Cardio: Ischemia Flashcards
Periop PCI complications
How to recognize cholesterol embolization
purpura,
livedo reticularis
renal impairment
blue toes
PCI complications Restenosis when does it happen ? How does it present
- first 3-6 months
Occurs 5-20% of pts
recurrence of angina symptoms
PCI complications stent thrombosis
-When does it present and how
- first month
- occurs in 1-2% of patients,
- presents with acute MI
Presentation of absent limb pulse.
Consider Takayasu’s arteritis is a large vessel vasculitis
MI: How to manage
Glycaemic control in patients with diabetes mellitus
dose-adjusted insulin infusion with regular monitoring of blood glucose levels to glucose below 11.0 mmol/l
Best marker for reinfarction
CK-MB
ST elevation V1-V4
What artery?
Left anterior descending
Anteroseptal
ST elevation II, III, aVF What artery?
Right coronary
Inferior MI
Tall R waves V1-2
Posterior
Usually left circumflex, also right coronary
ST elevation V4-6, I, aVL
Left anterior descending or left circumflex
Anterolateral
angina-like chest pain on exertion
ST depression on exercise stress test
but normal coronary arteries on angiography
Syndrome X
transient ST elevations
Which can occur at rest
Prinzmetal
List the 3 components of Anginal pain
How is typical and Atypical angina defined
- Constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
- Precipitated by physical exertion
- Relieved by rest or GTN in about 5 minutes
Interpretation:
Pts with all 3 features = typical angina
pts w/ 2 of the above features = atypical angina
Pts with 1 or none=non-anginal chest pain
If starting duel therapy for angina but cant have the addition of CCB/ β-blocker
What other drug should be considered (4)
Consider one of the following drugs: a
long-acting nitrate,
ivabradine,
nicorandil or ranolazine
If a further drug is needed after duel tx in angina
what should they be lined up for?
is awaiting assessment for PCI or CABG
Criteria for PCI (3)
- within 12 hours of the onset of symptoms + PCI can be delivered within 120 minutes
- Pt presenting >hr12 but evidence of ongoing ischemia
Or - Pts ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI
Drug used in Fibrinolysis
Streptokinase/ Alteplase
Indications for Fibrinolysis
Within 12 hours of the onset of symptoms + BUT PCI can’t be delivered within 120 minutes
All MI pts get
All pt rx
300 Aspirin
morphine ONLY with severe pain
nitrates but not in hypotension
Drug commenced prior to PCI
-on oral anticoagulant
- not on oral anticoagulant
Dual anti platelet therapy aspirin + another drug
Give
Prasugrel- if not taking an oral anticoagulant. Nb high bleeding risk
clopidogrel if already on oral anticoagulant
Drug given during PCI
Radial access-unfractionated heparin w/bailout glycoprotein IIb/IIIa inhibitor (GPI)
femoral access: bivalirudin with bailout GPI
During Fibrinolysis
What drug is given during
ECG should be repeated after 60-90 minutes to look for resolution. If not PCI
Give Antithrombin - unfractionated heparin (UFH),
LMWH,
fondaparinux
bivalirudin.)
Drug give Post Fibrinolysis & when should ECG be repeated?
Post Fibrinolysis
-Ticagrelor
ECG should be repeated after 60-90 minutes to look for resolution. If not PCI
Initial Rx of unstable angina/ NSTEMI if PCI is NOT planned immediately &
patients creatinine is <265 µmol/L
Aspirin
Fondaparinux
If > 265 give unfractionated heparin
Initial Rx of unstable angina/ NSTEMI if PCI is planned or patients creatinine is >265 µmol/L
Aspirin
unfractionated heparin
Prasugrel or ticagrelor
Indications for immediate angiography for NSTEMI/Angina
Clinically unstable
Indications for angiography within 72 hours
Pt w/ Grace score >3 %
5 or 6 Drugs started post MI
- ACEi/ ARB - ( ramipril)
- β-blocker - continued for at least 12 months after a MI.
-
Dual antiplatelet therapy ASPRIN + 2nd antiplatelet agent – clopidogrel/prasugrel/ ticagrelor; 2nd usually continued for up to 12 months following a MI
- Cant tolerate aspirin- clopidogrel monotherapy - Statin-
- Aldosterone antagonists - acute MI +HF(LVD); initiated within 3-14 days of the MI,
After PCI What causes
* Eosinophilia
* purpura, livedo reticularis
* renal impairment
* blue toes
cholesterol embolization
with in a month of PCI
presenting w/ MI
Stent Thrombosis
occurs in 1-2% of patients,
After PCI when does Restenosis occur and how does it present?
- first 3-6 months
Occurs 5-20% of pts
usually presents with the recurrence of angina symptom
What cause Cardiac arrest after MI
VF
What arrhythmia occurs after inferior MI
Bradyarrhythmias/ AV block
What often occurs within the first 48 hours following a transmural MI
Pericarditis
What is Dressler’s syndrome? when is it likely to occur?
2-6 weeks following a MI-
autoimmune reaction
Raised ESR fever, pleuritic pain and pericardial effusion,
Persistent ST elevation+ LVF after MI but no chest pain
Left ventricular aneurysm
How and when does
Ventricular free wall rupture present
RX
1-2 weeks
acute HF 2dary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds).
Urgent pericardiocentesis and thoracotomy are require
1st week After MI presents with
acute HF w/ a pan-systolic murmur
Rupture of the interventricular septum/ VSD
