CAD Flashcards
greatest risk factors for CAD
a. Prior coronary event B. Non-cardiac atherosclerosis C. Diabetes mellitus D. Dyslipidemia E. Hypertension F. Family History G. Cigarette smoking H. Sedentary lifestyle I. Obesity J. Age
strongest familial predictor of CAD
sibling
what is the correlation b/w DM and CAD
Small vessel dz
how does dyslipidemia
increase deposition of LDL into intima space –> reducing endothelial fxn
what age is a greater predictor of CAD than cigarette smopke
> 70
MCC of CAD
atherosclerosis
common underlying physiological process that leads to CAD
endothelial dysfunction of the vessels
lipid deposition in the wbc leads to smooth muscle proliferation known as
fatty streak
precipitated angina, caused by exertion and external factors
stable angina
acute coronary syndromes
acute coronary syndromes
ST elevation MI
Non ST elevation MI
Unstable angina
noncardiac chest pain
any condition brought on by a sudden reduction or blockage of blood flow to the heart - most often caused by plaque rupture or clot formation in the coronary arteries
Acute Coronary Syndrome
Endothelial dysfunction results in lipid (cholesterol) deposition btwn INTIMA and MEDIA. Dysfunction results from…
" HTN " ↑ LDL " Smoking " DM " Stress factors " Sedentary lifestyle
Endothelial dysfunction results in lipid (cholesterol) deposition btwn _____ and ____.
Endothelial dysfunction results in lipid (cholesterol) deposition btwn INTIMA and MEDIA.
precipitating external factors of stable angina
exercise
eating
anxiety or stress
cold environment
etiology of unstable angina
1) Atherosclerosis - MCC of MI –> caused by plaque rupture
2) Coronary artery spasm
3) REDUCTION in flow in the coronary artery
* acute coronary syndrome that is defined by the ABSENCE of biochemical evidence of myocardial damage
pathophysiology of unstable angina
TRANSIENT occlusion
Abrupt ↓ in coronary BF w/o ↑ in myocardial O2 demand.
Results from coronary thrombus 2˚ atherosclerosis
New onset chest pain w/i 2 wks is a classic manifestation of
stable angina
long term DOC for prevention of the progression of stable angina
Long term tx
DOC: Aspirin
reduces incidence of stroke and MI
classic outpatient regimen of stable chronic angina
aspirin, sublingual nitroglycerin as needed, and daily beta blocker and stain
cardioselective B1 beta blockers
metoprolol
atenolol
nonselective beta blockers
propranalol
nadolol
these three drugs have been show to reduce the risk of adverse cardiovascular events
Statins, ezetimibe, and PCSK9 inhibitors have been shown to reduce the risk of adverse cardiovascular events.
for pts with established atherosclerotic CVD what is the go to platelet tx
For patients with established and stable atherosclerotic CVD, we recommend long-term aspirin therapy. Long-term antiplatelet therapy with aspirin reduces the risk of subsequent myocardial infarction (MI), stroke, and cardiovascular death among patients with a wide range of manifestations of occlusive CVD.
for pts that can’t take aspirin b/c of risk of GIB what is the go to for anti platelet tx of CVD
ADP inhibitors: Clopidogrel (Plavix) for 1yr íASA allergies
if you have chest pain for more than 30 minutes what diagnostic marker would you expect to see
traponin
diagnostic tests to evaluate:
” ECG: ST depression &/or T wave inversion
“ Neg cardiac enzymes
_____ are effective at reducing the severity and frequency of anginal attacks in patients with stable ischemic heart disease and should be used for this purpose.
Beta blockers are effective at reducing the severity and frequency of anginal attacks in patients with stable ischemic heart disease and should be used for this purpose.
80% of pts benefit from this form of CVD tx that can be indicated for lowering bp or tx of acute myocardial infarction, hf, or EF <40
About 80 percent of patients with established cardiovascular disease will benefit from angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARBs) therapy.
The most common indications range from attainment of goal blood pressure to the treatment of acute myocardial infarction, heart failure or left ventricular ejection fraction below 40 percent, diabetes, and proteinuric kidney disease.
Certain focal areas under the___ become sites of LIPID POOLS
intima
full of fatty material that become covered in fibrous caps
Body wants to “clean up” lipid pools —> WBC leave circulation, the dissolve the fibrous cap via enzymes which can have what complication…
Body wants to “clean up” lipid pools –> WBC leave circulation & enter pool “eating” the lipids
can lead to rupture
following the rupture of fibrous caps what occurs
exposes the thrombogenic lipid pool to the circulation triggering clotting factors
Circulating platelets aggregate & a platelet thrombus is formed - aka white thrombus
difference between white thrombus and red thrombus
first Circulating platelets aggregate & a platelet thrombus is formed –> white thrombus
Fibrin thrombus then forms trapping RBC in the large fibrin clot (red thrombus) & partially or totally occludes the coronary artery
acute tx of unstable angina
Acute tx
“ Stress test
“ Cardiac cath: angio if indicated
long term tx of unstable angina
Long term tx
“ DOC: Aspirin
“ ADP inhibitors: Clopidogrel (Plavix) for 1yr –>ASA allergies
“ Adj tx: B-blockers, NTG, CCB
“ Lifestyle changes (↓ wt, daily exercise)
“ HTN, lipid control (consider Statins)
“ Low MW heparin
“ Unfractionated heparin: given w/ ACS, EKG changes, + cardiac marker
STEMI and non STEMI
what distinguishes them from people with MI
troponin
how to dx MI
MI dx:
1) Chest pain
2) Troponin
* Do serial troponin
Positive cardiac enzymes:
“ CK/CK-MB: appears 4-6 hr, peaks 12-24 hr and returns to baseline 3-4 d
“ Troponin I&T: appears 4-8hr, peaks 12-24 hr, returns to baseline 7-10day “ MOST SENSITIVE & SPECIFIC
ECG:
“ STdepression, +/- T wave inversion = can be normal looking
what is the immediate tx goal of NSTEMI
” Urgent angioplasty 1-3d after admisssion
what is the immediate tx goal of a STEMI
the goal is a door to balloon time (angioplasty) of less than an hour and half
Reperfusion!
Percutaneous coronary intervention - best w/i 3 hrs of sx onset
May need CABG if 3 vessel dz
TPA
anti-throm tx and adj tx following STEMI
Anti-throm tx: ASA, heparin, GP IIB/IIIA inhibitor
Adj tx: Bblockers, ACE-I, NTG, Morphine, Statin
ASA dose that prolongs like for individuals with ACS
75-100MG
decreases GIB without decreasing thrombotic risk
PTCA
what is it and when is it indicated
percutaneous transluminal coronary angioplasty
indicated with 1 or 2 vessel dz not involving LAD in whom ventricular function is near normal
restoneosis can be reduced with stents
calcium scores, CAC (coronary artery calcium)
seen in almost everyone over 65 so really only indicated in pts under 50
pain under the left axilla
is virtually never cardiac pain
pain under the left breast that doesn’t start at the sternum is _____ to be cardiac
unlikely
diagnostic gold for stable angina
coronary angiogram
medical tx for stable angina
BB
statin
ASA
nitro for acute sublingual NTG PRN
tx for unstable angina
agioplasty if indicated
anti-platlets : ASA
anticoagulants: heparin
maybe CCB of BB
NSTEMI tx
angiplasty 1-3 days after admission
STEMI
emergency angio
