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General Medicine & Family Medicine > Cardiology\ Coronary Artery Disease > Flashcards

Cardiology\ Coronary Artery Disease Flashcards

1
Q

Describe the initial pathogenesis of atherosclerosis

A
  • Endothelial injury leads to
    • increased leukocyte adhesion to the endothelium
    • increased endothelial permeability, and
    • endothelial release of hemostatic and vasoactive substances
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2
Q

How is angina pectoris diagnosed?

A

Clinical history of a retrosternal pressure-like or squeezing sensation, frequently with radiation to the arms, neck, and jaw

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3
Q

Chest pain relief with nitroglycerin is diagnostic for angina. True or false?

A

False. Nitroglycerin can also decrease pain due to esophageal spasm.

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4
Q

What characterizes chronic stable angina?

A

Reproducibility with a consistent amount of exertion and long-standing symptoms

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5
Q

How is exercise-induced angina diagnosed?

A

Stress test results demonstrate ST depression during exercise.

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6
Q

Which stress-test findings may imply a poorer prognosis in cases of chronic stable angina?

A
  • ST depression greater than 2 mm
  • ischemia at low stress levels
  • hypotension resulting from exertion
  • the presence of ischemic changes in more than five ECG leads
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7
Q

What three general management strategies should be considered in chronic stable angina?

A
  1. Modification of risk factors
  2. Symptomatic relief of angina via medication or interventional modalities
  3. Treatment of other contributing diseases
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8
Q

What other diseases may exacerbate chronic stable angina?

A
  • Fever
  • anemia
  • congestive heart failure
  • infection
  • thyrotoxicosis
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9
Q

What medications may provide symptomatic relief of angina?

A
  • Nitrates
  • calcium channel blockers
  • beta-blockers
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10
Q

Describe the mechanism by which nitrates provide symptomatic relief.

A

Vasodilation of the following:

  • Coronary vessels → increase myocardial oxygen supply
  • Peripheral veins → decrease venous return to the heart → preload reduction → decrease in myocardial oxygen demand
  • Peripheral arteries → decrease in peripheral vascular resistance → afterload reduction → decrease in myocardial oxygen demand
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11
Q

Do nitrates have a predominant effect on veins or arteries?

A

Veins (and therefore preload)

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12
Q

Describe the mechanism by which beta-blockers and calcium channel blockers provide symptomatic relief

A

Decrease myocardial oxygen demand by decreasingheart rate (HR), blood pressure (BP), and contractility

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13
Q

If angina continues despite maximal medical management, what strategies may be employed?

A
  • Cardiac catheterization to evaluate coronary anatomy
  • revascularisation can e considered via coronary angioplasty, stenting or CABG
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14
Q

Describe Prinzmetal variant angina

A

Angina at rest characterized by transient coronary artery spasm and ST elevation

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15
Q

What conditions fall under the heading of acute coronary syndromes (ACS)?

A
  • Unstable angina (UA)
  • non-ST-elevation myocardial infarction (MI) (NSTEMI)
  • ST-elevation MI (STEMI)
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16
Q

What physical exam findings are typical of ACS?

A
  • Tachycardia
  • transient S3 or S4
  • hypertension
  • mitral regurgitation secondary to ischemia of the papillary muscle
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17
Q

Describe UA

A
  • New onset angina (<2 months) with only minimal exertion
  • crescendo angina in the setting of existing stable angina
  • angina at rest of greater than 20 minutes
  • angina occurring greater than 24 hrs post-MI
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18
Q

What ECG findings may be seen in UA?

A

ST depression or symmetric T-wave inversions

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19
Q

In what percentage of patients does UA progress to MI?

A

Approximately 5%

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20
Q

In cases of UA, what are the major steps for providing symptomatic relief and preserving myocardial function?

A
  • Provide analgesia
  • improve coronary blood flow
  • prevent coronary thrombosis
  • decrease myocardial oxygen demand
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21
Q

What drug options should be considered to address analgesia?

A

Morphine to decrease pain and anxiety

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22
Q

Why is it important to control pain in a patient with UA?

A

Analgesia can decrease the sympathetic response (lower HR and BP), which decreases myocardial oxygen demand.

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23
Q

When should antiplatelet therapy be started?

A

Immediately after UA is suspected

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24
Q

What drug should be used to provide antiplatelet action acutely?

A

Aspirin 162-325 mg

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25
Q

What drug options should be used to provide long-term antiplatelet action?

A

Aspirin 81-325 mg and clopidogrel 75 mg, daily

26
Q

What class of drugs should be used to reduce myocardial demand in all patients with UA/NSTEMI?

A

Beta-blockers

27
Q

Is thrombolytic therapy used in the treatment of UA and NSTEMI?

A

No

28
Q

Following stabilization of the UA/NSTEMI patient, what further studies should be undertaken in low-risk patients?

A

Noninvasive stress testing

29
Q

Following stabilization of the UA/NSTEMI patient, what further studies should be undertaken in high-risk patients?

A

Cardiac catheterization followed by revascularization procedures, if indicated

30
Q

How is UA differentiated from NSTEMI?

A

In NSTEMI, ischemia is significant enough to cause myocardial damage, leading to an elevation of troponin I and creatine kinase from cardiac muscle (CK-MB)

31
Q

Which biomarker is the most sensitive and specific for myocardial injury?

A

Troponin I

32
Q

How are NSTEMI and STEMI similar?

A

In both conditions, troponin I and CK-MB are elevated

33
Q

How are NSTEMI and STEMI different?

A
  • In STEMIs, ECGs show ST segment elevations or Q waves in at least two contiguous leads.
  • In NSTEMIs, ECGs show ST segment depression but lack ST segment elevations or Q waves.
34
Q

ECG changes in which leads are indicative of Anterior wall ischemia?

A

V1-V6

35
Q

ECG changes indicative of Anteroseptal ischemia?

A

V1-V3

36
Q

ECG changes indicative of Lateral ischemia?

A

AVL, I, V4-V6

37
Q

ECG changes indicative Inferior ischemia?

A

II, III, aVF

38
Q

What group of patients are more likely to present with atypical symptoms of myocardial infarction?

A
  • Women
  • diabetics
  • the elderly
39
Q

What accounts for most of the deaths that take place within a few hours of a STEMI?

A

Ventricular tachyarrhythmia

40
Q

ECG changes during a STEMI

  • immediate
A
41
Q

ECG changes during a STEMI

  • Minutes
A
42
Q

ECG changes during a STEMI

  • Hours
A
43
Q

ECG changes during a STEMI

24-48 hrs

A
44
Q

ECG changes during a STEMI

Days tp weeks

A
45
Q

What does echocardiography show during STEMI?

A
  • LV hypokinesis or akinesis in the area supplied by the occluded vessel
46
Q

What two pharmacologic agents should be started immediately after diagnosing a patient with either NSTEMI or STEMI?

A
  1. Aspirin
  2. Anti-thrombotic agents (unfractionated or LMW heparin)
47
Q

Despite its increased effectiveness, when is LMW heparin contraindicated?

A

Renal insufficiency as it is cleared by kidneys

48
Q

What steps should be taken after diagnosis of either NSTEMI or STEMI?

A
  1. Aspirin
  2. anit-thrombotic agents(unfractionated or LMW heparing - unless renal insufficiency)
  3. Morphine if indicated
  4. Oxygen if indicated
  5. Nitroglycerin
  6. Anxiolytics if indicated
  7. Beta-blockers
49
Q

How should the first dose of aspirin be taken?

A
  • Chewed, to ensure rapid uptake
50
Q

If the patient continues to show ST-elevation and has persistent angina, what therapy should be initiated?

A
  • Reperfusion with primary angioplasty or
  • initiation of thrombolysis
    • tissue Plasminogen activator
51
Q

Tissue plasminogen activator (tPA) can restore patency to an occluded coronary vessel in what percentage of patients?

A

Approximately 75%-80%

52
Q

Primary angioplasty can restore patency to an occluded coronary vessel in what percentage of patients?

A

approx. 95%

53
Q

Beyond what period of time from the onset of initial symptoms does thrombolysis lose effectiveness?

A

6 hours

54
Q

What is the major limitation of primary angioplasty?

A

Lack of widespread availability

55
Q

Following thrombolysis, for how long should heparin be continued?

A

24-48 hours

56
Q

How long should aspirin be continued?

A

Indefinitely

57
Q

What other drugs should be initiated on a long-term basis?

A
  • Beta-blockers
  • ACEI
  • high-dose statins (eg, atorvastatin 80 mg once daily)
58
Q

What diagnostic study should be performed several days after acute MI

A

Echocardiography

59
Q

What vaccination should be given to patients with coronary artery disease?

A
  • annual influenza
  • pneumococcal
60
Q
A

General Medicine & Family Medicine (150 decks)

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