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CMT-uno > CAD > Flashcards

CAD Flashcards

1
Q
A
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2
Q

Stable Angina

general

A

predictable
if i excercise i get chest tightness

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3
Q

Unstable Angina

general

A

increase in durations, onset, or intensity

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4
Q

NSTEMI Angina

General

A

not showing on ECG

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5
Q

Get loading dose on all of which kind of med?

Assessed by?

A

Antiplatelet meds which can be assessed via PRU value

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6
Q

What med is preferred for DM pts with MI

A

Ticagrelor over Clopidogrel

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7
Q

Coronary Vasospasm

general

AKA, age, gender, induced by

A

AKA Prinzmetal’s or Variant Angina

Angina pain usually at rest (often b/w midnight-early morning) with no change in exercise function
More common in women < 50
May be induced by exposure to cold, emotional stress, or vasoconstricting medications
Usually involves right coronary artery (RCA)

woman watching tv or shoveling snow

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8
Q

Coronary Vasospasm

Dx

A

EKG
ST-segment elevation rather than depression

Diagnostics
Coronary angiography: no lesions with poss spasm; may give intracoronary nitroglycerine/ CCB

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9
Q

Coronary Vasospasm

Treatment
What do you avoid?

A

Calcium channel blockers (daily) and/or nitrates
Avoidance of nicotine, caffeine, cocaine, ergot’s

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10
Q

38 yo female presents in follow up after ER visit for chest pain. She had negative work up at hospital including LHC (left heart catherization) which revealed no CAD. She continues to have episodes of acute chest pressure 10-15 minutes in am while watching tv and smoking. No trigger or modifier.

A) verapamil ( calcium channel blocker)
B) aspirin 81 mg daily
C) atorvastatin 20 mg daily ( statin)
D) SL nitroglycerine prn

A

A: verapamil

resting sx..
put her on daily ca channel blocker

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11
Q

Non modifiable RF for CAD

A

Family hx
Age
Sex

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12
Q

Stable Angina Pectoris
general

A

Chest wall discomfort precipitated by stress or exertion and relieved by rest or nitrates

Occurs whenever myocardial oxygen demand exceeds oxygen supply

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13
Q

stable angina

Sx

A

Sx’s are EXERTIONAL and RELIEVED WITH REST
< 20 minutes duration

Pt’s c/o pressure, pain, squeezing, tightness, heaviness…

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14
Q

Stable angina

May present with atypical symptoms

what are they and who are affected

A

Dyspnea, indigestion, arm or jaw pain, exertional SOB, nausea, diaphoresis, fatigue, or all of the above with NO PAIN

presents in DM and females

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15
Q

Which of the following suggests ischemic etiology of chest pain?
A) exertional pain relieved with rest or nitrates
B) positional pain
C) post prandial burning relived with belching/tums
D) pain that is reproducible on physical exam
E) pain that is associated with cough or deep inspiration

A

A: describes angina
B: pericarditis, pleurisy
C: reflux
D: musculoskeletal
E: PE, pericarditis

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16
Q

Stable Angina Pectoris

labs and ECG

A

Labs
Negative troponin/CK-MB

EKG
Resting EKG is often normal
Possible Ischemic changes: ST depression, T wave flattening or inversion
During anginal episodes: horizontal or down sloping ST-segment depression that reverses after the ischemia disappears

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17
Q

Unstable Angina & NSTEMI

TX in hospital

A

MONA-BAS

Morphine
Oxygen
Nitrates
Aspirin
Beta blocker
Antiplatelet
Statin

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18
Q

STEMI

general

A

EMERGENCY!!!

Acute episode of chest discomfort that results in most cases, from an occlusive coronary thrombus at the site of a preexisting atherosclerotic plaque

Other causes: prolonged vasospasm, inadequate myocardial blood flow, emboli, coronary dissection, cocaine

COMPLETE LOSS OF FLOW

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19
Q

STEMI

Sx

A

Symptoms: depends on severity of infarct
Sudden death and early arrhythmias
50% of deaths occur before the patients arrive at the hospital
Death is presumably caused by ventricular fibrillation

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20
Q

STEMI

Dx Labs

A

Positive troponin I/T or CK-MB

each should be pos as early as 4-6 hours and abnormal by 8-12 hours

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21
Q

STEMI

Tending enzymes

A

get 3 sets every 8 hours

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22
Q

A patient presents to the ED with CP. ECG reveals ST elevation and initial troponin is normal. Which of the following is indicated?
A. administer nitrates
B. initiate MONA- B and repeat troponin in 6 hours
C. coronary revascularization
D. start heparin drip

A

C. coronary revascularization

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23
Q
A

Nitro, dont wanna bottom out their pressure

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24
Q

STEMI

Reperfusion therapy

A
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25
Q

RF for CAD

A

HTN, HLP, CVA, PAD, DM, tobacco, family hx, obesity, sedentary lifestyle

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26
Q

Primary Prevention

A

Do not have a diagnosis of ASCVD but have risk factors

Prevent the FIRST event
Lifestyle interventions
No smoking
Daily exercise
Target BMI

Target risk reduction
Bp goal < 130/80
LDL goal < 100
A1c goal < 7.0

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27
Q

Secondary prevention

A

Have a diagnosis of ASCVD or equivalent:
DM
PAD
CVA/TIA
CKD

Prevent a SECOND event

Target risk reduction
Bp goal < 130/80
LDL goal < 55mg/dL
A1c goal < 7.0

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28
Q

Medications for secondary prevention

If DM?
If CKD?

A

*Medications
Antiplatelet (aspirin)
Statin (moderate or high intensity)
If DM: GLP-1
If CKD: ACE/ARB, SGLT2-inhibitor

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29
Q
A
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30
Q

Stable angina

Lab and ECG

A

no troponin elevation

no ECG acute changes

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31
Q

Stable angina

Tx (3)

A

BB, ASA, Statin

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32
Q

Unstable Angina

clin presentation

A

Sx at rest

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33
Q

Unstable angina

Tx

A

cath lab, hospitalization

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34
Q

NSTEMI

Labs and ECG

A

+ troponin elevation

ST depression or other changes

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35
Q

NSTEMI

Tx

A

BB,ASA, Statin
+/- ischemia assessment; hosp

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36
Q

STEMI

Lab and ECG

A

troponin elevation

ST elevation

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37
Q

STEMI

Tx

A

Cath lab (90 min door: balloon time)/reperfusion
BB, ASA, Statin ACE; hosp

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38
Q

Stable Angina

most commonly caused by? other causes?

A

Most commonly caused by atherosclerotic obstruction of one or more coronary arteries

Other causes: Coronary artery vasospasm, congenital anomalies, emboli, arteritis, LVH, cocaine, and dissection

39
Q

Stable Angina

Tests to Evaluate Perfusion

A

Stress test w or w/o imaging ( myocardial perfusion scan or stress echo)
Cardiac CTA

40
Q

Stable angina

First line Tx
To reduce risk

A

reduce risk of further attacks

Beta blocker
Aspirin or clopidogrel

41
Q

stable angina

Secondary Tx (3)

A

long lasting nitrates
Ranolazine
Calcium channel blockers

42
Q

Angina

non pharm ways to reduce risk

A

**risk reduction: stop smoking, BP control, lipid control, DM control, weight reduction etc

43
Q

Which of the following medications has been shown to improve cardiac outcomes in patient w/CAD?
A) beta blockers
B) calcium channel blockers
C) nitrates
D) ranolazine

A

A- beta blockers

44
Q

stable angina

the most common noninvasive testing in evaluating for inducible ischemia stable patient

A

Exercise ECG

Contraindicated if unstable angina, active ECG changes, aortic stenosis

45
Q

stable angina

If patient has a negative stress test and resolution of symptoms on Rx therapy ( asa/statin/bb) then..?

A

continue monitoring and consider other etiology

46
Q

stable angina

If patient has a negative stress test and ongoing symptoms refractory to medical therapy, consider

A

cath

47
Q

stable angina

If patient has a positive stress test proceed with

A

cath

48
Q

stable angina

is stable a part of ACS?

A

NO

49
Q

stable angina

typically lasts

A

2-15 minutes

50
Q

Which treatment for stable angina is INCORRECT?
A) sl ntg prn
B) diltiazem 120 mg po daily ( CCB)
C) metoprolol 25 mg daily
D) asa 81 mg daily

A

B- you want beta blocker not calcium channel blocker

51
Q

differece in troponin with Unstable angina and NSTEMI?

A

angina= negative troponin

NSTEMI= positive troponin

52
Q

Fibrinolytic therapy has been found to be harmful for

A

NON STEMI

53
Q

If hypertensive what is BP BB of choice?

A

labetalol IV- most BP reduction

54
Q

A patient presents to ED for CP and is diagnosed with NSTEMI. Which therapy is contraindicated?
A) Aspirin
B) Morphine
C) Nitroglycerine
D) Beta blocker
E) fibrolytics

A

E) fibrolytics

55
Q

Unstable angina and NSTEMI

Risk-Stratification Tools
HEART Score

A

predicts 6 week risk adverse event

Low risk (0-3), Moderate risk (4-6), High risk (7-10)

56
Q

Unstable angina and NSTEMI

Risk-Stratification Tools used to evaluate patients long term risk post ACS

A

GRACE risk score and TIMI risk score

57
Q

Unstable angina and NSTEMI

Tx when discharged

A

Beta Blocker
Aspirin +/- antiplatelet ( 1 year)
Statin
Cardiac rehab

58
Q

Unstable angina and NSTEMI

hosptal admission Tx

A

Medical Therapy (for all)
MONA-BAS
Antiplatelet agents & Anticoagulants
+/- cath

59
Q

68 y/o WF presents in office as work in new patient. No previous PMHx. +fam hx CAD. + tobacco use. She states she just returned from vacation during which she was hospitalized w “heart attack”, she had heart cath and “stents” put in. She took the last of her pills today and needs urgent refill. She can’t remember what she was taking.
-What rx should she be on post MI?

A

beta blocker, Ace-I/ ARB, DAPT, statin

DAPT= dual antiplatelet therapy

60
Q
A
61
Q

STEMI

Diagnostic ST elevation according to ACC or AHA

A

Diagnostic ST elevation at the J point in at least 2 contiguous leads of ≥ 2 mm in men or ≥ 1.5 mm in women in leads V2-V3 and/or of ≥ 1 mm in other contiguous chest leads or the limb leads

62
Q

STEMI

A
63
Q

STEMI

12 lead ST elevation

anterior, lateral, inferior wall

A

V2-V4: anterior wall
Left Anterior Descending Artery
Prone ventricular arrythmias/ shock

I, avL, V5, V6: lateral wall
Circumflex Artery

II, III, aVF: inferior wall
Right Coronary Artery
Give IV fluids!!! Pre-load dependent so caution with nitroglycerine and morphine
Transient AV blocks

64
Q

Anterior wall MI

A

V2-V4: anterior wall
Left Anterior Descending Artery
Prone ventricular arrythmias/ shock (VF/VT)

think about septum and L ventricle

65
Q

inferior wall MI
Avoid?

A

II,III,aVF
Right Coronary Artery
Prone blocks and RV failure

think about R ventricle and SA/AV node

Give IV fluids!!! Pre load dependent so caution with nitroglycerine and morphine or fibrinolytics
Transient av blocks

66
Q
A

Inferior wall MI

67
Q
A

lateral wall MI

68
Q

lateral wall MI

A

I, aVL, V5, V6
Left Circumflex Artery

69
Q

STEMI

Tx

A
70
Q

STEMI

Fibrinolytic therapy

A
71
Q

STEMI

Fibrinolytic Contraindications
Absolute

A

Previous hemorrhagic stroke, or strokes or cerebrovascular events within 1 year
Known intracranial neoplasm
Recent head trauma
Active internal bleeding (excluding menstruation)
Suspected aortic dissection

72
Q

STEMI

Fibrinolytic Contraindications
Relative

A

BP > 180/110
CVA > 3 months ago
Bleeding / surgery within 2-4 weeks
Intracranial tumor (benign)
Pregnancy
Traumatic/prolonged CPR
Current OAC tx
Dementia

73
Q

Which patient is a good candidate for fibrinolytics?
A) CP with positive enzymes, flattened t waves on ECG
B) tearing CP in scapula/ PMH of aortic aneurysm and marfan’s
C) CP started 18 hours ago, + enzymes, ST elevation on ECG
D) CP in patient with history of CVA 2 months ago
E) CP hx of CAD, + enzymes, new LBBB

A

A is considered NSTEMI- no lytics
B do not have ecg to determine if STEMI- presentation most like aortic dissection
C stemi- > 18 hours- prefer cath due to > 3 hour
D – do not have ECG , don’t know if stemi; recent stroke- not candidate
E- new LBBB is equivalent – if > 2 hours to lab via transfer then lytics

74
Q

STEMI

Post fibrinolytic management

A

Continue with aspirin and anticoagulation until revascularization or for the duration of the hospital stay (up to 8 days)

Myocardial reperfusion can be recognized clinically by the early cessation of pain and the resolution of ST-segment elevation. Although at least 50% resolution of ST-segment elevation by 90 minutes may occur without coronary reperfusion, ST resolution is a strong predictor of better outcome.

GI bleeding prophylaxis
Some PPIs may decrease the effect of clopidogrel

75
Q

STEMI

After reperfusion therapy
EF < 45

A
76
Q

STEMI

AFTER Reperfusion Therapy NO NO’S

A

Calcium Channel Blockers
No role in nearly all patients with acute myocardial infarction (may exacerbate ischemia)
NSAIDs
Other than aspirin, should be avoided around the time of STEMI due to increased risk of mortality, myocardial rupture, hypertension, and heart failure

77
Q

Which of the following rx should not be prescribed post ACS? A) aspirin
B) metoprolol
C) clopidogrel
D) ibuprofen
E) rosuvastatin

A

D) ibuprofen
(No NSAIDS)

78
Q

is indicated for all ACS pts for 1 year

A

Acute Coronary Syndrome
Dual antiplatelet therapy is indicated for 1 year in all patients

79
Q

Post MI complications

A

ACT RAPID

Arrhythmia
Congestive Heart Failure
Tamponade/Thromboembolic
Rupture (ventricular, septum, papillary muscle)
Aneurysm
Pericarditis
Infection
Death/Dresslers

80
Q

Complications of MI

Arrythmias

A

Sinus bradycardia – inferior infarctions
SVT – correct electrolyte abnormalities, hypoxia
A.Fib – BB, Amiodarone, Cardioversion
Ventricular arrhythmias – common in 1st few hours
Antiarrhythmics (IV lidocaine, IV amiodarone)
Electrical cardioversion
AV block
1st degree > 2nd degree, 3rd degree

81
Q

Which of the following is NOT a sign of cardiogenic shock?
A) decreased urine output
B) hypotension
C) cool extremities
D) bradycardia

A

D- usually tachycardic in shock

82
Q

Patient with anterior wall MI post PCI to LAD EF 30%. transferred to ICU. In last 12 hours they are becoming hypotensive , rales BLL, decreasing O2 sat. No murmur

What is the most likely cause of shock?
A) RV failure
B) LV failure
C) chordae rupture
D) free wall rupture

A

B) LV failure

83
Q

Patient with anterior wall MI post PCI to LAD EF 30%. transferred to ICU. In last 12 hours they are becoming hypotensive , rales BLL, decreasing O2 sat. No murmur

What treatment is NOT indicated?
A) IV fluids
B) IV diuresis
C) Inotropes
D) IABP

A

A) IV fluids

84
Q

STEMI complications

RV Infarction

A
85
Q

Post MI Complications
Mechanical

A

Acute ventricular septal defect
Acute mitral regurgitation
Left ventricular free wall rupture
* All would present with new loud/harsh murmur

86
Q
A
87
Q

STEMI complications

LV Aneurysm

A
88
Q

STEMI complications

Pericarditis

A

Audible friction rub with positional chest discomfort
Treatment: High-dose aspirin and colchicine

89
Q

STEMI complication

Dressler syndrome (post-myocardial infarction syndrome) and Tx

A

1-12 weeks after infarction
Autoimmune phenomenon with pericarditis fever, leukocytosis, and occasionally, pericardial or pleural effusions

Treatment: High-dose aspirin and colchicine

90
Q

STEMI complications

Mural Thrombus

A

Common in large anterior infarctions
Emboli occur in ~2% of patients with known infarction, usually within 6 weeks

Anticoagulation-
Initially with heparin
Followed with warfarin or NOAC/DOAC therapy

91
Q

STEMI

Post-infarction Management

A

IF they had impaired EF will need to recheck with Echo as outpatient

92
Q

CABG

A

Multivessel disease
Significant Left main coronary blockage
Surgical correction of MI complications
VSD, ventricular aneurysm, etc.
LV dysfunction
NSTEMI and high-risk features

93
Q

Which of the following pre-operative physical exam findings may alter CABG plan?
A) poor dentition, dental caries
B) history of vein stripping
C) history or radiation to chest
D) abnormal Allen’s test

A

If poor dentition increased risk infection- consider treatment
Vein stripping you need to make sure they have conduit
Chest radiation need to consider LIMA/RIMA may be damaged
Allen’s test abn need to access if can use radial artery

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