Approach to Coronary Heart Disease Flashcards
There are 2 groups of risk factors for coronary heart disease, namely___
Modifiable and non-modifiable
Name 4 non-modifiable risk factors for coronary heart disease
Age
Gender
Race/Ethnicity
Family history of CVD
Name 4 modifiable risk factors for cardiovascular disease
Blood pressure
Diabetes
Hyperlipidemia
Smoking
Review this slide on CAD Prevention
Ms. A is a 48-yo female high school teacher who has no abnormal symptoms and is coming in for a routine visit.
Family History:
Mother with stroke at age 53; Father with myocardial infarction age 58
BP: 145/90, taking amlodipine
Diabetes: No history, normal blood sugar
Lipids (mg/dL): Total cholesterol 190, HDL 30 (low), Triglycerides 190 (high), LDL 122 (high)
Tobacco: Smokes 5 cigarettes a day
***
What are 3 things you could do/give to reduce a pts risk for coronary artery disease?
Lifestyle changes
Statins to control lipids
Aspirin to reduce risk of MI **does cause increased risk of GI bleeding**
Define myocardial ischemia
Myocardial ischemia: supply-demand mismatch – not enough O2 to the heart to meet its O2 needs
Name 6 conditions that can increase myocardial oxygen demand
Increased physical activity
Infection
Severe hypertension (effects on afterload)
Acute congestive heart failure
Blood loss
Pregnancy
Name some possible causes of myocardial ischemia (4)
(Obstructive) Coronary artery disease
Coronary vasospasm (Prinzmetal’s angina)
Microvascular heart disease
(Extracardiac problems like pulmonary disease)
Explain this slide
Ischemia causes abnormal contraction/relaxation of heart, anaerobic metabolism>>lactate production, ECG changes
Symptoms are the last to arise
Describe a typical angina presentation
Pt may describe what feels like indigestion, an chest “tightness/squeezing”, pressure, aching
**pain can radiate to the neck or arm**
Certain groups of people, namely ___, often present with ___, as opposed to typical angina symptoms
Certain groups of people, namely women, diabetics and the elderly often present with non-specific symptoms as opposed to typical angina symptoms
3 characteristics of angina are ___
What is the difference between typical and atypical angina?
Classical symptoms
The symptoms are precipitated by stress (physical or emotional)
The symptoms are relieved by rest or nitroglycerin (**recall that this is a nitrate med used for vasodilation)
***
Typical angina = experiences all 3; atypical = experiences only 1-2/3
Describe the difference between stable vs unstable angina
Stable angina: angina with exertion/stress and is relieved by rest
Unstable angina: angina w/ decreasing exertion/occurs even at rest
**stable angina suggestive of stable plaque, unstable angina suggestive of unstable plaque (might be rupturing/have ruptured)
Define a myocardial infarction
MI: Irreversible necrosis of the myocardium due to prolonged ischemia
(can cause decreased heart function/unstable rhythms)
For a STABLE patient, how would you perform the diagnosis for angina? myocardial ischemia?
For angina - from pts history
Myocardial ischemia - stress test/CT angiogra,/invasive coronary angiogram
(which one you use depends on risk of pt)
On which group of patients (high vs low risk) would you perform a stress test/coronary CT angiogram/invasive coronary angiogram?
Intermediate risk pts: stress test/coronary CT angiogram
High-risk pts: invasive coronary angiogram
Review this slide on stress testing
Describe what happens with a coronary angiography/catheterization
Access coronary arteries and visualize where the blockage is (if there is one)
Treat blockage with stents + ballon angioplasty
When would you perform coronary artery bypass grafting (CABG)?
Performed on pts w/
3 vessel disease
Left main coronary artery or proximal LAD disease (+/- multi-vessel disease)
Diabetes (w/ multi-vessel disease)
How do you treat stable angina from coronary artery disease?
- Lifestyle changes
- Medical management: aspirin, statins (lowers lipids), beta blockers (decrease O2 demand), nitrates, antihypertensives, ranolazine, +/- cardiac rehab
- Revascularization
Review this slide on Dx and Rx for CAD
Fill in the blanks
Acute coronary syndrome (ACS) can be grouped into __ and __
Acute coronary syndrome (ACS) can be grouped into N-STEMI and STEMI
(Non-ST elevation ACS and ST elevation ACS)
What are the categories of Non-ST elevation ACS? (2)
Unstable angina
Non-ST elevation myocaridal infarction
Define STEMI
ST-elevation ACS/MI
(see ST-elevations on ECG >> 100% occluded artery)
Most ACS is caused by __
Most ACS is caused by plaque rupture
How do you manage a case of STEMI vs NSTEMI?
**see below**
Basically since w/ STEMI you have 100% occlusion, you’ll want to revascularize and give meds immediately
There are 3 things to look for on an ECG for MI patient. What are they?
ST depressions
ST elevations
Q waves
The presence of ST depressions suggest ___
The presence of ___ indicates transmural ischemia (suggests complete occlusion)
___ indicate myocardial infarction
The presence of ST depressions suggests subendocardial ischemia (suggests partial occlusion)
The presence of ST elevations indicates transmural ischemia (suggests complete occlusion)
Q waves indicate myocardial infarction
***
If you don’t see ST elevations, need to look for ST depressions
Ischemia starts happening from the inside out. When endocardial ischemia starts happening but there hasn’t been full thickness yet, there may be ST depressions
Full thickness involvement of the myocardium results in ST elevations
Review the function of troponin in myocardial contraction
**see below**
Why do you check troponin levels in a suspected MI case?
Troponin is released when myocardium is undergoing necrosis
T/F: Increased troponin levels = MI
Falsehood. ***Troponin is sensitive and specific for ischemia – does NOT always mean someone is having a heart attack***
The first drug given to a pt with ACS is ___
Aspirin, to stop further clotting/irreversibly inhibits platelets
What other medications would you give to a pt with ACS?
(4)
Nitroglycerin (coronary vasodilation)
Clopidogrel/ticagrelor/prasugrel
Statin
IV Heparin/enoxaparin
**see below**
(4) Other drugs that can be considered (outside the ER) for ACS are __
Beta blockers
Calcium channel blockers
ACE inhibitor/ARB
Aldosterone
What would you use to Rx STEMI only?
Fibrinolytics - but they cause very bad bleeding!!
What makes this heart ECG characteristic for STEMI? (recall the 3 things you’re looking for in an ECG for an ACS patient)
ST elevations
ST depressions
Q waves
Review the anatomic territories of the heart/where the ECG leads go
The highest ST elevations are seen in the region ___
The highest ST elevations are seen in the region perfused by the affected artery
Why do you have to respond to a STEMI with urgency? (i.e. within 2 hours)
In the first two hours, the amount of myocardium that can be saved with reperfusion drops significantly.
What factors can kill patients with STEMI:
acutely?
w/in 3-5 days?
chronically?
Acutely: ventricular arrhythmias (VT or V-fib)
W/in 3-5 days: Myocardial rupture (happens due to an strong inflammatory response to dead myocardium)
Chronically: heart failure
Ms. C is a 72-yo woman who started developing nausea, cold sweats, and chest squeezing while chasing her grandchildren. She stopped to rest and wait it out, but then called 911 after 20 minutes with unchanged symptoms. She is now in the ED.
Other than plaque rupture, what 3 other conditions can cause this pts ACS?
Coronary vasospasm (Prinzmetal’s angina/Vasospastic angina)
Plaque erosion
Coronary microvascular disease
Describe Coronary vasospasm
What causes it?
Name some potential causes of coronary vasospasm
How do you Rx this condition?
Coronary vasospasm - angina caused by the arterial smooth muscle abnormally constricting the blood vessel
Causes: endothelial damage (idiopathic), chemical exposure (e.g. adenosine, cocaine), iatrogenic
Rx: nitroglycerin + CCBs
***
The smooth muscle in the artery inappropriately constricts the blood vessel
Cocaine is a strong vasoconstrictor and will cause a STEMI presentation
What is the difference between plaque erosion and plaque rupture?
Plaque erosion has forms a non-obstructive thrombus and is noteable for little holes where part of the plaque breaks through
**typical pt will be a young female smoker**
Describe coronary microvasculature disease
How do you treat this disorder?
Basically damage/disease to small coronary arteries
Rx: statins and blood pressure control
Review the slide below
Statins
ADP antagonist
IV Heparin
Nitroglycerin/Nitrates
Beta blockers
CCBs
ACE inhibitors/ARBs
Aldosterone antagonists
Ranolazine
