CAD Flashcards
Stable Angina
general
predictable
if i excercise i get chest tightness
Unstable Angina
general
increase in durations, onset, or intensity
NSTEMI Angina
General
not showing on ECG
Get loading dose on all of which kind of med?
Assessed by?
Antiplatelet meds which can be assessed via PRU value
What med is preferred for DM pts with MI
Ticagrelor over Clopidogrel
Coronary Vasospasm
general
AKA, age, gender, induced by
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
Coronary Vasospasm
Dx
EKG
ST-segment elevation rather than depression
Diagnostics
Coronary angiography: no lesions with poss spasm; may give intracoronary nitroglycerine/ CCB
Coronary Vasospasm
Treatment
What do you avoid?
Calcium channel blockers (daily) and/or nitrates
Avoidance of nicotine, caffeine, cocaine, ergot’s
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: verapamil
resting sx..
put her on daily ca channel blocker
Non modifiable RF for CAD
Family hx
Age
Sex
Stable Angina Pectoris
general
Chest wall discomfort precipitated by stress or exertion and relieved by rest or nitrates
Occurs whenever myocardial oxygen demand exceeds oxygen supply
stable angina
Sx
Sx’s are EXERTIONAL and RELIEVED WITH REST
< 20 minutes duration
Pt’s c/o pressure, pain, squeezing, tightness, heaviness…
Stable angina
May present with atypical symptoms
what are they and who are affected
Dyspnea, indigestion, arm or jaw pain, exertional SOB, nausea, diaphoresis, fatigue, or all of the above with NO PAIN
presents in DM and females
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: describes angina
B: pericarditis, pleurisy
C: reflux
D: musculoskeletal
E: PE, pericarditis
Stable Angina Pectoris
labs and ECG
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
Unstable Angina & NSTEMI
TX in hospital
MONA-BAS
Morphine
Oxygen
Nitrates
Aspirin
Beta blocker
Antiplatelet
Statin
STEMI
general
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
STEMI
Sx
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
STEMI
Dx Labs
Positive troponin I/T or CK-MB
each should be pos as early as 4-6 hours and abnormal by 8-12 hours
STEMI
Tending enzymes
get 3 sets every 8 hours
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
C. coronary revascularization
Nitro, dont wanna bottom out their pressure
STEMI
Reperfusion therapy
RF for CAD
HTN, HLP, CVA, PAD, DM, tobacco, family hx, obesity, sedentary lifestyle
Primary Prevention
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
Secondary prevention
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
Medications for secondary prevention
If DM?
If CKD?
*Medications
Antiplatelet (aspirin)
Statin (moderate or high intensity)
If DM: GLP-1
If CKD: ACE/ARB, SGLT2-inhibitor
Stable angina
Lab and ECG
no troponin elevation
no ECG acute changes
Stable angina
Tx (3)
BB, ASA, Statin
Unstable Angina
clin presentation
Sx at rest
Unstable angina
Tx
cath lab, hospitalization
NSTEMI
Labs and ECG
+ troponin elevation
ST depression or other changes
NSTEMI
Tx
BB,ASA, Statin
+/- ischemia assessment; hosp
STEMI
Lab and ECG
troponin elevation
ST elevation
STEMI
Tx
Cath lab (90 min door: balloon time)/reperfusion
BB, ASA, Statin ACE; hosp
Stable Angina
most commonly caused by? other causes?
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
Stable Angina
Tests to Evaluate Perfusion
Stress test w or w/o imaging ( myocardial perfusion scan or stress echo)
Cardiac CTA
Stable angina
First line Tx
To reduce risk
reduce risk of further attacks
Beta blocker
Aspirin or clopidogrel
stable angina
Secondary Tx (3)
long lasting nitrates
Ranolazine
Calcium channel blockers
Angina
non pharm ways to reduce risk
**risk reduction: stop smoking, BP control, lipid control, DM control, weight reduction etc
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- beta blockers
stable angina
the most common noninvasive testing in evaluating for inducible ischemia stable patient
Exercise ECG
Contraindicated if unstable angina, active ECG changes, aortic stenosis
stable angina
If patient has a negative stress test and resolution of symptoms on Rx therapy ( asa/statin/bb) then..?
continue monitoring and consider other etiology
stable angina
If patient has a negative stress test and ongoing symptoms refractory to medical therapy, consider
cath
stable angina
If patient has a positive stress test proceed with
cath
stable angina
is stable a part of ACS?
NO
stable angina
typically lasts
2-15 minutes
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
B- you want beta blocker not calcium channel blocker
differece in troponin with Unstable angina and NSTEMI?
angina= negative troponin
NSTEMI= positive troponin
Fibrinolytic therapy has been found to be harmful for
NON STEMI
If hypertensive what is BP BB of choice?
labetalol IV- most BP reduction
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
E) fibrolytics
Unstable angina and NSTEMI
Risk-Stratification Tools
HEART Score
predicts 6 week risk adverse event
Low risk (0-3), Moderate risk (4-6), High risk (7-10)
Unstable angina and NSTEMI
Risk-Stratification Tools used to evaluate patients long term risk post ACS
GRACE risk score and TIMI risk score
Unstable angina and NSTEMI
Tx when discharged
Beta Blocker
Aspirin +/- antiplatelet ( 1 year)
Statin
Cardiac rehab
Unstable angina and NSTEMI
hosptal admission Tx
Medical Therapy (for all)
MONA-BAS
Antiplatelet agents & Anticoagulants
+/- cath
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?
beta blocker, Ace-I/ ARB, DAPT, statin
DAPT= dual antiplatelet therapy
STEMI
Diagnostic ST elevation according to ACC or AHA
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
STEMI
STEMI
12 lead ST elevation
anterior, lateral, inferior wall
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
Anterior wall MI
V2-V4: anterior wall
Left Anterior Descending Artery
Prone ventricular arrythmias/ shock (VF/VT)
think about septum and L ventricle
inferior wall MI
Avoid?
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
Inferior wall MI
lateral wall MI
lateral wall MI
I, aVL, V5, V6
Left Circumflex Artery
STEMI
Tx
STEMI
Fibrinolytic therapy
STEMI
Fibrinolytic Contraindications
Absolute
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
STEMI
Fibrinolytic Contraindications
Relative
BP > 180/110
CVA > 3 months ago
Bleeding / surgery within 2-4 weeks
Intracranial tumor (benign)
Pregnancy
Traumatic/prolonged CPR
Current OAC tx
Dementia
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 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
STEMI
Post fibrinolytic management
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
STEMI
After reperfusion therapy
EF < 45
STEMI
AFTER Reperfusion Therapy NO NO’S
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
Which of the following rx should not be prescribed post ACS? A) aspirin
B) metoprolol
C) clopidogrel
D) ibuprofen
E) rosuvastatin
D) ibuprofen
(No NSAIDS)
is indicated for all ACS pts for 1 year
Acute Coronary Syndrome
Dual antiplatelet therapy is indicated for 1 year in all patients
Post MI complications
ACT RAPID
Arrhythmia
Congestive Heart Failure
Tamponade/Thromboembolic
Rupture (ventricular, septum, papillary muscle)
Aneurysm
Pericarditis
Infection
Death/Dresslers
Complications of MI
Arrythmias
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
Which of the following is NOT a sign of cardiogenic shock?
A) decreased urine output
B) hypotension
C) cool extremities
D) bradycardia
D- usually tachycardic in shock
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
B) LV failure
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) IV fluids
STEMI complications
RV Infarction
Post MI Complications
Mechanical
Acute ventricular septal defect
Acute mitral regurgitation
Left ventricular free wall rupture
* All would present with new loud/harsh murmur
STEMI complications
LV Aneurysm
STEMI complications
Pericarditis
Audible friction rub with positional chest discomfort
Treatment: High-dose aspirin and colchicine
STEMI complication
Dressler syndrome (post-myocardial infarction syndrome) and Tx
1-12 weeks after infarction
Autoimmune phenomenon with pericarditis fever, leukocytosis, and occasionally, pericardial or pleural effusions
Treatment: High-dose aspirin and colchicine
STEMI complications
Mural Thrombus
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
STEMI
Post-infarction Management
IF they had impaired EF will need to recheck with Echo as outpatient
CABG
Multivessel disease
Significant Left main coronary blockage
Surgical correction of MI complications
VSD, ventricular aneurysm, etc.
LV dysfunction
NSTEMI and high-risk features
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
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
