Atherosclerosis/ PVD/ CHD Flashcards
Characterized by lipid deposition, fibrosis, calcification and plaque formation in large and medium vessels
Atherosclerosis
Atherosclerotic heart disease is the most common cause of..
Cardiovascular death and disability
Men are more affected by atherosclerosis 4:1 until age….
70, where the ratio becomes 1:1
Smoking and elevated cholesterol levels (greater than 200) due to diet or familiar dyslipidemias…
RISK FACTORS** for atherosclerosis
CRP level with atherosclerosis
Increased!
Inflammation thought to play a role*
Managent of ______ and _______ are essential to the control of vascular disease
Blood glucose
Blood pressure
Smoking cessation!!**
Control of HTN, tx of diabetes, tx of dyslipidemia
Low BMI, regular exercise
Modified diet..low saturated, low fat, low cholesterol
Treatment for atherosclerosis
characterized by insufficient oxygen supply to cardiac muscle, most commonly caused by atherosclerotic narrowing
Ischemic heart disease
Risk factors: HTN, diabetes, increased age, tobacco use, family hx (CV dz in males under 55, females under 65), physical inactivity, obesity, dyslipidemias, ETOH
Ischemic heart disease
Abdominal obesity Triglycerides above 150 HDL less than 40 (men) or 50 (women) Fasting glucose higher than 110 HTN
If a pt has at least 3 of these, MAJOR CONTRIBUTOR TO CORONARY HEART DISEASE***
Pts with... Cerebrovascular disease Peripheral artery disease Abdominal aorta aneurysm Chornic/end stage renal dz Diabetes
**HIGH RISK! for coronary heart disease
_____ use is associated with MI and infarction secondary to vasospasm. Pts often much younger than typical cardiac patients
Cocaine
What causes angina pectoris?
Ischemia
characterized by paroxysmal chest “squeezing” or pressure, often accompanied by a sensation of smothering and fear of impending death
Angina
Predictably exacerbated by physical activity and relieved by rest
Stable angina
Caused by vasospasm at rest, with preservation of exercise capacity
Prinzmetal (variant) angina
Closely related to non-ST segment elevation myocardial infarction (NSTEMI) and is a common manifestation of cardiovascular disease
Unstable angina
- angina at rest
- new onset of angina symptoms
- increasing pattern of pain in previously stable patients
Common presentations of unstable angina
What is the most common presentation of unstable angina?
REST PAIN (ANGINA)
What should you suspect when the patients pain is less responsive to Nitro, lasts longer and occurs at rest or with less exertion than previous episodes of angina?
Unstable angina
_______ sign, which is a clenched fist over the sternum and clenched teeth when describing chest pain, may be seen in patients with ischemia
Levine
Midsternal but may radiate to jaw, shoulders, arms, wrists, back of neck or any combo of these
Angina
Who presents more with right shoulder and back pain radiation?
Women
Stable angina usually lasts less than..
3 minutes
Angina pectoris lasting longer than 30 minutes suggest….
Unstable angina, MI, or another diagnosis
The pain of stable angina can be significantly relieved by..
Sublingual nitro
How often can you use sublingual nitro?
Every 5 minutes up to 3 times
if pain is not completely relieved after these 3 doses, unstable angina, MI or other diagnosis likely!!!!!**
Horizontal or downsloping ST segment depression on ECG is amon the most sensitive clinical signs of..
An anginal attack
ECG will normal in about ____% of patients with angina
25
What is he most useful and cost effective, non invasive test to look at angina?
Exercise stress testing
An ST segment depression of 1 mm (0.1 mV) during an exercise stress test…
POSITIVE result!
If a person cannot exercise, what is an alternative way of stress testing?
Pharmacologic stress testing
Myocardial perfusion scintigraphy, radionuclide angiography, and stress echocardiography can help determine…
Extent and location of ischemia
What is the definitive diagnostic procedure to diagnose ischemic heart disease (but should be used selectively because of cost and invasiveness)**
Coronary angiography!***
Long acting nitrate should include a daily _________ hour treatment free interval to prevent drug tolerance
8-10 hr
Headache, nausea, light headedness, hypotension
ADVERSE effects of Nitro
This class of drugs prolongs life in patients with coronary disease and are FIRST LINE THERAPY** FOR CHRONIC ANGINA..they are indicated for treatment of ischemic symptoms
Beta blockers
This class of drug are useful in the treatment of UNSTABLE ANGINA, particularly with patients who have symptoms of heart failure
ACE inhibitors
This class of drug decreases cardiac muscle oxygen demand but are considered alternative therapy. They re indicated for treatment of ischemic symptoms in patients for whom Beta-blockers are contraindicated or have been maximized
Ca channel blockers
Diagnosis of acute MI is based on evolution of..
Cardiac biomarkers
1/5 of patients with acute MI will die, usually from..
Ventricular fibrillation
before reaching a hospital
Non traumatic chest pain is the most common presenting factor in
Acute coronary syndrome
Crushing retrosternal pain or pressure; heaviness or tightness; unexplained indigestion; epigastric pain
MI
Denotes formation of fibro-fatty lesions in the intimal lining of large and medium sized arteries
Atherosclerosis
Oxidized LDL within a macrophage helps make up..
Atherosclerosis
if the plaque ruptures or fissures…circulating blood gets exposed to contents of the plaque (ie collagen), which is very ….
Thrombogenic
a HUGE risk factor for large, medium and SMALL vessels
Diabetes
if small vessels involved, arteriosclerosis
Total cholesterol, LDL, HDL, triglycerides Hypertension Cigarette smoking Diabetes**** Fam hx in first degree relative (male under 55, female under 65) Male gender Age (men over 45, women 55) Hypoestrogenemia Physical inactivity CENTRAL OBESITY Elevated plasma homocysteine levels Elevated CRP
Risk factors for Atherosclerosis**
CRP under 1 mcg/ml
low risk for atherosclerosis
CRP 1-3 mcg/ml
intermediate risk for atherosclerosis
CRP over 3 mcg/ml
high risk for atherosclerosis
made by the endothelial cells and is PROTECTIVE: vasodilator with anti-atherosclerotic properties
Nitric oxid (NO)
What does smoking do to NO levels
Decreased or absent production of NO in smoking (HTN and diabetes also)
Risk factor modification- smoking cessation, antihypertensive rx, treatment of dyslipidemia, estrogen replacement, glucose regulation, regular exercise, aspirin prophylaxis
(NO HX OF DISEASE!!)
Primary prevention of atherosclerosis
Delay or abort disease progression in patients with documented CHD; risk factor modification
(DO have HX of dz, now trying to slow progression!)
Secondary prevention
if we lower lipids, we can prevent
Atherosclerosis
What drug is ALWAYS used in secondary prevention. If you have atherosclerosis, you WILL be on this (unless contraindicated)
Aspirin
Increased LDL increases risk of…
CAD
PAD
Stroke
How long without oxygen until cells begin to die?
10-20 minutes
Temporary reduction of blood flow to an organ, potentially reversible
Ischemia
A significant ________ ________ can lead to an in imbalance between blood supply and demand. The reduction in blood flow limits the normal increase in perfusion when there is increased demand (activity, exercise)
Coronary stenosis
Significant left ventricular hypertrophy
Aortic stenosis
Tachyarrhythmias
All increase O2 demand, putting patient at higher risk of….
Myocardial Ischemia
False negative stress tests are common in what group of people?
Women
bc they are more likely to have single vessel dz, which may not show up on stress test
Chest discomfort- heaviness, tightness, pressure, squeezing, burning, aching or choking; may not be described as “pain”. Classic symptoms of…
Reversible myocardial ischemia
Precipitating factors include..Exertion, exercise, emotional duress, cold weather, sexual activity, cigarette smoke, large meals.
*reproducible with activity
Stable angina
Xanthelasma, xanthomas- hyperlipidemia.
Funduscopic abnormalities: A-V nicking, hypertensive, diabetic changes
May be seen in PE in patients with..
Angina
sharply demarcated yellowish deposit of fat underneath the skin, usually on or around the eyelids. While they are neither harmful nor painful, these minor growths may be disfiguring and can be removed.
Xanthelasma
an irregular yellow patch or nodule on the skin, caused by deposition of lipids.
Xanthoma
ST segment depression and/or T wave changes are characteristic of..
Ischemic changes
Most useful non invasive test for pt with angina?
Exercise stress test
What is the GOLD STANDARD** for assessing severity of coronary artery disease?
Coronary angiography
used in conjunction with patients symptoms and extent of ischemia, via stress testing
Which vessels do Nitro effect?
Healthy veins!..healthy vessels will dilate because nitro relaxes smooth muscle
**nitro will not dilate diseased vessels
Venodilates, reducing LV volume (preload), which decreases oxygen consumption
Nitro
This class of drug prevents angina by decreasing myocardial consumption of oxygen, decreases HR, contractility and BP *improves exercise tolerance and reduces symptoms
Beta receptor blockers
Reduce mortality rate post MI
Reduce mortality rate in patients with heart failure
Beta blockers
Decrease myocardial O2 requirements by dilating peripheral arteries/arterioles, reducing BP, LV wall stress and after load!
*result is a lower myocardial O2 consumption
Calcium channel blockers
Do we use long or short term acting calcium channel blockers?
LONG!
short term can cause significant swings in BP
Dihydropyridine
Diltiazem
Verapamil
Ranolazine
Ca channel blockers
Which is the weakest vasodilator of all Ca channel blockers?
Verapamil
Avoid calcium channel blockers in which type of people?
THOSE WITH HEART FAILURE!**
these drugs decrease contractility
Has unique MOA of decreasing late Na current, decreasing intracellular Ca.
*increased QT interval without causing arrhythmias
Ranolazine
**ALL PATIENTS WITH CHD SHOULD BE ON….
Anti platelet drugs
decreases incidence of subsequent MI, cardiac death
Inhibits ADP-induced platelet aggregation; option if ASA is contraindicated
Clopidogrel
Patients with unacceptable symptoms in spit of optimal medical treatment
Revascularization
3 vessel CAD, especially w LV dysfunction
Left main or left main equivalent dz
Pt may be candidate for…
CABG
Indicated primarily for single or 2 vessel disease
*low morbidity, mortality and rapid recovery
Angioplasty
Metal scaffolding devices that prevent elastic recoil
Stents
Saphenous veins and internal mammary arteries are commonly used in…
Coronary bypass surgery
Which surgical procedure has the best long term results of potency and flow
Coronary artery bypass
Often induced by exposure to cold, emotional stress, meds, drugs
**chest discomfort AT REST accompanied by ST segment elevation and arrhythmias
Coronary vasospasm
may progress to MI if spasm does not resolve
2 drugs that can prevent spasm or reverse spasm
Ca channel blockers
Nitrates
Coronary ischemia as a result of vasospasm
Symptoms at rest, esp in early AM
Women>men..AKA variant angina
Coronary arteriography often identifies normal appearing vessels- vasospasm can be induced pharmacologically in cardiac cath lab.
Prinzmetal’s Angina
There is considerable overlap between unstable angina and _____. The pathology is nearly identical.
NSTEMI
Difference between NSTEMI and unstable angina (UA)?
NSTEMI has abnormal cardiac markers (CK MB or troponins) that indicate cell necrosis
(NO CELL NECROSIS HAS OCCURRED YET IN UNSTABLE ANGINA)
Pathology: complex coronary lesions- stenosis with placque rupture, hemorrhage, thrombus.
Prognosis (untreated): High risk of developing MI in following days/weeks.
Unstable angina
Tx: full anticoagulation and anti platelet therapy
Unstable angina
Prolonged ischemia resulting from inadequate tissue perfusion leading to tissue necrosis and myocardial cell death.
Myocardial infarction
Atypical presentations of MIs (often painless infarcts) in…
Elderly
Diabetics
Women
- Pulse and BP variable and change frequently; hemodynamic instability common.
- Irregularities in pulse may represent arrhythmias.
- Lungs usually clear unless heart failure present.
MI
- S4 gallop in most; S3 unusual unless CHF.
- Transient apical mitral regurgitant murmurs usually represent papillary muscle dysfunction.
- Extremities: cyanosis/cold indicate low CO.
MI
- S4 gallop in most; S3 unusual unless CHF.
- Transient apical mitral regurgitant murmurs usually represent papillary muscle dysfunction.
- Extremities: cyanosis/cold indicate low CO.
MI
If ischemia to papillary muscle during MI, what may happen?
Mitral regurg
enzyme released from damaged skeletal muscle and heart. Always elevated with MI.
CK (creatine kinase)
Cardiac specific troponin will rise within about..
4-6 hours
peak in 8-12!
CKMB levels increase with..
Myocardial damage
Pts with ST segment depression are initially considered to have either…
Unstable angina OR
NSTEMI
If deciding between NSTEMI or unstable angina…and cardiac biomarkers become elevated. What is your dx?
NSTEMI
ST elevation of greater or equal to 1 mm in 2 contagious leads
**must be readily identified!!
STEMI
All patients with acute coronary syndrome with ongoing discomfort should receive…
IV fluids
Oxygen
Nitro
An oral ________ should be initiated within the first 24 hours for all patients with ACS, in the absence of contraindications (heart failure, bradycardia, heart block)
Beta blocker
If a patient has heart failure and cannot take a beta blocker, which medication should he/she go on within the first 24 hours of ACS
ACE inhibitor
Acute STEMI patients need to undergo immediate thrombolytic therapy to promote re-perfusion. Which drugs can you give?
tPA
Aspirin
Clopidogrel
Thrombolytic therapy within the first __ hours of the onset of pain reduces mortality and limits size of infarction
3
What is the time limit goal of opening the artery after presenting to the hospital?
90 minute “door to balloon time”
You want to open the artery how many hours after onset of symptoms
3 hours
Infarcts characterized by by prolonged ischemia, small elevations of cardiac markers and EKG changes showing ST depression and/or T wave inversions.
NSTEMI
Considered “incomplete infarcts” with lower initial mortality but high risk of re-infarction and with high mortality.
NSTEMI
WHICH CLASS OF DRUGS DO YOU ALWAYS AVOID AFTER AN MI???****
NSAIDs
associated with re-infarction, hinders healing***
