CAD, ACS Flashcards
Fibrinolytic/Thrombolytic therapy is the preferred mode ot treamtne for a STEMI patient if percutaneous coronary intervention is not available within what timeframe?
< 90 minutes
- door to balloon < 90 min
What are the modifiable risk factors for Coronary Artery Disease (CAD)?
- smoking, increases LDL and decreases HDL
- HTN
- uncontrolled DM
- obesity
- contraceptive use, usually if > 35 y/o
- HLD
What does ASCVD stand for?
atherosclerotic cardiovascular disease
What is the dosage of atorvastatin when starting a patient in high-intensity statin therapy?
40 or 80mg
How do statins affect the patients lipid profile?
HMG-CoA reductase inhibitor
- decreases LDL
- modestly decreases TG
What are potential complications of hyperlipidemia?
- atherosclerosis
- gallstones
- pancreatitis
- steatosis, fatty liver
What are the potential complications of statin therapy?
- rhabdomyolysis
- hepatitis
When should high intensity statin therapy be started?
1) clinical ASCVD (CAD, MI, etc)
2) LDL > 190
3) DM + 40 to 75yr + LDL >70
4) 40 to 75yr + LDL>70 + 10 ASCVD 10 risk of stroke/MI >7.5%
What is the dosage of rosuvastatin when starting a patient in high-intensity statin therapy?
20 or 40 mg
What baseline labs need to be drawn prior to starting high intensity statin therapy?
- creatine kinase to monitor for rhabdomyolysis
- LFT’s to monitor for hepatitis
How do bile acid sequestrants affect the patients lipid profile?
- inhibits bile acid absorption in the GIT
- lowers LDL
- causes diarrhea
What is the class and MOA of Cholestyramine?
- bile acid sequestrant
- lowers LDL
- inhibits bile acid absorption in the GIT
What does Ezetimibe do?
- lowers LDL
- inhibits cholesterol absorption in the GIT
- causes diarrhea
What effect do Fibrate medications have on the lipid profile?
- decrease TG
- slightly decrease LDL
- poss increase HDL
- ex: fenofibrate and gemfibrozil
What is the difference between angina and an acute myocardial infarction?
- angina is discomfort or pressure in the chest with no myocardial damage
- MI is necrosis of the myocardial tissue
What is the underlying cause of an acute myocardial infarction?
- myocardial O2 demand is greater the ability of the coronary arteries to supply
- blockage of blood supply to myocardial tissue
What are risk factors for the having an acute myocardial infarction?
- CAD
- HTN
- metabolic syndrome
- obesity
- DM
- male
- sedentary lifestyle
- diet
- stress
How long should it take for a STEMI patient to receive fibrinolytics upon arrival to the hospital (door to fibrinolytics or needle)?
within 30 min
How long should it take for a STEMI patient to undergo an angioplasty/heart cath upon arrival to the hospital (door to balloon)?
within 90 mins
What should be suspected if a patient presents with intermittent chest pain/discomfort that has the same onset, intensity and duration. It is usually induced by exercise, exertion or stress and last between 5-20 mins?
Stable angina
- EKG may show ST depression at time of anginal pain due to ischemia
- may be relieved by nitroglycerin and/or rest
Why is nitroglycerin given a patient with stable angina?
- is converted into Nitric Oxide (NO) in the body causing arterial and venous dilation
- dilation of the coronary arteries increases the blood and O2 supply to the myocardium
What is the term for chest discomfort or pain that occurs at rest and may last up to 30 mins and usually shows ST-segment elevation at time of event?
Prinzmetal angina
- aka: vasospastic or variant angina
What is Prinzmetal angina?
- aka: vasospastic or variant
- chest discomfort or pain that occurs at rest and may last up to 30 mins
- usually shows ST-segment elevation at time of event
What type of EKG change is usually seen in a patient experiencing Prinzmetal angina?
- usually shows ST-segment elevation at time of event
What is/are the main causes of Prinzmetal angina?
coronary arterial spasms
- may be precipitated by sumatriptan, amphetamines, EtoH, cocaine
- occurs more frequently in females and individuals of Japanese descent
What is the treatment(s) for Prinzmetal angina?
Calcium channel blockers to manage the coronary arterial spasms
Why are calcium channel blockers used to treat Prinzmetal angina?
CCB are used to manage coronary artery spasms
What is the treatment(s) for stable angina?
- lifestyle modifications (diet, exercise, smoking cessation)
- nitrates
- beta blockers
- calcium channel blockers
What are common symptoms a woman would report if having an myocardial infarction?
- GI like symptoms
- pain that radiates to the back
- fatigue
- SOB
Lack of pain during an Myocardial Infarction is common in what patient population?
diabetics and elderly secondary to neuropathies
Should a cardiac workup be completed on an woman presenting with GI-like symptoms, fatigue, SOB and pain radiating to their back?
Yes, these are common presentations in women experiencing a myocardial infarction or unstable angina
What are the 3 subclassifications of acute coronary syndrome?
- unstable angina
- NSTEMI
- STEMI
What ECG changes, if any, would be seen in a patient experiencing a Non-ST segment elevation MI?
may see:
- ST segment depression
- T-wave inversion
What are the symptoms of Acute Coronary Syndrome?
- chest pain
- N/V
- diaphoresis
- cool, clammy skin
- dyspnea
- feeling of impending doom
How do you differentiate an MI from unstable angina?
chest pain associated with MI is not relieved by nitroglycerin
ST segment depression seen on a 12-lead ECG is indicative of what?
myocardial ischemia
The following are indicative of what?
- T-wave inversion
- peaked T-waves
- ST segment depression
myocardial ischemia
What EKG changes are indicative of myocardial ischemia?
- T-wave inversion
- peaked T-waves
- ST segment depression
Which vessels are involved if a ST-segment elevation seen in leads II, III and aVF?
Inferior MI involving the:
- right coronary artery (80-90%
- left circumflex (10-20%)
Which vessels are involved if a ST-segment elevation seen in leads II, III, aVF, V5 and V6?
Inferolateral MI involving:
- left circumflex artery
Which vessels are involved if a ST-segment elevation seen in leads V3 and V4?
Anterior MI involving the left anterior descending artery
Which vessels are involved if a ST-segment elevation seen in leads I, aVL, and V3-V6?
Anterolateral and lateral MI involving:
- left anterior descending artery
- left circumflex artery
Which vessels are involved if a ST-segment depression without T-wave inversion and broad or tall R-waves are seen in leads V1, V2 and V3?
Posterior MI involving:
- right coronary artery
- left circumflex
How often should serial cardiac enzymes be drawn on a suspected MI patient?
q6-8 hrs
What is the preferred biomarker for identifying Acute Coronary Syndromes (UA, STEMI, NSTEMI)
Troponin (T and I)
What serum cardiac enzymes should be drawn in a patient suspected of having experiencing Acute Coronary Syndrome?
- Troponin T
- Troponin I
- myoglobin
- CK-MB
- total CK
- B-type natriuretic peptide (BNP)
What BNP serum levels are associated with an MI?
100-400 pg/ml
What labs should be drawn on a patient suspected of experiencing Acute Coronary Syndrome?
- BNP
- CBC
- prothrombin time (PT)
- partial prothrombin time (PTT)
- BMP
- Lipoprotein profile (lipid panel)
What is the treatment/management of acute coronary syndrome?
- aspirin 162-325 mg (chew)
- nitroglycerin 0.4 mg
- morphine (2-4mg)
- O2 (goal > 92%)
- 12 lead EKG
- place pt on telemetry
- labs
- admit to hospital
- start beta-blocker if hemodynamically stable
- consider anticoagulation
- high intensity statin
- fibrinolytic therapy for STEMI
- cardiac catheterization
What is the dosage of aspirin prescribed to a suspected MI patient?
162-325mg PO chewable
What is the dosage for nitroglycerin when prescribed for a suspected MI patient?
0.4mg sublingual tablet
- q5 min x 3
What is aspirin’s MOA?
- non-selective irreversible inhibition of COX-1 (primarily) and COX-2 (in high doses) enzymes
- results in the inhibition of platelet aggregation and production of pain-causing prostaglandins.
- stops the conversion of arachidonic acid to thromboxane A2 (TXA2), which is a potent inducer of platelet aggregation
What is the average lifespan of a platelet cell?
7-10 days
For hemodynamically stable ACS patients, starting oral beta-blocker therapy should be done within what timeframe?
within the 24hrs of admission
Which medication should be started within 24hrs of admission for a hemodynamically stable ACS patients?
oral beta-blocker
- metoprolol 25-50mg, then titrate to maintenance dose of 50-100mg BID
What is the reversal agent for heparin?
protamine sulfate
Which lab value should be monitored when a patients is receiving scheduled heparin (fractionated) or lovenox (low-molecular weight heparin)?
prothrombin time (PTT)
- normal range = 11-13.5 secs
- therapeutic range = 1.5-2
What medication should be given if a patient is allergic or cannot tolerate aspirin?
clopidogrel (plavix)
What does t-Pa stand for and why is the risk of bleeding less than other fibrinolytics?
- Tissue plasminogen activator
- less risk because it is fibrin specific and does not deplete clotting factors
- converts plasminogen into plasmin which breaks down fibrin clots
What is plasmin?
protein enzyme that breaks down fibrin in clots
What is the normal ACT range?
70-120 secs
Drug eluting stents require 12 months of dual antiplatelet therapy with which meds?
aspirin and plavix (clopidogrel)
What is the term for the accumulation of blood and/or fluid in the pericardial space?
cardiac tamponade
- causes decreased CO
What is Beck’s Triad?
- indicative of cardiac tamponade
1) jugular vein distention
2) narrowing pulse pressure
3) distant/muffled heart tones
What is the term for a patient presenting with jugular vein distention, narrowing pulse pressure and distant/muffled heart sounds?
Beck’s Triad
- indicative of cardiac tamponade or fluid/blood accumulation in the pericardial space
What is the gold standard to confirm the diagnosis of cardiac tamponade?
echocardiogram
What is the management for a patient with cardiac tamponade?
pericardiocentesis
- symptom management with fluids, chronotropic and inotropic agents PRN
What are the 2 categories of Peripheral Vascular Diseases?
- Peripheral arterial disease
- Chronic venous insufficiency
What are the 2 biggest risk factors for PVD?
- DM
- smoking
What are the six “Ps” r/t PAD symptoms?
- Pain/intermittent claudication
- Pallor
- Pulse absent/diminished distal to occlusion
- Paresthesia
- Paralysis
- Poikilothermia: inability to maintain core temp
What are the s/s of PAD?
- Pain/intermittent claudication
- Pallor
- Pulse absent/diminished distal to occlusion
- Paresthesia
- Paralysis
- Poikilothermia
- loss of hair on LE
- shiny, think, cool, dry skin
- dependent rubor/blushing
- slow wound healing
how is the ankle brachial index calculated?
- need doppler
- highest BP in arms / highest in foot
- Normal > 1.0
- PAD < 1.0
What are the 2 tools used to diagnose PAD?
- Rutherford’s categories
- Ankle brachial index
What is the med Cilostazol (Pletal) used to treat?
- treats claudication in patients with PAD
- inhibits platelet aggregation and induces vasodilation
What are the s/s of chronic venous insufficiency?
- leg ache that improves with elevation
- tingling, burning, cramps, throbbing
- restless leg
- fatigue
- dependent edema
- shiny, taut, hyperpigmented skin
- varicosities/varicose veins
What exam confirms the diagnosis of chronic venous insufficiency (CVI)?
venous duplex imaging/ultrasound
What is Virchow’s triad?
risk factors for DVT development
1) stasis of blood flow
2) endothelial injury
3) hypercoagulability
What is the treatment for a DVT?
- bed rest with extremity elevated
- anticoagulation for 3-6 months for first, then for life if recurrent
- Inferior vena cava (IVC) filter if anticoagulation is contraindicated
What medications are used for anticoagulation therapy for a patient with a DVT?
- heparin: 80mg bolus, gtt 18units/kg/hr
- lovenox (enoxaparin)
- direct thrombin inhibitor: dabigatran
- factor Xa inhibitor: Eliquis (apixaban)
- xarelto
- warfarin (coumadin)
Which serum marker is 100% specific for myocardial necrosis?
Troponin I
Tirofiban (Aggrastat) and Abciximab (ReoPro) are what class of medication?
antiplatelet agents
- glycoprotein IIb/IIIa inhibitor
What are the recommended medications to use for fibrinolytic therapy in a STEMI patient?
- Alteplase (tissue plasminogen activator or t-PA)
- streptokinase
- reteplase (r-PA)
- tenecteplase (TNKase)
What are the absolute/major contraindications for fibrinolytic/thrombolytic therapy ?
- active bleeding
- major trauma/surgery or stroke within the last 3 months
- SBP > 180 or DBP >110
- pregnancy
- aortic dissection
- acute pericarditis
