CAD Flashcards
What is the Most Common cause of death in high income countries?
CAD
Usual onset of CAD for Females vs. Males
F 55
M 45
Define Coronary Artery Disease
Narrowing or blockage of the arteries and vessels that provide oxygen and nutrients to the heart
Define Cardiovascular Disease
Broader category that includes CAD, arrhythmias, stroke, and heart valve d/o
Define atherosclerosis
buildup of plaque within blood vessels
Define angina pectoris
Myocardial 02 demand exceeds supply
define MI (myocardial infarction)
Heart attack which can be further differentiated into STEMI, or NSTEMI
What are the risk factors included in the Framingham Risk Score?
Age Sex Elevated BP Cholesterol Cigarette smoking
What are the most important risk factors for predicting possible cardiac event.?
Early CAD
Family hx
What factors are unique to women and put them at risk of Cardiac event?
Smaller coronary arteries
Loss of estrogen-elevated inflammatory state
Lower baseline HDL
Vague symptoms are the norm
Less symptom relief with tx, and poorer outcomes from CABG
Higher rates of post MI heart failure
Stop smoking for 1 year and you decrease the risk of MI by _____ %?
50
What is the number 1 most preventable cause of death and illness in the US?
Smoking
What is the summary - pathological reason behind why smoking raises the risk of CVD?
Increased demand
decreased O2 to tissues
Hyper coagulable state
damaged endothelium
What effect can LDL have on contributing to the risk of CVD?
Main component of atherosclerotic plaques
What effect can TG have on contributing to the risk of CVD?
Lipid made from converting foods high in carbohydrates or fat. Also a component of plaques
What effect can HDL cholesterol have on contributing to the risk of CVD?
Absorbs other cholesterol and carries it back to the liver.
“good” cholesterol-reduces risk of CVD
Why does DM contribute to the risk of CVD?
- Tends to lower HDL and raise TG and LDL
- contributes to Hypercoag state
- Nephropathy leads to cardio-renal syndrome
- Neuropathy allows multi vessel atherosclerosis to develop before ischemic symptoms occur resulting in Cardiomyopathy
How does HTN contribute to the risk of CVD?
- causes microscopic tears in artery walls allowing for assume. of atherosclerosis
- Causes decreased elasticity of arteries, increased after load, more strain on heart leading to cardiomyopathy
How does Sleep Apnea contribute to the risk of CVD?
Paused shallow breathing while sleeping
- Increased neg. intrathoracic pressure increases after-load results in increased demand in an already hypoxic state
- pro-inflammatory promotes atherosclerosis
- Increased platelet activity, reduced fibrinogen, promotes thrombus
What can be done to dx a pt with possible sleep apnea?
Sleep study
What aggravating factors may a pt report on Hx?
Symptoms aggravated by:
- exertion (less than before)
- Supine
- emotional
- AM symptoms
- Post prandial
- Cold exposure
- intercourse
What might a patient report as an alleviating factor for their symptoms?
Cessation of activity (less than 3 min)
NTG
What is important to ask the patient about their alleviating factors? (2 questions)
How long after cessation of activity do their symptoms resolve?
How often do they use their NTG?
What descriptors might a patient c/o?
Tightness Squeezing Burning pressing choking aching gas
What are the descriptors “bursting” or “tearing” usually associated with?
thoracic aneurysm
What information might a patient give in regards to the location of their symptoms?
Clenched fist over chest “levine sign”
substernal/left sided
Radiates to shoulder, arm, neck, jaw, back or abdomen
What should be looked for on physical exam?
Murmur
DM (retinopathy, neuropathy)
Hypercholesterolemia (xanthelasmas)
Hypothyroid (myxedema, cardiomegaly, fluid retention
Peripheral artery dz: (claudication, diminished pulses)
Active Angina!!! (htn, gallop, tachy-arrhythmia, mital regurg
DDX for cardiovascular dz (CARDIAC)
Angina/MI
Pericarditis
Myocarditis
TAA
Work up for CAD
Risk stratification (QRISK2, Framingham, HEART, ASCVD)
Labs
EKG
CXR
What labs would be drawn for CAD?
CBC Chem 7 Lipid panel A1C Cardiac enzymes for active pain CRP-inflammatory marker
What might be seen on EKG in the presence of CAD
Normal, LVH. ST elevation/depressions, T inversions during pain
What might be seen in CXR in the presence of CAD?
Normal or cardiomegaly, assess for non-cardiac etiology
What non-cardiac DDX are possible?
Derm-Zoster MSK-chostochondritis, CA Lung-PE, Pna, Ca GI-GERD, ulcer Psych-drug/attention, anxiety
How many stages does the Canadian Cardiovascular Society have for Angina Pectoris?
I-IV
What is the difference between stage 1 and 4?
Stage 1 is least effected
Stage 4 is most effected
Workup for CAD?
Stress test
Exercise or Dobutamine, stress Echo-adds US
Sestamibi (nuclear) (myocardial perfusion sinctography)
MUGA (radionuclide angiography)
CTA
What are contraindications for stress test?
Pain at rest of with minimal activity, aortic stenosis
What would a positive result on a Stress test be?
1mm horizontal or downsloping ST depression measured 80msec past the J point
Indications for sestamibi?
Resting ST-segment depression Complete LBBB Ventricular paced rhythm ventricular pre-excitation syndrome Prior revascularization with PCI or CABG Inability to exercise Renal or allergic patients unable to have dye
What is the benefit of a sestamibi?
Provides simultaneous assessment of myocardial perfusion and function in one study
What is MUGA best used for?
Evaluates Ventricle contractility monitor cardiotoxic (chemotherapy) drug effects during tx.
Is it safe to do MUGA on a renal pt?
Yes-MUGA is safe in renal pt’s nucleotide excreted via liver to GI
What can be determined with CT angio?
Coronary artery stenosis
Stent and bypass graft patency
venous anatomy
calcified and non-calcified plaque burden
Is CTA contraindicated in renal failure?
YES-this is a dye study—not good for those with renal dz
What test might be ordered for a pt with unstable angina who requires further work-up after positive stress test, and requires a final r/o after other causes of pain have been excluded and stress negative?
Cardiac Catheterization (with or without angioplasty)
What general medical management must be done for a pt with CAD?
BP control
DM Control
Lifestyle changes (smoking, diet, exercise)
What medications are suggested for pt’s with CAD?
Platelet inhibitors (ASA) NTG B-Blockers Ranolazine Statin
Define MI?
Blockage of flow to one or more coronary arteries not relieved by decreased demand. Results in damage to myocardium.
Define STEMI
Acute occlusion of an atherosclerotic area resulting in FULL THICKNESS necrosis of myocardium
Etiology of STEMI
Thrombus or plaque rupture most common Vasospasm Hypotension Coronary artery dissection Cocaine
HX of STEMI
same as Angina Increased severity of angina diaphoresis nausea dyspnea arrhythmia sudden death 1/3rd may be completely asymptomatic/have vague symptoms
PE of pt with STEMI
anxious uncomfortable Brady/tachy/arrhythmia HS WNL gallops or mitral regurg possible JVD possible with large infarct
What cardiac lab is the most specific to MI
Troponin
What will be seen on EKG in the event of an STEMI
-ST segment elevation
Greater than 1 mm in 2 or more precordial leads or adjacent limb leads
OR
-New or presumed L bundle branch block
Pathologic Q waves
-Hyperacute T-waves
What can “hide” an MI on EKG?
A new or presumed L bundle branch block
What must be done in the event of a STEMI?
Emergent percutaneous coronary intervention (PCI) While waiting for this..... Oxygen ASA 325 NTG Morphine Hemparin B-blocker Fibrinolytic After the event...... lifestyle mods and meds
Define NSTEMI
Acute occlusion of an atherosclerotic area resulting in PARTIAL THICKNESS necrosis of myocardium
What is the most reliable way to diagnose NSTEMI?
Cardiac enzymes
What may appear on EKG in the event of an NSTEMI
Normal or subtle change possible
ST-stement depression 0.5mm or greater OR
Dynamic T wave inversion with pain or discomfort/transient ST elevation of 0.5mm or greater for less than 20 minutes
Tx for NSTEMI
Oxygen ASA 325 NTG Morphine GIIb/IIIa inhibitor Anticoag (heparin, fondaparinux) Cath lab if unable to get pt pain free Post event-lifestyle mods and meds
Define Printzmetal angina
Coronary artery spasm generally in the setting of clean coronary arteries. More common in younger pt/s and women and generally occurs in early AM.
Etiology of Printzmetal angina?
Cold stress cocaine smoking vasconstricitng meds (B-blocker, antihistamine, decongestant, ADHD stims)
What might the EKG of Printzmetal Angina look like on EKG?
STemi
Work up for Printz. angina?
Cardiac cath (usually comes back clean but has to be done to rule out STEMI).
tx for Printz. Angina?
Generally responds well to NTG,
Prophylax with CCB’s/long acting nitrates
MI complications (4)
Cardiogenic shock
Heart failure
Dressler’s syndrome
Arryhthmias
Define Cardiogenic shock
Large L vent infarct leads to significant decrease of contractility. This leads to very low BP and inadequate systemic perfusion
Define Dressler’s syndrome?
Fever
Pleuritis
Pericarditis
Caused by autoimmune reaction to damaged heart muscle
When can Dressler’s syndrome occur?
weeks-months after an MI
What surgical options exist for a pt who can’t be catheterized?
CABG
