Cardiology - CAD and ACS Flashcards
Goal HR on beta blocker?
Beta blocker contraindicated in patients with?
55-60
#Symptomatic bradycardia you #High grade AV block #Acute decompensated heart failure #Severe reactive airway disease
Medical therapy for patients with STABLE angina?
If continued symptoms?
If continued symptoms?
If continued symptoms?
Left heart catheterization
#aspirin #Beta Blocker #Long acting Nitrate #Statin #sublingual nitroglycerin #ACE inhibitor (?)
#increase beta blocker deuce #Increase long-acting nitrate does #Add calcium channel blocker
#Optimize current medications #Consider ranolazine
Patient with medically refractory angina is not suitable for PCI or surgical revascularization – options for management?
#External enhanced counterpulsation #Spinal cord stimulation
Indications for moderate to high intensity statin?
#LDL over 190 #Diabetes #7.5% ASCVD 10 year risk
Patients at risk for CVD should get which vaccine?
Influenza
Calcium channel blockers that are better for CAD?
Non-dihydropyridines (provides coronary vasodilation AND reductions in heart rate) #Diltiazem #Verapamil
Calcium channel blocker are contraindicated in patients with?
#Left ventricular systolic dysfunction #Advanced AV block
Ranolazine - MoA? When to prescribe?
Selected inhibitor of late in word sodium channel in the myocardium
For patients who remain symptomatic after beta blockers, nitrates, and calcium channel blockers
SYNTAX score?
Anatomic scoring system based on the results of angiography (useful in predicting outcomes of revascularization strategies)
PCI versus optimal medical management in stable angina?
No mortality benefit but improvement in quality of life
CABG warranted in which patients?
#Left main disease #Multivessel disease involving proximal LAD
Duration of dual antiplatelet therapy in patients with stable angina after:
- No stent
- Bare metal stent
- Drug-eluting stent
- CABG
- No do therapy
- Aspirin and Plavix for one month
- Aspirin and Plavix for one year
- Not indicated
Duration of dual antiplatelet therapy in patients with unstable angina/NSTEMI or STEMI after:
- No stent
- Bare metal stent
- Drug-eluting stent
- CABG
Aspirin plus
- Plavix/ticagrelor for one year
- Plavix/ticagrelor/prasugrel for 1-12 months
- Plavix/ticagrelor/prasugrel for 1 year
- Plavix/ticagrelor for 1 year
When to give dual antiplatelet therapy?
#following PCI #following ACS
Medical therapy for STEMI?
#Aspirin #Statin #Nitrates #BetaBlocker #Heparin #P2Y inhibitor (clopidogrel, ticagrelor)
Contraindications to thrombolytic therapy during MI?
#Any previous intracerebral hemorrhage #Known cerebrovascular lesion (AV malformation) #Stroke in prior three months #Suspected Aortic dissection #Active bleeding #Significant closed Head/facial trauma and past three months
Thrombolytic options for MI treatment? (TIMI Flow grade 2/3?)
Streptokinase (55%)
Alteplase (75%)
Reteplase (83%)
Tenectoplase (83%)
The higher the flow grade 2/3, the more effective for thrombolytic
Arrhythmia that is considered benign if within 24 hours of reperfusion?
Accelerated idioventricular rhythm
Thrombolytic failure occurs how often? How to tell if thrombolytics fail?
30%
#Failure to resolve chest pain #Failure to improve ST elevation by 50%
Caution using nitrates and analgesics in these type of infarcts? (Why?)
Inferior or right ventricular infarction
Can result in reduced preload and significant hypotension
In patient with STEMI, beta blockers recommended in all patients except those with?
#Hypertension #Bradycardia #Advanced AV Block #Heart Failure
Dosing of metoprolol in acute ACS?
Three 5 mg increments q5 minutes
Contraindications to ACE therapy?
#Systolic blood pressure under 90 #Advanced kidney dysfunction #Hyperkalemia
How long to IDEALLY continue dual antiplatelet therapy after STEMI?
Minimum duration of dual antiplatelet therapy?
One year
Four weeks if bare metal stent implanted
Role of heparin in acute ACS?
Prefer unfractionated or low molecular weight heparin?
When using heparin for primary PCI, guidelines recommend concomitant administration of?
Reduced incidence of reocclusion
Unfractionated (can monitor degree of anticoagulation)
Glycoprotein 2b/3a inhibitor
Instead of heparin + glycoprotein 2B/3A inhibitor, can consider using? Advantage?
Bivalirudin (Direct thrombin inhibitor)
Similar rate of ischemic events but fewer bleeding events
Diabetic presents with ACS, gold glucose level?
Under 180
After/During MI, patient develops hypotension, jugular venous distention, but has clear lung fields.
Cause? EKG finding? ECHO finding? PA catheter finding?
Right ventricular infarction
ST segment elevation in V3R and V4R;
dilated RV with reduced systolic function;
elevated RA and RV pressure with low wedge pressure
After/During MI, patient develops systolic blood pressure under 90?
Cause? EKG finding? ECHO finding? PA catheter finding?
LV infarction
ST elevation in anterior leads
Severe LV dysfunction
CI under 2; wedge pressure over 18
After/During MI, patient develops holosystolic murmur along left sternal border. Often also presents with this sound?
Cause? EKG finding? ECHO finding? PA catheter finding?
VSD; thrill
Nonspecific (50% associated with anterior wall MI)
#High velocity left-to-right systolic jet #systolic turbulence RV side
#Large V waves in wedge pressure tracing #Step up in oxygen saturation from right atrium to left ventricle
After/During MI, patient develops Holosystolic murmur at the left sternal border. Crackles on pulmonary exam. May also present with this auscultation finding?
Cause? EKG finding? ECHO finding? PA catheter finding?
Papillary muscle rupture (radiation of murmur to axillae)
Usually inferior/inferior-posterior wall MI
#Flail mitral valve leaflet with attached mass (papillary muscle head) #Severe MR
Prominent large V waves in wedge pressure tracing
After/During MI, patient develops hypotension, jugular venous distention, and distant heart sounds.
Cause? EKG finding? ECHO finding? PA catheter finding?
Left ventricular free wall rupture
Potentially pulseless electrical activity
#Pericardial fusion with Tamponade #Discrete wall motion abnormality #Defect in myocardium
#Equalization of diastolic pressures #CI under 2
Sinus bradycardia typically occurs after which type of myocardial infarction?
May also see these type of arrhythmias?
Inferior wall MI
#Atrial fibrillation #Heart block
Ventricular rhythm is arrhythmias suggest poorer mortality/mobility if?
After first 24 hours
Patient develops persistent high degree atrioventricular block or symptomatic bradycardia after MI - next step?
Temporary transcutaneous or transvenous pacemaker
RV infarction triad?
#Hypotension #Elevated JVP #Clear lung exam
RV infarction treatment?
inotropes (dopamine or Dobutamine) until RV function improves (usually 2-3 days)
VSD after MI – management?
#Vasopressor agents #Intra-aortic balloon pump
Must get SURGERY (or if not, percutaneous VSD closure device)
Etiologies of mitral regurgitation after STEMI?
#LE dysfunction with annulus that location #Worsening of pre-existing mitral vegetation #Rupture of papillary muscle/chordae tendinae
Treatment of mitral regurgitation after STEMI?
#Vasodilators to reduce afterload #Diuretics to decrease preload #If unstable, intra-aortic balloon pump
Risk factors for LV rupture?
#Female #Anterior Myocardial Infarction #Incomplete Reperfusion
LV thrombus is common (how common?) after which type of MI?
Treatment?
10-20% after anterior wall MI
Warfarin for 3-6 months
