CAD 2 Flashcards
symptoms of cardiac ischemia (6)
retrosternal chest pain (dull, pressure, crushing, constricting)
radiation of pain to L arm/shoulder
dyspnea
nausea
diaphoresis
feeling of impending doom
SYMPTOMS LAST 3-10 MIN
signs of cardiac ischemia (5)
normal with no ischemia
uncomfortable/pale.diaphoretic
dyspnea
altered mentation
additional heart sounds
CAD symptoms suggestions
worseingin dyspnea or exercise intolerance
palpitations and light headedness
weight gain over days
DO NOT RELIABLY CORRESPOND WITH DISEASE
women symptoms?
fatigue sleep disturbance SOB indigestion anxiety
1 month before HA
symptoms suggesting something else
MSK cause (4)
if have P = pulmonary (3)
pleuritic pain (knife like related to movements or cough) *P
localized with one finger
discomfort reproduced by movement or palpitation (pushing down) *P
pain lasts longer than a few days *P
symptoms suggesting something else
GERD, GI, PUD, esophagitis, pancreatitis
primary pain in mid to lower abdomen
most sensitive test to use for chest pain CAUSED by CAD
+ types and score
history
substernal chest pain
exertion chest pain
chest pain relieved with rest or nitroglycerin
anginal chest pain (3)
atypical anginal chest pain (2)
non anginal chest pain (1)
disease manifestations due to arteriosclerosis
- stable angina
- unstable angina
- NSTEMI
- STEMI
stable angina
predictable, reproducible symptoms
induced by exercise, cold, emotional stress
lasts 5-10 min, received by rest or NTG
occurs 2/2 fixed, stable plaque blocking 50% (mc 70%)
unstable angina
increase in cardiac ischemia symptom frequency, severity, or duration
occurring at rest
less responsive to rest or NTG for relief
caused by plaque rupture or progression
symptoms suggestive of ACS with no elevation in troponin
may have EKG changes
NSTEMI
increase in cardiac ischemia symptom frequency, severity, or duration
occur at rest
less responsive to rest or NTG for relief
ischemic symptoms suggestive of ACS and ELEVATIONS of tropnonins
with or without ECG NO ST elevation
STEMI
symptoms of cardiac ischemia
elevated bio markers
ST segment elevation
OLDCARTS of CP
O: sudden L: substernal D: several min-hrs C: pressure, dull A: rest, NG (worse w/exertion) R: L arm, shoulder, jaw T
risk of CVD and CP analysis
symptoms are not GERD or pleuritic chest pain
CV risk factors? if present increases likelihood of CAD being cause
PE will show carotid bruit, poor peripheral pulses
resting EG abnormalities concerning for coronary ischemia
T wave inversion
ST depression/elevation
New bungle branch block
increase likelihood 2-10 fold
limitations - not good enough to diagnose
pre-test probability
probability that target disorder is present PRIOR to performing diagnostic test
diamond Forrester criteria gives likelihood ratio
diamond Forrester criteria
high risk is? low risk?
High >90%
low <10%
what risk of diamond Forrester criteria do you stress test
Intermediate
low risk = think of something else
high risk = it’s probably there, move on to cardiac cath
grading angina (I-IV
I: ordinary activity doesn’t cause angina
II: slight citation of ordinary activity
III: marked limitation of physical activity
IV: inability to do ANY physical activity without discomfort
goal of Angina/Cad therapy
slow/arrest progression of CAD (decreasing risk of ACS)
relief of anginal symptoms (lifestyle, revascularization, pharmacotherapy)
aggressive risk factor reduction
management goals in CAD
DM: A1c <7%
Hyperlipid: LDL < 70 (statin) Tgs <200 (fabric acid, fish oils)
smoking cessation
HTN (<140/90)
Obesity
Sedentary lifestyle
pharm management of CAD
statin therapy and anti-platelet (LOWERS mortality)
ACE/ARBS (DM, LV systolic)
BB, CCB, Nitrates, Ranolazine
nitroglycerin
decreases preload and after load,, coronary vasodilation
can cause HA, flushing
BB/CCB
decreases heart rate, contractility, BO
may worsen HF and cause heart block
indications for revascularization
angina despite medical therapy (class III-iV)
high risk: EKG changes in stress test (VTach), unstable angina, arrhythmia with angina, survive sudden cardiac arrest
options for revascularization
CABG (coronary artery bypass grafting)
PCI (PCTA or intracornary) PCTA stenting
Percutaneous transluminal coronary angioplasty (PTCA)
cardiac cath with small balloon inflated at opening of stenosis
5% of patients experience arterial thrombosis
50% develop restenosis in 1-6 months
intracoronary stoning
1-2% thrombosis, 20-25% restenosis
first choice for coronary arterial lesions, not good for the small ones
two types: BMS and DES
bare metal stent (BMS)
patient will be on aspirin indefinitely
clopidogrel for 4 weeks to 1 year after stent
good option for patients who need surgery
Drug Eluting Stent (DES)
coated with anti-proliferative drugs to prevent restenosis
delays endothelialization of stent (higher thrombosis risk)
restenosis in 5-10%, 70% reduction in restenosis
aspirin indefinitely plus thienopyridene for 12 months MINIMUM
stent complications
- hemorrhage/hematoma at access site
- vascular damage
- peri-procedural MI
- real failure
- instEnt thrombosis
- instEnt restenosis
- cholesterol emboli syndrome
hemorrhage at access site
check H&H to evaluate if suspected
common
retroperitoneal hemorrhage (anemia and back pain)
cholesterol emboli syndrome
hx of norther atheroma manifests as renal failure, mesenteric ischemia, toe necrosis (with distal pulses) and lived reticular
CABG veins used
saphenous beins
internal mammary artery** or radial artery
harvested and anastomosed to ascending aorta and coronary to BYPASS areas of atherosclerosis
indications of CABG
> 50% stenosis of L MAIN CORONARY
three major epicardial coronary arteries w/LV systolic dysfunction (EF <50%)
multi vessel disease in diabetics
PCI is better
limited lesions, normal ventricular systolic function
medication therapy for
stable CAD without critical stenosis (<70%) and without left ventricular systolic dysfunction
