cardiology 2: CAD/Angina Flashcards
what are the 3 steps in evaluation of patient with chest pain?
- determine the probability of CAD
- noninvasive testing for diagnosis and risk stratification
- additional workup based on estimated risk
what determines to need to go through to further CAD risk stratification
- medium to high pretest probability
- low probability does not need to be tested
for which patient with chronic stable angina do you do an echocardiogram?
assess LV systolic dysfunction only in patients with:
- prior MI
- pathological Q waves
- heart failure
- arrhythmias
- heart murmur
In working up a patient with chronic stable angina, what do you do for low/intermediate/high risk patient?
- Low risk - medical management
- intermediate-risk - stress imaging/further tests
- high risk - coronary angiogram
what is the treatment for chronic stable angina to prevent MI and death?
- antiplatelet therapy: aspirin/plavix
- high dose statin
- beta blockers (if LVEF<40%)
- Ace inhibitors (if LVEF<40%, DM, HTN, CKD)
what is the medical therapy treatment for symptoms relief for chronic stable angina?
- beta-blocker as initial therapy
- CCB
- Ranexa
- Nitrates
what are the guidelines for aspirin in women for cardiovascular disease prevention?
do not use aspirin in healthy women<65 for primary prevention of MI.
what population is more at risk for MI without chest pain or atypical chest pain?
- age>75
- diabetics
- women
- those with prior CAD
what are inferior MIs associated with?
- mitral regurgitation due to papillary muscle dysfunction
- VSD (anterior and inferior)
- stable arrhythmias: junctional escape/mobitz 1
when do troponins first elevate and peak? Is it sensitive or specific?
- elevate first at 4 hours
- peak at 44 hours
- elevated 10-14 days
- It is sensitive, not specific
Troponins can be elevated in which conditions?
- chronic renal failure
- myopericarditis
- HF
- PE
- sepsis
when does CKMB first elevate, peak, and return to normal? sensitive or specific?
- initial elevation: 3-12 hour
- Peak in 24 hours
- Return to normal in 2-3 days
- specific test
what are the prehospital guidelines for chest pain?
- ASA
- nitroglycerin provided no PDE
- ECG
what are the high risk features of ACS?
what are the 3 groups after evaluation for ACS?
- noncardiac chest pain
- possible ACS
- definitive ACS
what do you do for possible ACS?
- observe at least 12 hours from symptoms onset
- 2 sets of cardiac markers/ekg
- stress study/LV function
what are the general anti-ischemic measures for all patients with ACS?
- continuous ECG
- aspirin
- NTG
- morphine
- oral beta-blocker
- ACE/ARB
which parenteral anticoagulants is preferred if CABG?
unfractioned heparin if CABG
when do you give fibrinolytic therapy for ACS? when do you not give?
- Do not give for UA/NSTEMI because it increases mortality
- Give fibrinolytic therapy for ACS patient with STEMI or new LBB if immediate PCI is not available.
what is the general acute ischemia pathway for UA/NSTEMI?
what is the possible ACS algorithim?
what is the definitieve ACS algorithim?
when do patients chosen for early conservative therapy need immediate angiography?
- if they have recurrent symptoms, ischemia, heart failure, serious arrhythmia .
- EF<40%
- stress test reveals not low risk
what is early conservative treatment for UA/NSTEMI?
- anticoagulant for 48 hours
- dual antiplatelet therapy (ASA +cllopridogrel, ticagrelor)
what is long term antiplatelet therapy after UA/NSTEMI WITHOUT stent?
ASA + plavix/ticagrelor x 1 month to 1 year
what is long term antiplatelet therapy after UA/NSTEMI with BMS?
- ASA 162-325mg/dl x 1 month then 75-162mg/d for life
- clopridogrel, prasugrel, or ticagrelor x 1 month to 1 year
what is long term antiplatelet therapy after UA/NSTEMI with a DES?
- ASA 162-325mg/d for 3-6 months, then 75-162 for life
- clopridogrel, prasugrel or ticagelor for at least 1 year.
- Consider continuing for longer than 1 year.
what agents do you use for patients with cocaine and methamphetamine users with ST elevation?
- give nitro, CCB, and benzodiazepines
- DO NOT give beta blocker
- If ST-segments elevated, and no immediate improvement with treatment, proceed with angiogram/fibrinolytics
what do you give for STEMI or new LBBB MI?
- aspirin, beta blocker, nitrate prn
- UFH, enoxaparin, or bivalirudin
- give clopridogrel, prasugrel, or tiacgelor
- abciximab (GP2b/3a) only if immediate PCI
- PCI/fibrinolytic therapy
- PCI should be done within 12 hours of chest pain onset and within 90 min of arrival to ED.
what the reperfusion therapies you consider for those with STEMI/new LBBB?
- PCI or fibrinolytic therapy
- PCI preferred for patients with high bleeding risk, inability to comply with DAPT or anticipated invasive/surgical procedures within the year.
what are the absolute contraindications to fibrinolytic therapy?
- previous hemorrhaigc stroke or CVA within 1 year
- intracranial neoplasm
- active internal bleeding
- suspected aortic dissection
what are the relative contraindications for fibrinolytic therapy?
- persistent BP>180/110
- remote non-hemorrhagic stroke>1 year
- concurrent use of anticoagulants with INR 2-3; bleeding diathesis
- recent 2-4 weeks surgery
- previous exposure to fibrinolytic
- pregnancy
- active peptic ulcer
- noncompressible vascular puncture
- advanced age
If urgent CABG planned, what should be held/started?
- aspirin held
- Statin continued
- short acting (eptifabitide)GP2b/3A discontinued at least 2-4 hours
- abciximab discontinued at least 12 hours before CABG
- start oral beta blocker within 24 hours if no signs of HF, AV blocks, asthma
what is the primary cause of in-hospital death from STMEI?
LV dysfunction post MI
what frequently accompanies right ventricular infarction?
- accompanies inferior MI
- occlusion of proximal right coronary artery
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what clinical triad to you see in inferior MI with RVI?
- triad of hypotension, clear lung fields, elevated JVP
- kussmaul sign frequently present (paradoxical rise in jugular venous pressure (JVP) on inspiration, or a failure in the appropriate fall of the JVP with inspiration.)
what do you see on EKG and right heart cath for RVI?
- ST elevation in V1 and ST elevation in lead 3 > lead 2.
- STEMI in V3R-V7R
- Elevated RAP pressure of >10 with decreased PCWP and CO
how does the management of RVI compare to LVI?
- avoid nitrates and preload reducing agents
- FLuid support is essential
- inotropic support typically with dobutamine
what is the treatment of Afib with hemodynamic instability?
emergent treatment with DC synchronized cardioversion.
what is the treatment for sustained VT with a pulse accompanied by hemodynamic instability?
DC synchronized cardioversion
what ist eh treatment VF and pulseless VT?
defibrillation (DC unsynchronized cardioversion)
what is the treatment of sustained VT not associated with hemodynamic instability?
- amiodarone
- correct any potassium or magnesium deficiencies
- routine prophylatic use of lidocaine to prevent VT is no longer recommended.
which patients with VT after MI get DC cardioversion?
VF, pulseless VT, VT with pulse and hemodynamic instability
what are the indications for temporary pacing?
- symptomatic bradyarrhythmias unresponsive to medical treatment
- asystole or sinus arrest
- Mobitz type 2/3rd degree AV block
why is bradycardia and AV block more common with inferior MIs than anterior MIs?
- increased vagal tone and AV nodal ischemia with inferior MIs.
- AV block with anterior MI implies large amount of destruction of IV septum and frequently requires permanent pacing.
who requires ICD?
- those with develop sustained VT/VF >48 hours post - STEMI with LVEF is typically re-evaluated 40 days following revascularization
- ICD indicated if there are baseline episodes of VT.
what increases HDL?
- exercise
- estrogens
- niacin
- EtoH
what decreases HDL?
- smoking
- androgens
what are the 4 statin benefit groups?
- clinical ASCVD
- LDL>190
- age 40-75, with LDL 70-189
- age 40-75 with LDL 70-189 with an estimated 10-year ASCVD risk>7.5%
what groups does CABG improve symptoms and survival?
- left-main
- left-main equivalent (2 vessel disease with 1 vessel being proximal LAD)
- 3 major CAD
- multivessel CAD or proximal LAD with LV dysfunction
- complex 3 vessel CAD
- multivessel CAD with DM
what groups benefit with CABG for survival?
- 3 vessel disease with significant LV dysfunction
- left-main or left main equivalent disease
- diabetes
with saphenous vein bypass, what percentage of veins occluded in 10 years? how about internal mammary grats?
- Vein has 5 words, 50% chance open in 10 years
- LIM-artery has 9 words, 90% open in 10 years
- diabetics do better with mammary grafts
name 3 drugs used with drug eluding stents (the drug in the stent)?
sirolimus, paclitaxel and everolimus
how do you calculate LDL?
LDL = TC - HDL - 1/5 of TGL
who should receive a high-intensity statin regardless of levels?
all patients with CAD regardless of lipid levels
how do you define a high-intensity vs medium intensity statin?
- high-intensity statin lower LDL cholesterol at least 50% on average
- medium intensity statin lower LDL cholesterol by at least 30-50% on average
what are the two major causes of PAD?
diabetes (5x) and smoking (2x)
what is buerger’s disease?
atherosclerosis in typically smoking males<30 years old involving medium and small arteries.
how would you differentiate vascular claudication from lumbar spinal stenosis?
- lumbar spinal stenosis is caused by pseudoclaudication, relieved by sitting down and flexing the spine but not by standing still. Exacerbated by anything that extends the spine.
- Vascular claudication is relieved by sitting down or standing still.
what antiplatelet therapy is recommended in PAD?
aspirin or plavix.
what do you need to watch out for when prescribiling cilostazol? MOA?
- phosphodiesterase inhibitor that increase cAMP in platelets resulting in reversible inhibition of platelet aggregation.
- use only if LV function normal as patients with class 3/4 have increased mortality with any phosphodiesterase inhibitor.
what is primary raynaud’s phenomenon? tx?
constriction of small arteries and arterioles when cold leading to acryocyanosis.
Associated with livedo reticularis
tx with CCB
biofeedback/nitro if CCB not effective
where does atherosclerosis most commonly occur in the neck?
within the common carotid bifurcation and proximal internal carotid artery
people with atherosclerosis carotid artery disease are at the highest risk of having?
MI than TIA/CVA
when is carotid endarterectomy indicated?
patients who experience nondisabling ischemic stroke or symptomatic TIA symptoms within 6 months should undergo endarterectomy if:
- the diameter of the lumen of ipsilateral internal carotid artery is reduced by >70% by noninvasive imaging or >50% by angiography
- anticipated rate of perioperative stroke/mortality>6%
when should you suspect internal carotid artery dissection? what should you see on physical exam?
- patient with the unilateral headache associated with either TIAs or a dilated pupil.
- look for cholesterol emboli on the funduscopic exam.
what is the medical treatment for TIA secondary to atherosclerosis?
- ASA alone
- ASA + dipyridamole
- clopidogrel alone
what are the causes of cerebral embolic events of cardiac origin?
- Afib
- MI
- ventricular aneurysm
- valvular
when or at what size is surgery indicated for thoracic aortic aneurysms?
- 5cm if Marfans
- 5.5cm in the ascending aorta
- 6cm in the descending aorta
- greater than 1cm per year
- compression of surrounding structures
- symptomatic
what type of aneurysms dissect vs rupture?
thoracic dissect and rupture
abdominal tend to rupture rather than dissect
at what size is surgery indicated for AAA?
- AAA>5.5cm
- expand >0.5cm in 6 months
- symptomatic (abdominal/back pain, + pulsatile mass + hypotension)
screening for asymptomatic AAA?
- 4- until 5.4cm monitored with US or CT every 6-12 months
- place on beta-blockers during the observation period
what conditions require infective endocarditis antibiotic prophylaxis
High-risk patients that have:
- all dental procedures involving gingival tissue or periapical region of teeth or perforation of the mucosa
- respiratory tract procedures
- skin or musculoskeletal infection
- not indicated for any GI/GU procedures
what is a high risk group of patients that would need antibiotic prophylaxis?
- prosthetic valves
- a previous episode of endocarditis
- Congenital heart disease (unrepaired cyanotic CHD, repaired CHD within 6 months of the procedure, repaired CHD with residual defects)
- cardiac transplant patients with valve lesions
what is the preferred regimen for IE oral prophylaxis for dental procedures?
amoxicillin 2g orally 30-60 minutes before procedure
what is the preferred regimen for IE prophylaxis for dental procedures unable to take oral medications?
ampicillin or cefazolin or ceftriaxone 30-60 minutes before the procedure
what is the preferred regimen for IE oral prophylaxis for dental procedures if they are allergic to penicillin?
clindamycin or cephalexin or azithromycin
following acute rheumatic fever, how long does it take for valvular dysfunction to occur?
20 years
how do you distinguish the joint affliction of rheumatic fever vs rheumatoid arthritis?
rheumatic fever does not have the joint deformities and has a negative RF factor
what key associations for rheumatic fever? (mnemonic + dx)
- JONES CAFE PAL
- Major: Joint involvement, O - heart , nodules (subcutaneous), Erythema marginatum, Sydenham chorea
- Minor: CRP increased, arthralgia, Fever, ESR elevation, Prolonged PR, anamensis of rheumatism, leukocytosis
- 2 major + group A strep infection/ASO titer
- 1 major + 2 minor + group A strep infection/ASO titer
- MCC mitral stenosis and tricuspid stenosis
