Approach to Coronary Heart Disease Flashcards

1
Q

There are 2 groups of risk factors for coronary heart disease, namely___

A

Modifiable and non-modifiable

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2
Q

Name 4 non-modifiable risk factors for coronary heart disease

A

Age

Gender

Race/Ethnicity

Family history of CVD

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3
Q

Name 4 modifiable risk factors for cardiovascular disease

A

Blood pressure

Diabetes

Hyperlipidemia

Smoking

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4
Q

Review this slide on CAD Prevention

A
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5
Q

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?

A

Lifestyle changes

Statins to control lipids

Aspirin to reduce risk of MI **does cause increased risk of GI bleeding**

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6
Q

Define myocardial ischemia

A

Myocardial ischemia: supply-demand mismatch – not enough O2 to the heart to meet its O2 needs

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7
Q

Name 6 conditions that can increase myocardial oxygen demand

A

Increased physical activity

Infection

Severe hypertension (effects on afterload)

Acute congestive heart failure

Blood loss

Pregnancy

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8
Q

Name some possible causes of myocardial ischemia (4)

A

(Obstructive) Coronary artery disease

Coronary vasospasm (Prinzmetal’s angina)

Microvascular heart disease

(Extracardiac problems like pulmonary disease)

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9
Q

Explain this slide

A

Ischemia causes abnormal contraction/relaxation of heart, anaerobic metabolism>>lactate production, ECG changes

Symptoms are the last to arise

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10
Q

Describe a typical angina presentation

A

Pt may describe what feels like indigestion, an chest “tightness/squeezing”, pressure, aching

**pain can radiate to the neck or arm**

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11
Q

Certain groups of people, namely ___, often present with ___, as opposed to typical angina symptoms

A

Certain groups of people, namely women, diabetics and the elderly often present with non-specific symptoms as opposed to typical angina symptoms

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12
Q

3 characteristics of angina are ___

What is the difference between typical and atypical angina?

A

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

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13
Q

Describe the difference between stable vs unstable angina

A

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)

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14
Q

Define a myocardial infarction

A

MI: Irreversible necrosis of the myocardium due to prolonged ischemia

(can cause decreased heart function/unstable rhythms)

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15
Q

For a STABLE patient, how would you perform the diagnosis for angina? myocardial ischemia?

A

For angina - from pts history

Myocardial ischemia - stress test/CT angiogra,/invasive coronary angiogram

(which one you use depends on risk of pt)

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16
Q

On which group of patients (high vs low risk) would you perform a stress test/coronary CT angiogram/invasive coronary angiogram?

A

Intermediate risk pts: stress test/coronary CT angiogram

High-risk pts: invasive coronary angiogram

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17
Q

Review this slide on stress testing

A
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18
Q

Describe what happens with a coronary angiography/catheterization

A

Access coronary arteries and visualize where the blockage is (if there is one)

Treat blockage with stents + ballon angioplasty

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19
Q

When would you perform coronary artery bypass grafting (CABG)?

A

Performed on pts w/

3 vessel disease

Left main coronary artery or proximal LAD disease (+/- multi-vessel disease)

Diabetes (w/ multi-vessel disease)

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20
Q

How do you treat stable angina from coronary artery disease?

A
  1. Lifestyle changes
  2. Medical management: aspirin, statins (lowers lipids), beta blockers (decrease O2 demand), nitrates, antihypertensives, ranolazine, +/- cardiac rehab
  3. Revascularization
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21
Q

Review this slide on Dx and Rx for CAD

A
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22
Q

Fill in the blanks

A
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23
Q

Acute coronary syndrome (ACS) can be grouped into __ and __

A

Acute coronary syndrome (ACS) can be grouped into N-STEMI and STEMI

(Non-ST elevation ACS and ST elevation ACS)

24
Q

What are the categories of Non-ST elevation ACS? (2)

A

Unstable angina

Non-ST elevation myocaridal infarction

25
Q

Define STEMI

A

ST-elevation ACS/MI

(see ST-elevations on ECG >> 100% occluded artery)

26
Q

Most ACS is caused by __

A

Most ACS is caused by plaque rupture

27
Q

How do you manage a case of STEMI vs NSTEMI?

A

**see below**

Basically since w/ STEMI you have 100% occlusion, you’ll want to revascularize and give meds immediately

28
Q

There are 3 things to look for on an ECG for MI patient. What are they?

A

ST depressions

ST elevations

Q waves

29
Q

The presence of ST depressions suggest ___

The presence of ___ indicates transmural ischemia (suggests complete occlusion)

___ indicate myocardial infarction

A

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

30
Q

Review the function of troponin in myocardial contraction

A

**see below**

31
Q

Why do you check troponin levels in a suspected MI case?

A

Troponin is released when myocardium is undergoing necrosis

32
Q

T/F: Increased troponin levels = MI

A

Falsehood. ***Troponin is sensitive and specific for ischemia – does NOT always mean someone is having a heart attack***

33
Q

The first drug given to a pt with ACS is ___

A

Aspirin, to stop further clotting/irreversibly inhibits platelets

34
Q

What other medications would you give to a pt with ACS?

(4)

A

Nitroglycerin (coronary vasodilation)

Clopidogrel/ticagrelor/prasugrel

Statin

IV Heparin/enoxaparin

**see below**

35
Q

(4) Other drugs that can be considered (outside the ER) for ACS are __

A

Beta blockers

Calcium channel blockers

ACE inhibitor/ARB

Aldosterone

36
Q

What would you use to Rx STEMI only?

A

Fibrinolytics - but they cause very bad bleeding!!

37
Q

What makes this heart ECG characteristic for STEMI? (recall the 3 things you’re looking for in an ECG for an ACS patient)

A

ST elevations

ST depressions

Q waves

38
Q

Review the anatomic territories of the heart/where the ECG leads go

A
39
Q

The highest ST elevations are seen in the region ___

A

The highest ST elevations are seen in the region perfused by the affected artery

40
Q

Why do you have to respond to a STEMI with urgency? (i.e. within 2 hours)

A

In the first two hours, the amount of myocardium that can be saved with reperfusion drops significantly.

41
Q

What factors can kill patients with STEMI:

acutely?

w/in 3-5 days?

chronically?

A

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

42
Q

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?

A

Coronary vasospasm (Prinzmetal’s angina/Vasospastic angina)

Plaque erosion

Coronary microvascular disease

43
Q

Describe Coronary vasospasm

What causes it?

Name some potential causes of coronary vasospasm

How do you Rx this condition?

A

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

44
Q

What is the difference between plaque erosion and plaque rupture?

A

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**

45
Q

Describe coronary microvasculature disease

How do you treat this disorder?

A

Basically damage/disease to small coronary arteries

Rx: statins and blood pressure control

46
Q

Review the slide below

A
47
Q

Statins

A
48
Q

ADP antagonist

A
49
Q

IV Heparin

A
50
Q

Nitroglycerin/Nitrates

A
51
Q

Beta blockers

A
52
Q

CCBs

A
53
Q

ACE inhibitors/ARBs

A
54
Q

Aldosterone antagonists

A
55
Q

Ranolazine

A