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Clin Med I > CAD > Flashcards

CAD Flashcards

1
Q

Coronary heart disease or atherosclerotic coronary artery disease (CAD) is ____________ of the small blood vessels that supply blood and oxygen to the heart

A

narrowing

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2
Q

Patho phys of atherosclerosis: ….

A

endothelial dysfunction allows LDL to be pulled into the artery wall > LDL is oxidized and taken up by macrophages into the subendothelial space = foam cells > cytokines are release and smooth muscle cells migrate to the lesion > smooth muscle cells release collagen > fibrous cap forms over the lesion

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3
Q

CAD pathophys:
Atherosclerotic plaques may:

  1. Remain stable
  2. Progress rapidly
    2a) …
    2b) …
  3. Rupture
    3a)…
A
  1. Remain stable
  2. Progress rapdily
    - stable angina when increased oxygen demand
    -stenosis to cause rest anginal symptoms
  3. Rupture
    causing thrombosis
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4
Q

CAD Risk factors: (10)

A

fam hx
male
hyperlipidemia
DM
HTN
Inactivity
Abdominal obesity
cig smoking
diet low in fruits/veggies
heavy alcohol use

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5
Q

What are primary and secondary preventions for CAD?

A

smoking cessation
weight loss
exercise
prevention and control of HTN
statin therapy
ACEI in DM
antiplatelet therapy (in secondary)

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6
Q

Angina is chest pain of cardiac origin caused by oxygen ___________ and _________ mismatch. There is _____________ pain and the most common cause is ____________________ heart disease.

A

supply, demand
ischemic
atherosclerotic

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7
Q

What are the symptoms of angina?

A
  1. occurs during activity, relieved with rest
  2. pain = tightness, burning, squeezing, choking. Not spasmodic
  3. Location = mid sternal/left of sternum
  4. radiate to L shoulder/arm, jaw, neck, back
  5. Duration = <3 min no longer than 20-30
  6. Relieved with rest/nitroglycerin
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8
Q

What are the signs of angina?

A
  1. pts often have their clenched fist over sternum
  2. elevated BP
  3. Tachy secondary to pain
  4. CV exam listen for AS/AR
  5. assess for signs of diseases that may be related to CAD (neuropathy in DM, HTN, PAD)
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9
Q

What are the atypical angina symptoms of women/pts

A

“anything with extertion”
nausea, back pain, epigastric pain, palpitations

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10
Q

Angina work up
What blood work?
What imaging?

A

BW: cardiac enzymes, CBC to r/o anemia, lipids, glucose/HbA1C

Imaging: ECG (resting ECG without pain is normal)
anginal episode: horizontal/downslopping ST segment depression that resolves when ischemia resoles
Severe cases: ST elevation/T wave inversion

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11
Q

Stable Angina

A

predictable
“ i can always walk 3 blocks, then i get pain”
can get progressively worse over time - SLOWLY

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12
Q

Unstable Angina

A

unpredictable
“i used to be able to walk 3 blocks, now i can only walk 10 ft before i get pain”
angina at rest
rapid worsening of once stable symptoms

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13
Q

Stress Test Indications:
1
2
3
4
5
6

A

To confirm the diagnosis of angina
To determine the severity of limitation of activity due to angina
To evaluate responses to therapy/revascularization
To evaluate functional ability after MI
Pre-op clearance
Occupational evaluation

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14
Q

A positive stress test is _________________

A

1mm ST depression

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15
Q

How does a nuclear stress test give more information than the exercise ECG alone? In what case should this be done?

A

It shows the localized region of the ischemia better. This should be done if the patient has baseline ECG abnormalities

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16
Q

What does a stress echocardiography look for?

A

looks for exercise induced segmental wall motion abnormalities that may represent ischemia

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17
Q

A holter monitor is not typically used for the detection of ______________ rather it is more for _______________. The patient wears this for 24-48 hours during normal activity and is monitored continuously for ECG changes.

A

ischemia, dysrythmias

18
Q

A ________________ is the definitive diagnostic procedure for CAD. It offers the best evaluation of ___________________ function. It is both, diagnostic and therapeutic. Narrowing of _______________ is considered significant

A

cardiac cath
left ventricular
> 50%

19
Q

What is the treatment for an acute angina attack?

A
  1. Rest
  2. Nitroglycerin
    -acts in 1-2 minutes
    -reduces preload/afterload, decreases tone, lower oxygen demand
    -sublingual- 1 tab every 3-5 minutes. Can repeat 3 times.
20
Q

How do you prevent angina?

A
  1. Nitro prior to strenuous activity
  2. BB FIRST LINE FOR ANGINA
  3. Long acting nitrates
  4. Ranexa
  5. CCB- NOT FIRST LINE
  6. ALL PTS SHOULD BE ON ANTIPLATELETS (aspirin, clopidogrel, brilinta)
21
Q

What are the indications for revascularization for angina? Which types of pts may not receive a significant benefit to revascularization?

A
  1. unacceptable symptoms despite medical therapy
  2. left main stenosis >50%
  3. 3 vessel disease with LV dysfunction
  4. unstable angina
  5. Post MI with continuing angina

Pts who have mild to moderate CAD and limited symptoms

22
Q

Percutaneous coronary intervention (PCI) (balloon angioplasty and coronary stenting) opens up ______________ It is either bare metal stents or drug-eluting stents.
_________________ reduce the risk of re-stenosis
Antiplatelet therapy after stenting decreases the risk of _______________ (aspirin + clopidogrel)

Continue ____________ for at least 1 yr post stenting

A

stenotic coronary arteries
drug-eluting stents
acute thrombosis
P2Y12

23
Q

What is coronary artery bypass grafting CABG? Grafts are typically harvested from the _____________ OR the _____________ OR _____________

A

uses healthy blood vessels from another part of the body to bypass stenosed areas of the coronary arteries to improve blood flow and oxygenation

internal mammary arteries, saphenous vein, radial artery

24
Q

Patients with left main disease or 3 vessel disease, with reduced EF and DM pts have better outcomes with _______________

A

CABG

25
Q

Coronary vasospasm aka Prinzmetal (variant) angina is chest pain caused by ___________________. Often it affects ____________ and occurs in the _______________. The EKG changes are consistent with ___________________. Treat with ___________ or ___________. Cocaine can also cause coronary artery vasoconstriction

A

coronary vasocontriction.
young adults
early morning
ischemia
nitrates, CCB

26
Q

Acute coronary syndrome is the spectrum of ___________ cardaic ischemia. Unstable angina (may be reversible) to MI (irreversible). Classified based on ECG findings:
1.
2.

A

unstable.
1. STEMI
2. NSTEMI

27
Q

What are the signs and symptoms of acute coronary syndrome?
The pain often occurs___________. Patients may present saying that “it just feels different”.

How do patients often appear?

A

substernal CP that may radiate to the jaw, left shoulder, arm, back, dyspnea, nausea, vomiting, diaphoresis, CHF, sudden cardiac death.

at rest

Pts often appear anxious, brady/tachy, elevated BP/low BP, JVD, new murmur, papillary muscle dysfunction, cyanosis

28
Q

MI is the rise of cardiac biomarkers with at least one value above the __________percentile of the upper reference limit together with evidence of ______________ with at least one of the following:

A

99th
myocardial ischemia
symptoms of ischemia, ECG changes of new ischemia, new Q waves, or imaging evidence of new loss of viable myocardium or new wall motion abnormality.

29
Q

MI lab findings:
1.
2
3.
4.

A
  1. CK-MB (creatine kinase myocardial band)
    rise within 4-8 hrs, peaks 12-20 hours
    returns to normal within 2-3 days
  2. Troponin
    rise within 4 hours
    return to normal within 7-14 days
  3. CBC to assess for anemia
  4. BMP to assess renal function for drug dosing
30
Q

MI ECG Patterns:
1.
2.
3.
4.

A

ST elevation = infarction
ST depression = ischemia
Q waves appear at the site of previous infarction
T wave inversion = recent MI or ischemia

31
Q

STEMI

A

transmural infarction of the myocardium
full thickness of the muscle
usually a complete occlusion of a main artery
ST elevation on ECG
REQUIRES IMMEDIATE PCI OR THROMBOLYTICS

32
Q

NSTEMI (5)

A

not a full thickness infarction
partial or very distal blockage of an artery
cardiac enzymes will be elevated
may see ST depression on ECG
**NO THROMBOLYTICS- risk>benefit **

33
Q

STEMI: Classic evolution of ECG changes involves…..

A

peaked T waves, ST elevation, to q wave development, to t wave inversion
q waves dont occur 30-50% of the time

34
Q

STEMI management

A

all pts with suspected MI should receive aspirin immediately- chew
reperfusion therapy for all pts who seek medical attention within 12 hours of onset of symptoms
-primary PCI or fibrinolytic therapy
-PCI is preferable if FMC to balloon time is <90 min

35
Q

Management of all ACS

A
  1. MONA: morphine, oxygen, nitroglycerin, aspirin
  2. P2T12 inhibitor > clopidogrel
  3. Anticoag- cont until PCI
  4. BB IF NO ACUTE HF
  5. ACEI - esp in DM or LVEF <40%
  6. statin (atorvastatin 80 mg regardless of LDL)
  7. ambulation after 24 hours
36
Q

For STEMI management, if patients receive fibrinolytic therapy, they should be transferred for ____________ within 24 hours.

Risks of fibrinolytic therapy:
1.

A

PCI

  1. bleeding
37
Q

What are the absolute contraindications for fibrinolytic therapy?

A

history of hemorrhagic CVA
CVA within a year
known intracranial neoplasm
known internal bleeding
suspected aortic dissection

38
Q

What are the relative contraindications for fibrinolytic therapy?

A

BP > 180/110
Other brain pathology
Major surgery within 3 weeks
Recent trauma or internal bleeding (2-4 weeks)
CPR > 10 minutes
Active PUD
Pregnancy
Hx of severe HTN
Current use of anticoagulant with INR > 2

39
Q

Indications for Cardiac Catheterization in a pt. with NSTEMI/UA

A

Recurrent angina/ischemia at rest or with low level activity
Elevated troponin
ST-segment depression
Recurrent ischemia with heart failure
High-risk stress test results
EF < 40%
Hemodynamic instability
Sustained V-tach
PCI within 6 months
Prior CABG

40
Q

What are complications of MI?

A
  1. Post infarction ischemia
  2. Arrythmia
    - sinus brady, SVT (less serious)
    -ventricular arrythmias- serious
  3. Myocardial dysfunction
  4. Mechanical defect (papillary muscle rupture/dysfunction)
  5. Myocardial rupture
  6. LV aneurysm
  7. Dressler syndrome -pericarditis
  8. Mural thrombus

Clin Med I (20 decks)

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