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Cardio II Final > Angina, Unstable Angina, ACS, and testing > Flashcards

Angina, Unstable Angina, ACS, and testing Flashcards

1
Q

Risk factors for atherosclerosis

A

o Hyperlipidemia – high LDL, low HDL, high TG, high lipoprotein (a)
o Smoking
o DM – major risk factor
o HTN
o Family hx of coronary heart disease, ischemic stroke, or peripheral vascular disease
o Obesity
o Physical inactivity (need 30-60 min medium intensity 4-7 days/week)
o Psychosocial stress – causes catecholamine release
o Sleep disturbances – arrhythmias, hypoxia due to OSA
o Age and gender (males >55, females >65)

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2
Q

Metabolic Syndrome

A 
o	Insulin resistant
o	HTN
o	High TG, low HDL
o	Hyperuricemia
o	Hyper coagulable
o	Obese, overweight (need to get back to desirable weight)
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3
Q

Mechanical complications of ischemia

A
  • HF – LVF or RVF or both
  • Angina – prolonged ischemia or develop coronary occlusion, may lead to nyocardial necrosis
  • Segmental akinesis bulging (dyskinesis
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4
Q

Biochemical consequences of ischemia

A
  • Fatty acids can’t be oxidized
  • Increased lactate production
  • Reduced pH with metabolic acidosis (higher lactic acid, higher mortality)
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5
Q

Electrical consequences of ischemia

A
  • Inversion of T wave
  • Transient displacement of ST segment
  • Depression – subendocardial portion of heart
  • Elevation – subepicardial portion or transmural injury of the heart
  • Electrical instability – VT, VF
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6
Q

LAD distribution

A

Anterior wall infarction
Most of septum and anterior portion of the heart
Leads V1-V6

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7
Q

RCA distribution

A

inferior wall infarction
• Most of inferior of heart and part of RV
• Leads II, III, AVF; V3R – V6R

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8
Q

Circumflex A distribution

A

– lateral wall

• I, AVL, V5, V6

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9
Q

Posterior Descending A distribution

A

posterior wall infarction

• Reciprocal changes anteriorly - V1-V3

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10
Q

Non CP symptoms of chronic ischemic heart disease

A 
o	Dyspnea
o	Non chest locations of discomfort – exertion or rest
o	Mid-epigastric or abdominal
o	Diaphoresis
o	Excessive fatigue and weakness
o	Dizziness and syncope
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11
Q

Chronic stable angina

A

consequence of imbalance between oxygen supply demand

• Low risk of plaque rupture – small lipid core and thick fibrous cap

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12
Q

Supply angina

A
  • Decrease O2 deliver to tissue lead to ischemia
  • Coronary vasoconstriction, stenosis, platelets release serotonin, TxA2
  • Tx: aspirin to inhibit COX to inhibit platelet aggregation
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13
Q

Demand angina

A
  • Increase myocardial O2 requirements, workload can lead to ischemia
  • Exercise, stress, emotion, fever, thyrotoxicosis
  • LVH due to AS
  • Anemia – low O2 carrying capacity
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14
Q

ECG findings in angina

A
  • Initial (early) may be normal, or nonspecific half the time – look at hx
  • During angina attack, may have displaced ST segment, most commonly depression
  • Subendocardial injury-ischemia
  • May show old MI
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15
Q

Classic hx for angina pectoris

A

• Chest discomfort brought on by exertion/emotion/excitement
• Relief by rest usually predictable, stable, not occurring more often, not lasting longer
• Men 50-60; Women 60-70
Fx: premature IHD

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16
Q

Physical exam findings in angina pectoris

A
  • Often normal
  • Xanthelasma – soft, yellowish spots on eyelids
  • Xanthomas
  • Diabetic skin lesions
  • Nicotine stains
  • Pale
  • Absent peripheral pulses
  • Abnormal cardiac impulse (LV dyskinetic)
  • Bruits – carotid, abdominal aorta, femorals
  • Gallop – S3, S4, or both
  • Systolic murmur of MR if papillary muscle is dysfunctional
  • Associated with inferior or inferior-posterior ischemia due to RCA disease
17
Q

DDX for angina pectoris

A

• Aortic valve disease, pulmonary HTN, hypertrophic cardiomyopathy

18
Q

Discomfort experienced in angina pectoris

A

o Varies – heavy, pressure, squeezing tightness, smothering, choking, dullness, ache, sharp, heart burn, indigestion, gas
o Substernal, clenched fist – Levine’s sign
o Crescendo/decrescendo pattern lasts 15-20 min
o May radial into L shoulder, down ulnar surface of forearm/hand; both arms
o May radiate or arise in neck, jaw, teeth, epigastric, or back
o May be precipitated by heavy meal, cold exposure

19
Q

Anginal equivalent

A

o Causes dyspnea, fatigue, faintness, gastric eructation’s (belching)
o Pathogenesis: ischemia causing elevated LV filling pressure leading to pulmonary edema
o Seen in diabetics, elderly, women

20
Q

Unstable angina (Acute coronary syndrome)

A

o New or worsening chest pain
o Tempo has changed, more severe, prolonged more frequent
o May occur at rest, awaken from sleep
o Pain lasting longer than 20 min
o Using more medication for relief
o Less effort to provoke symptoms
o No evidence of myocyte necrosis (no elevation of troponin I or CK-MB)

21
Q

Non-ST elevation MI

A

o CP with elevation of cardiac enzymes (troponin I or CK-MB) and WITHOUT ST elevation
o Ddx
• PE – ECG changes, elevated troponin
• RBBB, sinus tach, afib, S1Q3T3
• Nonspecific
• Aortic dissection
• VHD – AS, AI, hypertrophic cardiomyopathy
• Huge QRS voltage
• Myocarditis – pericarditis
• Stress cardiomyopathy – takotsubo syndrome – deeply inverted T wave

22
Q

Unstable Angina and NSTEMI patients

A

o Atherosclerotic plaque rupture or erosion with platelet aggregation and thrombus leading to a PARTIAL occlusion of the coronary artery
o ECG:
• Magnitude of ST segment depression correlates with prognosis
• 1mm or greater in 2 or more leads – 4x likely to die within 1 year
• 2 mm or greater – 6x more likely to die within 1 year
• 2 mm or greater in more than 1 region of ECG – mortality is 10 fold

23
Q

Labs for Acute Coronary Syndrome

A

o Cardiac enzymes – Troponin I – detected in 2-4 hrs in NSTEMI
o Increased CK-MB – after 3-6 hours
o BNP – increased BNP associated with increased mortality in NSTEMI
• Marker for ventricle stretching
o CRP – inflammatory biomarker
o CMP, BUN, Cr, liver panel, electrolytes, CBC
o FLP (fasting lipid profile), TSH

24
Q

Signs of risk for coronary event

A

o Positive stress test at low work load
o ST depression greater than 5 min after completion of test
o Decreased BP – systolic fall > 10mmHg during exercise
o VT during exercise
o Reduced EF during exercise (stress echo)

25
Q

Variant Angina or Prinzmetal Angina

A

o Transient ST segment elevation during CP in absence of severe CAD
o Spasm of coronary arteries
o CP predominantly at rest, awaken from sleep
o Relieved by Nitro
o Rx: dihydropyridine CCB (amlodipine)

26
Q

Stress test contraindications

A

• Recent MI or acute MI, unstable arrhythmias, acute PE, aortic dissection, unstable angina, severe AS, decompensated HF, endocarditis, DVT

27
Q

Pharmacologic stress test

A
  • Use adenosine/regadenosine
  • Vasodilators increase HR
  • Dobutamine increase HR
28
Q

Nuclear myocardial perfusion imaging

A
  • SPECT – single proton emission CT

* Useful in LBBB, LVH, digitalis effect

29
Q

Stress Echocardiogram

A
  • With exercise or dobutamine

* Defect wall motion abnormality and EF

30
Q

Cardiac CT Angiography (CCTA)

A
  • Detect coronary calcification

* Specificity 50% in identifying obstructive CAD

31
Q

CXR

A

usually normal unless hx of HI, HF, VHD

• Cardiomegalia in HTN, VHD, cardiomyopathy, pericardial effusion

32
Q

Coronary Angiography

A

(cardiac catherization)
• Gold standard
• Percutaneous coronary intervention (PCI) – stent insertion – 1 or 2 vessels
• Criteria for CABG – L main disease or 3 vessel disease

33
Q

Aspirin

A
  • Blocks platelet aggregation

* Inhibits cyclooxygenase

34
Q

Beta Blockers

A
  • Slow everything – decrease HR, workload, O2 consumption
  • Contraindicated if decompensated HF, hypotension, advanced AV block (higher than 1st degree)
  • Get them out of HF first
  • Symptoms initiating drug – fatigue “wearing them out”
  • Lower mortality
35
Q

Nitro/Nitrates

A
  • Decrease preload

* Need 8-12 hour free interval to prevent tolerance

36
Q

CCBs

A
  • Not shown to decrease mortality

* Caution with verapamil in impaired LV function – negative inotropic effect

37
Q

Aggravating conditions in Angina

A 
o	Obesity – weight loss if obese, consult dietitian
o	HTN – treat to goal
o	Hyperthyroid – meds, RAI
o	Anemia – find cause and tx
o	Smoking – cease
o	Hyperlipidemia – statins
•	Goals:
•	LDL-C less than 70 mg/dL
•	HDL-C greater than 60 mg/dL
•	TG below 150 mg/dL
•	Total Cholesterol less than 200 mg/dL
o	1% decrease in TC yields 3% decrease in risk of CAD
o	Diabetes – ADA diet, oral agents, insulin

Cardio II Final (15 decks)

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