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cardiology exam iii > Cardio 24: NSTEMI and ACS > Flashcards

Cardio 24: NSTEMI and ACS Flashcards

1
Q

Describe the events that leak to occlusion of coronary vessels

A

Plaque formation. Plaque gets larger and becomes less stable. Fibrous cap thins leading to rupture and thrombus formation !

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2
Q

Risk factors for ACS

A 
HTN (>140/90)
Age Men >45, women >55
Diabetes
Dyslipidemia
Family hx
Smoking
Sedentary lifestyle
Chronic Kidney Disease (CKD)
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3
Q

Symptoms of ACS

A 
Chest pain (Jaw, arm, back, shoulder)
Shortness of breath
Fatigue/weakness
Nausea 
Diaphoresis
lightheadedness
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4
Q

DDx for ACS

A 
Pericarditis
Aortic dissection
   Don’t miss and give anti-coagulants/platelets to. 
Pneumothorax
Pulmonary embolism
    Often presents similar to MI
GI causes
Musculoskeletal
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5
Q

When will might you not see ST elevation with MI or UA ?

A

if collateral circulation has formed

Vasospams causing erosion

Coronary artery inflammation (youger patients )

Secondary Unstable Angina: Non-occlusive, come in with pneumonia can lead to decrease of blood supply/ oxygen leading to chest pain

Coronary artery dissection

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6
Q

What is the most common cause of UA/NSTEMI ?

A

Atherosclerotic CAD

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7
Q

What are the diagnostic tools used for ACS ?

A 
H&P
EKG
CXR
Biomarkers
Cardiac imaging
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8
Q

What is the goal for placing an EKG ?

A

get it on in 10 minutes from presentation

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9
Q

Troponins are the biomarker of choice because

A

they are sensitive and specific .
Present at 2 hours after infarction
stay elevated for 14 days post infarction

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10
Q

What increases with a greater level of troponins in blood ?

A

Greater chance of death !

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11
Q

which biomarkers are useful to detect re-infarction >

A

CPK and CPK MB

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12
Q

Earliest biomarker to rise

A

myoglobin

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13
Q

BNP is not very important except for in assessment of …

A

Risk

Higher level = worse outcome

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14
Q

What will you look for on CXR to assess cardiac health ?

A

Mediastianal widening
CHF
Cardiomegaly

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15
Q

CT scans are useful in detecting

A

Aortic dissection
PE

Not very practical due to how long it takes

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16
Q

Echocardiogram is useful in assessing

A 
LV size and systolic function
    Very useful for Circumflex occlusion diagnosis. 
Wall motion abnormalities
Mitral regurgitation
Pericardial effusion
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17
Q

Which patients are amenable to Stress testing ?

A

Low risk and stable patients

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18
Q

What is the “Gold Standard” for imaging ?

A

Cardiac catheterization

Diagnosis and treatment in same setting !

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19
Q

List the classes of Anti-platelet drugs

A

ASA
Thienopyridines
IIB/IIIA Inhibitors

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20
Q

Aspirin MOA

A

Cox-1 inhibitor (irreversible) prevents formation of thromboxane A2 (TxA2  platelet activation)

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21
Q

WIll a heart patient need to be on aspirin for life following ACS ?

A

Yes, 81-325 mg daily

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22
Q

MOA for Clopidogrel (plavix)

A

ADP receptor agonist

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23
Q

How long will a patient with a bare metal stent need to be on plavix (minimum)

A

One month

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24
Q

How long will a patient with a drug eluting stent need to be on plavix (minimum)

A

12 months

25
Q

If you use ticlopidine instead of plavix what must be monitored ?

A

Complete blood count

26
Q

Prasugrel has a shorter onset and can be given at the time of catheterization, making it a useful drug. What is a CI for this drug ?

A

Previous stroke, TIA or risk for intercranial hemorrhage.

27
Q

What is a side effect of Ticagrelor ?

A

Chest tightness due to Adenosine release

28
Q

Abciximab, Eptifibatide and Tirofiban are representative of what class of drugs ?

A

IIB/IIIA inhibitors

abciximab is a large molecule (binds irreversibly)

The other two are small molecule (bind reversibly)

Useful for HIGH RISK patients

29
Q

If you do not plan to catheterize should you use Abciximab ?

A

nope

30
Q

What class of drugs should be used in all patients suspected of ACS ?

A

Anti-coagulants

31
Q

UFH inhibits Factor III leading to thrombin inactivation. The downside of this drug is…

A

Hard to control and must monitor

May actually activate platelets

32
Q

Enoxaparin (LMWH) is good choice because it can be dosed subq and does not need…

A

to be monitored like UFH

33
Q

Bivalrudin is a direct thrombin inhibitor. It does not require monitoring and has a reduced risk of bleeding. What is a downside ?

A

Expensive

34
Q

Fondaparinux inhibits

A

Factor Xa

35
Q

When is Fondaparinux considered the agent of choice ?

A

conservative treaments of individuals with increased bleeding risks !

36
Q

Absolute Contraindication for Thrombolytics Include

A

Unstable Angina
NSTEMI

Previous Stroke
Arteriovenous Malformation
Cerebral malignancy
Head  Trauma within the past week
Active bleeds
37
Q

Anti-ischemics include

A 
Bed rest 
O2
   Doesn’t reduce risk unless hypoxic but still done
   regularly
Β-blockers
Nitrates
Opiates
Ace-I/ARB
CA++ channel blockers
38
Q

Advantages of Beta Blockers

A

Decrease HR, BP & contractility–> DECREASES MYOCARDIAL WORKLOAD (MVO2)

Decrease infarct size and reinfarction
Decreases Arrhythmias
Decreases mortality? (short vs. lon

39
Q

When are BB’s contraindicated ?

A

Left sided heart failure
Hypotension –> shock
Severe asthma or COPD

40
Q

How is metoprolol (a BB) administered

A

5mg IV q5’ X3 (HR 55-60 & BP>100) (Cautiously)

25-50mg PO BID w/i 24°

41
Q

MOA for Nitrates

A

Coronary artery and venodilator
Decreases BP by decreasing preload
Decreased BP means decreased O2 demand
“Dilates coronary artery” actuallly just
decreases demand on the heart by decreasing
pre-load”

42
Q

Should nitrate administeration preclude ACEi or BB therapy ?

A

NO !

NO survival benefit ever proven therefore should not preclude use of β-blocker or ACE-I
0.4mg SL q5’ X3

43
Q

When should ACE-I be given within the first 24 hrs ?

A

EF <40%

Pulmonary congestion

44
Q

ACEi should not be used if patient is….

A

hypotensive !

Or sensitive. In which case use an ARB

45
Q

Non Dihydropyridine Ca+ channel blockers can be used if there is a contraindication for which class of drugs normally given to ACS patients ?

A

Beta Blockers

Non-DHP CCB’s

46
Q

Under what conditions will you give Non-DHP CCB’s and BB’s together ?

A

Refractory ischemia

47
Q

whens should you use caution with CCB’s and BB’s alike ?

A

Left ventricular dysfunction

48
Q

Intra Aortic blood pump

A

Diastole it inflates backpush of blood leading to coronary perfusion
Systole colapses  blood pumping

49
Q

When should statins be administered to admitted ACS patients ?

A

as early as possible.

Has pleiotropic effects

50
Q

TIMI Risk score

A

Important for assessing risk in invasive treatment of ACS

TIMI RISK-one point for each
Age >65
3 risk fx for CAD ( on the right)
    Diabetes
    Smoking
    Men >45 Women >55
    Low HDL
    Fam Hx
ASA use in prior 7 days
Already feeling pain….
 ST segment changes of ECG
Prior stenosis >50%
2 or more anginal events in prior 24°
\+ biomarkers

RIsk score is from 0-7 ( 4.7% - 40.9% risk of mortality)

51
Q

PCI

A 
Percutaneous coronary intervention (PCI)
    Balloon angioplasty
    Bare metal stents
    Drug eluting stents
    Other
52
Q

CABG

A

Coronary artery bypass grafting (CABG)

Use of internal mammary artery important

53
Q

Identify pts not considered high risk likely to benefit from invasive rx

A

Recurrent sx on appropriate med rx

High risk stress test

54
Q

Long Term Treatments with Anti-platelet drugs

A

ASA
Thienopyridines
Varying length of time (maybe a month, maybe a year)
Lifetime use
Warfarin
Not really indicated. No benefit over aspirin. Needs to be monitored and higher risk of bleeding.

55
Q

What is the goal of anti-ischemic and antihypertensive long term treatment

A

Goal BP <140/90 (130/80 w/ DM or CKD)

56
Q

What is the goal of Lipid lowering therapy long term

A

Goal LDL <70 in high risk pts)

57
Q

For diabetics, what is the goal HbA1c

A

< 7

58
Q

Mandatory vaccinations for patients with ACS include

A

Influenza
Mandatory !!
Pneumovax

59
Q

Why should patients with ACS avoid NSAIDs ?

A

Increases risk of heart disease and death.
Use nonselective only if absolutely necessary
Separate dose 4° from ASA

cardiology exam iii (12 decks)

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