EKG finding = non-spp ST changes
(UA can be norm) - differ w/ labs
- STEMI = (+) Cardiac enzymes
- UA = (-) Cardiac enzymes
ACS: STEMI and EKG
- what indicates ischemia on EKG
- what other abn seen
ACS: STEMI and EKG
- ischemia on EKG = ST depression
- Other abn = T wave inversions
ACS: NSTEMI Tx
- 3 meds given immed
- not as urgent as STEMI, but when do they need to be taken to cath lab by for PCI
note: post care = SAME as STEMI
ACS: NSTEMI Tx:
Immed Meds
- clopidrogrel
- LMWH/UFH
- Statin
- need to be taken to cath lab by for PCI w/in 72 hrs
ACS Tx: dosing, CIs
- ASA: loading dose and lifelong dose
- Plavix/Clopidrogrel: loading dose and lifelong dose
- What med cant be give if HoTN, Inferior MI, Viagara use in last 24 hrs
- What med CI if Hr < 60, SBP <90, heart block, Hf, H/o bronchospastic dz or cocaine use
ACS Tx: dosing, CIs
- ASA
- loading dose = 325 mg
- lifelong dose = 81 mg - Plavix/Clopidrogrel
- loading dose = 400-600 (mg?)
- lifelong dose = 75 (mg?) - NG = CI w/ HoTN, Inferior MI, Viagara use in last 24 hrs
- BB = CI if Hr < 60, SBP <90, heart block, Hf, H/o bronchospastic dz or cocaine use
ACS: Prognosis
- TIMI risk score indicates what mortality by STEMI
- Kilip Class indicates what type of mortality
ACS: Prognosis
- TIMI risk score = 30 day mortality by STEMI
- Kilip Class = inhospital mortality
ACS: Complication
- what should you suspect in pt who develops HF and audible murmur
- why does this need emergent surg
ACS: Complication
Develop HF and audible murmur –> Acute Mitral Regurg
- need emergent surg b/c ischemia –> necrosis
Pt presents w/ substernal CP that occurs only w/ activity. Pt says that stopping to rest relieves his Sxs
Dx?
Dx = Stable Angina
Pt presents w/ substernal CP that has been happening more freq recently, worsening, and lasting longer. Pt very recently the CP has now begun to happen at rest
Dx?
Dx = Unstable Angina
Stable Anging Dx
- What is the main form of Dx testing
- more definitive method
Stable Anging Dx
- main form of Dx testing = Stress Test
- more definitive method = CCTA
Stable Angina Tx
- what 4 meds given to Symptomatic pts
- what can be added if these dont work
Stable Angina Tx
- what 4 meds given to Symptomatic pts
- NTG
- Beta blocker
- ASA daily
- Statin (mod-high) - these dont work –> add CCB
Vascular Dz/Atherosclerosis
- what is it instigated by
- what gets incr in the body –> inflam –> and utimately leads to what
Vascular Dz/Atherosclerosis
- instigated by endothelial disruption
- inc lipids –> inflam –> calcification
permanent, localized dilation of artery
- in most pts the first Sx = death
(> 4 cm = usu diagnostic)
permanent, localized dilation of artery = Aortic Aneurysm
- in most pts the first Sx = death
(> 4 cm = usu diagnostic)
- Connective tissue d/o
- AAA
- inflam dz (giant cell, takayasu, bechets, etc)
- Infxn (syphilis)
- Decelerating Trauma
6 .Chronic dissection - Genetic Syn (Marfans, Loeys-Dietx, Ehler-Danlos, Turners)
causes of what
Causes of Aortic Aneurysm
- Connective tissue d/o
- AAA
- inflam dz (giant cell, takayasu, bechets, etc)
- Infxn (syphilis)
- Decelerating Trauma
6 .Chronic dissection - Genetic Syn (Marfans, Loeys-Dietx, Ehler-Danlos, Turners)
Location of Aortic Aneurysms
- occur before ligamentum arteriosum
- occur below ligamentum arteriosum
- occur below diaphragm
Location of Aortic Aneurysms
- ascending = before ligamentum arteriosum
- descending = below ligamentum arteriosum
- AAA = below diaphragm
Which types of aortic aneurysm STRONGLY a/w
Main tx for Dx
Descending and AAA = STRONGLY a/w PVD
Dx test = CT
Tx of aortic aneurysm (all types)
- Sxs –>
- surg is done when size > ______
Tx of aortic aneurysm (all types)
- Sxs –> surg
- surg is done when size > 5.5 cm
What d/o s precipitated by tear in vascular intima –> blood enters media –> disrupts blood vessels
Aortic Dissection
- precipitated by tear in vascular intima –> blood enters media –> disrupts blood vessels
Aortic Dissection Progression
- which affects coronary arteries
- which interferes w/ periph blood flow
Aortic Dissection Progression
- proximal = affects coronary arteries
- distal = interferes w/ periph blood flow
Pt presents w/ abrupt onset of chest/thoracic pain that he describes as sharp/tearing. Pt looks to be in distress. Vitals: BP 170/90, HR 125. On exam you are able to feel 2 radial pulses but only 1 pedal pulse, hear aortic regurg. CXR shows mediastinal widening of 9 cm
Dx (gen and spp)
What test to get to confirm Dx?
Dx = Aortic Dissection
- spp = promixal (b/c aortic regurg)
(could also have tamponade/coronary dissection)
Confirm Dx = CT