CAD 3 Flashcards by Sara Fieger

myocardial ischemia

decreased blood/oxygen supply to heart muscle

suggested on EKG as inverted waves

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myocardial injury

ischemia sufficiente enough to cause necrosis and release of biomarkers

EKG changes in ST elevation

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myocardial infection

irreversible injury to myocardium

suggested by EKG changes (ST Elevation and Q waves)

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types of MIs

STEMI or NSTEMI +

spontenous MI from coronary event
secondary to something else
a = PCI, b- angiography
associated with CABG

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unstable angina

SUB-endocardial injury

subtotal coronary artery occlusion

anginal chest pain at rest + ECG ST depression and T wave inversion, NEGATIVE cardiac biomarkers

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NSTEMI

subtotal coronary artery occlusion

anginal chest pain at rest + ECG ST depression or T wave inversion, POSITIVE cardiac biomarkers

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STEMI

COMPLETE coronary artery occlusion

anginal chest pain

ST elevation/new LBBB

positive cardiac biomarkers

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anterior MI: what artery?

LAD

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Laterial MI: what artery?

LCX

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Posterior MI: what artery?

RCAor LCX

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R. ventricle MI: what artery?

RCA

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atrial MI: what artery?

RCA

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patients are more likely to get an MI from ___ lesions

new

therefore small, recent lesions bc more likely to rupture

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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

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physical exam of MI

levine sign

diaphoretic, pale, respiratory distress

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initial therapy for suspect ACS

MONA

Morphine 2mg
Oxygen 2-4 L
Nitrates
Aspirin (chewed or swallowed once)

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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