CAD 3 Flashcards
myocardial ischemia
decreased blood/oxygen supply to heart muscle
suggested on EKG as inverted waves
myocardial injury
ischemia sufficiente enough to cause necrosis and release of biomarkers
EKG changes in ST elevation
myocardial infection
irreversible injury to myocardium
suggested by EKG changes (ST Elevation and Q waves)
types of MIs
STEMI or NSTEMI +
- spontenous MI from coronary event
- secondary to something else
- a = PCI, b- angiography
- associated with CABG
unstable angina
SUB-endocardial injury
subtotal coronary artery occlusion
anginal chest pain at rest + ECG ST depression and T wave inversion, NEGATIVE cardiac biomarkers
NSTEMI
subtotal coronary artery occlusion
anginal chest pain at rest + ECG ST depression or T wave inversion, POSITIVE cardiac biomarkers
STEMI
COMPLETE coronary artery occlusion
anginal chest pain
ST elevation/new LBBB
positive cardiac biomarkers
anterior MI: what artery?
LAD
Laterial MI: what artery?
LCX
Posterior MI: what artery?
RCAor LCX
R. ventricle MI: what artery?
RCA
atrial MI: what artery?
RCA
patients are more likely to get an MI from ___ lesions
new
therefore small, recent lesions bc more likely to rupture
HISTORY OF PATIENT WITH ACS
ANGINAL PAIN LSTING LONGER THAN 20 MINUTES
LIMITS PHYSICAL ACTIVITY
INCREASES DURATION OR FREQUENCY
DECREASE EXERTION DEEDED TO CAUSE ANDINAL CHEST PAIN
physical exam of MI
levine sign
diaphoretic, pale, respiratory distress
initial therapy for suspect ACS
MONA
Morphine 2mg
Oxygen 2-4 L
Nitrates
Aspirin (chewed or swallowed once)
MONA might not be good if:
Morphoine = avoid unless severe pain
ocygen= may increase vasospasm
nitrates = recent PDE-5
diagnosis of an MI (workup)
12 lead EKG (and repeat)
usual labs
BNP (heart failure)
CXR cardiac enzymes (q 6-8 hrs)
CK-MB and Troponin I
unstable angina/NSTEMI tx
steps
- anti-anginal (2)
- dual anti platelet therapy (DAPT) (2)
- anti-thrombotic therapy (1)
- Risk strategy
1-3 are always indicted in NSTEMI/UA
electrolytes and telemetry floor
anti-anginal therapy
beta blockers (cardioselective BB, doesn’t have HF hemodynamic compromise)
Nitroglycerin
DAPT
uncoated aspirin
thienopyridine or P2Y12 inhibitor
can use GP IIb/IIIa inhibitor
anti-thrombotic therapy
1 of 4
- unfractionated heparin
- LMWH
- fonduparinux
- IV direct thrombin inhibitors
inhibit further thrombin activation
risk stratification in UA/NSTEMI
high risk
1+ of, immediate angiogram and revascularizatoin
- hemodynamic instability or shock
- severe LV dysfunction of HF
- persistent resting angina despide meds
- new or worsening regurge
- sustained ventricular arrhythmia
risk stratification in UA/NSTEMI
stable risk
TIMI score used, cath in 24-48 hrs , 3+ is high risk
> 65, 3+ CAD risk factors, known CAD >50% stenosis, Aspirin, severe angina, elevated markers, ST deviation
TIMI 5+
immediate angiography
unstable patients
add re graph
TIMI 3+
invasive approach
cardiac cath 4-48 hrs
revascular options est depending on results
TIMI 0-2
conservative approach
intensify meds
if symptom free, stress test, if not cardiac cath
goal of STEMI management
total occlusion of large artery SO myself open ASAP to restore perfusion
door to balloon time goal? door to needle?
to balloon = 90 min (into hospital to time deploy stent)
to needle= 30 min (thrombolytic ASAP)
PCI with angioplasty or stent is preferred if either options are available (CAPBG is not emergent)
STEMI with normal coronaries
MC in young and women patients
causes: coronary spasm, toxins, collagen, coagulation dz, myocarditis, embolism
functional complications of AMI
CHF (left ventricle) = ACE
right ventricle failure = fluids, avoid nitro/diuretic
cardiogenic shock
mechanical complications of AMI
free wall rupture - high mortality, complete heart block
ventricular septal defect
papillary muscle rupture with acute mitral refuge
right ventricular infarction
coronary occlusion of R a. or branch
inferior MI
clinical triad of: hypotension, clear lungs, jugular venous distention
-backing up in systemic system , LV intact
treatment of right ventricular infarction
BP depends on preload
STEMI in precordial leads
myst get right sided EKG
avoid vasodilators and diuretics
treat hypotension = givese volume
CAD in elderly
elderly are more like to have NSTEMI and silent or atypical presentation
more likely to have HF associated with MI
medications in secondary prevention
beta blocker
aspirin
clopidogrel
ace (HF, LVEF <50%)
staitn
Takotsubo cardiomyopathy
transient systolic dysfunctional of apical or mid segments of LV that mimics MI
cocaine
cause CP, coronary artery vasospasm and MI
BB or contraindicated
nitrates and non-DHP CCB are recommend
Prinzmetal angina
vasospasm of artery
atypical chest pain occurring during rest (MC 12AM -morning)
young smokers, history of coaine use
transient ST elevation
responsive to nitrates, thought to be due to hyperactivity of vascular smooth muscle
prinzmetal angina treatment
smoking and drug cessation
treatment with non-DHP CCB
avoid beta blockers
best way to reduce CAD risk
predicting 10 yr risk
starting aggressive and early changes
control of lipids, HTN , DM
