Cardiovascular Part 1 Flashcards
What is signs and symptoms from imbalance between myocardial oxygen supply and demand with no elevation of biomarkers and no pathologic ST segment elevation
Unstable Angina
Acute chest pain lasts
<24 hours
Visceral pain feels
poorly localized and dull, heavy or aching
Initial approach to chest pain includes
prompt triage
Visceral pain, abnormal vitals, significant risk factors, dyspnea => place in bed, cardiac monitor, IV, oxygen, ECG
What PE characteristic increases the likelihood of AMI greatest
radiation to right arm or shoulder
Factors that decrease the likelihood of AMI
Pleuritic Positional Sharp Reproducible with palpation Inframammary location Not exertional
Who commonly has atypical presentations of ACS?
Women Nonwhite minorities Diabetics Elderly Psych pts/AMS
Cardiac risk factors include
Age > 40 Male or postmenopausal female HTN Smoking High cholesterol Diabetes Truncal obesity Family history Sedentary lifestyle Cocaine use
Does absence of chest pain rule out MI?
No
33% do not have CP
Does chest wall tenderness on palpation rule out MI?
No
15% have this
Chest pain that is sharp or dull and is worse with breathing should consider
costochondritis
What cardiac enzyme is most sensitive for MI?
Troponin
What cardiac enzyme is best to see reinfarction
CK-MB
Define hypoxia
Deficiency in oxygen supply or availability to tissues
Define ischemia
Oxygen deprivation with inadequate removal of metabolites due to reduced perfusion. Occurs when there is an imbalance between oxygen demand and supply
Hearing rales on PE Is suggestive of
LV dysfx
left sided CHF
JVD, peripheral edema, hepatojugular reflex on PE is suggestive of
right sided CHF
Changes in II, III, & aVF indicate what infarct area and occlusion to which vessel
Inferior Infarct
RCA
Changes in lateral leads (I, aVL, V5, V6) indicate what infarct area and occlusion to which vessel
Lateral Infarct
Left circumflex
Changes in V1-V6 indicate what infarct area and occlusion to which vessel
Anterior
LAD (left anterior descending)
V1 with tall R waves and ST depression indicate what infarct area and occlusion to which vessel
Posterior MI
Right Coronary Artery
Changes precordial leads + I & aVL indicate what infarct area and occlusion to which vessel
Anterolateral
Left Main Artery
Changes in II, III, aVF, and V1 indicate what infarct area and occlusion to which vessel
Inferoposterior MI
Right Coronary Artery
What type of angina can demonstrate ST elevation on ECG
Prinzmetal
PCI should goals are within _____ of ED arrival OR fibrinolysis within _____ if PCI cannot be done
90min
or fibrinolysis within 30min
ABSOLUTE contraindications to fibrinolytics
Any prior intracranial hemorrhage
Known structural cerebral vascular lesion (e.g., arteriovenous malformation)
Known intracranial neoplasm
Ischemic stroke within 3 mo
Active internal bleeding (excluding menses)
Suspected aortic dissection or pericarditis
Is history of GI bleed a contraindication to ASA in unstable angina/MI?
No
Only withhold in case of true allergy
If true allergy to ASA exists, what should be used instead?
Clopidogrel
If Clopidogrel is given when can the patient receive a CABG
Hold clopidogrel for 5 days if possible
should still give in ED if appropriate
What drugs are used in PCI but not in fibrinolytics
GP IIb/IIIa Inhibitors:
Abciximab, Eptifibatide, Tirofiban
When using unfractionated heparin, you should monitor _____.
Try to d/c after _____ hours to reduce risk of _____
Unfractionated Heparin:
Monitor PTT
d/c after 48 hrs to reduce risk of thrombocytopenia
LMWH monitored by
Do not need to monitor PTT
Nitrates should be used with caution in what type of MI?
Inferior MI
nitrates reduce preload and may cause hypotension due to RV involvement
When should BB be used in ACS?
Start oral (not IV) in pts with STEMI or NSTEMI within 24 hrs unless:
Signs of heart failure
Low cardiac output state
Increased risk for cardiogenic shock
Prolonged PR,
2nd or 3rd degree heart block,
active asthma,
reactive airway disease
cocaine use!What roles do ACEI play in MI treatment
should be started orally within 24hrs MI
-reduced mortality
When should ACEI not be used in MI treatment
HOTN, renal failure, hx angioedema, renal artery stenosis
How should postprocedural chest pain be approached?
ACS symptoms shortly after PCI should be assumed to have vessel closure until proven otherwise. Treat aggressively for ACS. Could also be pericarditis.
Are cardiac risk factors good predictors of risk for MI or ACS?
NO
A change in troponins 2 hours apart of _____ is significant, and can be seen in AMI
0.05
RF for Cardiogenic Shock
Elderly Female Acute or prior ischemic event Prior medical hx Hx MI CHF Diabetes
MCC of cardiogenic shock
Large MI
–>pump failure
Tx changes if pt has cardiogenic shock and acute MI
No Nitroglycerin if SBP <90
No BB
Tx cardiogenic shock hypotension if no improvement from small fluids or if pulmonary congestion present
Use vasopressors (Dopamine) and/or inotropes (dobutamine)
- Dobutamine DOC if SBP>90
- SBP <70 then atleast use dopamine
If dopamine is ineffective in the treatment of hypotension secondary to cardiogenic shock the next DOC is
norepinephrine
Cardiogenic shock + acute MI
best treatment targeted for MI
PCI preferred to thrombolytic
Mortality decreased with revascularization
Do CHF symptom severity predict outcome?
Yes
MC non-cardiac causes acute of CHF
noncompliance to diet/meds
Normal Eject Fraction is
60%
Pattern of progression respiratory symptoms in CHF
Exertional dyspnea
Paroxysmal nocturnal dyspnea
Orthopnea
Dyspnea at rest
(+) hepatojugular reflex with
right sided failure
Kerley B Lines on CXR
CHF
Obesity raises/lowers BNP
lower
BNP may be increased in
CHF
pulmonary HTN
PE
MI
Standard initial treatment for CHF
Cardiac monitoring Pulse oximetry Oxygen 12 Lead ECG, Labs, CXR IV access Frequent vitals Foley cath if critical pt
