Acute Coronary Syndrome 1 Flashcards
Recall 3 key points regarding the prevalence and significance of ischemic heart disease.
CV disease is the #1 cause of death in the world
death from ischemic heart disease is declining in the US due to improved prevention and therapy
the societal cost burden of ischemic heart disease is significant and increasing
How might a patient present with stable ischemic heart disease?
absence of symptoms
predictable, chronic angina pectoris
intact fibrous cap
minimal platelet activation
What are clinical indications suggestive of unstable inschemic heart disease?
rapidly progressive anginal symptoms
elevated cardiac biomarkers
ECG changes
Contrast the pathophysiology of stable angina and acute coronary syndrome.
the first is obstructive or non-obstructive coronary artery disease, intact fibrous cap and min platelet activation or thrombus
the second is obstructive coronary artery disease, plaque rupture or erosion, followed by platelet activation, inflammation and thrombus
What are the 1st line treatments for someone with chronic stable angina?
lifestyle modification, B-blocker, CCB and nitrate therapy
What is the options for patients with stable angina who are refractory medical therapy?
percutaneous (stenting) or surgical coronary artery revascularization may be considered
Under what circumstance should coronary artery bypass surgery be considered.
patient is refractory to medical therapy AND has three vessel disease with depressed left ventricular function and has no contra indications
if surgery is not possible, multi-vessel percutaneous stenting may be considered
Define the classes that can be used to describe the severity of angina pectoris.
I. only with strenuous, rapid or prolonged exertion
II. slight limitation of ordinary activity
III. marked limitation of ordinary activity
IV inability to carry on any physical activity without discomfort, angina may be present at rest
Presence of Q waves suggest what?
suggest prior myocardial.
__________ with exercise is most diagnostic of significant, obstructive coronary artery disease.
horizontal or down-sloping depression or elevation of the S-T segment with exercise is most diagnostic of significant, obstructive coronary artery disease
What can increase the predictive value of an electrocardiographic stress test?
increasing the prevalence of the disease- consider risk factors to stratify the population
or combination with non-invasive imaging methods (nuclear scintigraphy or echocardiography)
What characteristic of heart tissue does nuclear stress imaging highlight?
radionuclide tracer is taken up by myocardium in proportion to blood flow, can highlight ischemic portions of the heart
High risk coronary artery disease is likely when: (4)
onset of chest pain and or EKG changes of M ischemia occurs at a low level of physical exertion
exercise-induced hypertension occurs
malignant ventricular arrhythmias occur
large areas of myocardium demonstrate reduced perfusion or contractility using imaging
Name agents that can be used instead of exercise in a stress test.
coronary vasodilators- adenosine and dipyridamole and hyper contractility agents such as dobutamine
Describe fractional flow reserve.
coronary guide wire mounted with a transducer placed across the lesion can pressure difference can be diagnostic of functional obstruction
Non invasive testing can establish a diagnosis but it can also help to define _____
prognosis
The most important part of the clinical evaluation of a patient with suspected ischemic heart disease is what.
detailed history
What method is the gold standard for establishing diagnosis and assessing the severity of CAD?
invasive cardiac catherization
What approaches could you use to address symptom relief with acute coronary syndrome.
meds like B bluchers, CCBs and nitrates
ballon angioplasty, stenting and surgical bypass
What approaches could use to prolong a patients like that has acute coronary syndrome?
lifestyle modifications
anti-platelet medications (aspirin, clopiogrel and prasrugrel)
PB recution and plaque modifying meds ACE I or statins
Because of the diffuse nature of CAD, stenting and angioplasty have been able to offer symptom relief but not________ with stable ischmemic heart disease
reduce total rates of MI or death in patients with stable ischemic heart disease
The risk of repeat revascularization following PCI is highest in those with ?
diabetes
long stunted segments, multiple overlapping stents and small diameter vessels
What are the 3 types of acute coronary syndrome?
unstable angina
non ST elevated myocardial infarction (NSTEMI) and STelevation myocardial infarction (STEMI)
How do you differentiate NSTEMI and STEMI from unstable angina?
with serum biomarkers of myocardial cell necrosis such as troponin I and troponin T
Angina at rest implies what?
unstable plaque and platelet based pathology
Both unstable angina and NSTEMI are triggered by what?
plaque rupture that results in a transient and or incompletely occlusive thrombus
If not treated quickly, ST-segment elevation will usually be followed by development of Q waves which implies what?
competed transmural necrosis
The site of myocardial infarction is most commonly in the ___ portion of the coronary arteries, which may be related to the differences in mechanical stress in these locations.
proximal portion
Plaque rupture exposes several chemical factors on the vessel wall including (3).
tissue factor
collagen
vonWillebrand factor
_____ and _____ are both potent inhibitors of platelet activation are reduced int eh vicinity of atherosclerotic plaque.
NO and prostacyclin
TIMI score is based on 7 clinical variables.
age >65 presence of at least 3 risk factors for CAD prior coronary stenosis of >50 present ST segment deviation two angina episodes in prior 24hrs elevated serum cardiac biomarkers use of aspirin in prior seven days
