Cardiovascular System Flashcards by Bingjie Li

What are (7) major risk factors for stable angina? Which is the worst?

Diabetes (worst one)
Hyperlipidemia
Hypertension
Cigarette smoking
Age
FHx of CAD or MI
Low levels of HDL

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Below what EF leads to increased mortality risk in CAD?

EF <50%

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What vessel involvements in stable angina have an increased mortality risk?

LMCA - supplies ~2/3 of heart

2. 2 or 3-vessel involvement

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What are the clinical features of stable angina?

Chest pain / substernal pressure sensation <10-15m, usually more pressure than sharp, gradual onset
Worse with exertion / increased oxygen demands
Relieved with rest / NG
No change with position / breathing / chest wall tenderness

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What diagnostic tools are used to evaluate for stable angina and what is seen on those tools?

Physical Exam: normal
Resting ECG: normal
Stress test: ECG, ECHO
Cardiac catheterization w/coronary angiography

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What wave signs on an EKG escalate a stable angina to an unstable angina?

ST-segment or T-wave abnormalities

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What is the highest sensitivity exam in evaluating for CAD if the resting ECG is normal?
What does it involve?
When is it contraindicated?
What happens if the exam is positive?

Stress ECG

ECG done before, during, and after a treadmill
exercise induced ischemia causes subendocardial ischemia leading to ST-depression
Contraindicated: baseline ECG abnormalities (LBBB, LVH)
If (+) –> cardiac cath

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When is a stress ECHO indicated and what does it involve?

What happens if the exam is positive?

If resting ECG is normal and CAD is suspected.
More sensitive for detecting ischemia, can assess LV size / function, dx valvular disease, identify CAD w/pre-existing ECH abnormalities
ECHO performed before and after exercise, after may show wall motion abnormalities like akinesis or hypokinesis not present at rest
If (+) –> cardiac cath

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What is a stress myocardial perfusion imaging and what is it used for?

IV radioisotope injection during exercise that evaluates uptake of the isotope by viable myocytes during exercise

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What are the differences between the (3) medications used in pharmacological stress test administration?

Adenosine, Dipyridamole (used in perfusion imaging): causes generalized coronary vasodilation, so diseased arteries receive less flow when the whole cardiac system is also vasodilated
Dobutamine (used in stress ECHO): increases HR, BP, cardiac contractility

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What is the most definitive test for CAD?

Coronary catheterization with coronary angiography

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When is a stress test considered to be positive?

ST-Depression
Chest pain
Hypotension
Significant arrhythmias

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What are the (2) types of conditions termed “Syndrome X” and what do they involve?

Metabolic Syndrome X: 1+ HCh, HTG, impaired glucose tolerance, DM, hyperuricemia, HTN
Syndrome X: exertional angina w/normal CA (chest pain w/ exercise, but normal cardiac cath), exercise testing / nuclear imaging show MI

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What medication used in CAD treatment is proven to decrease morbidity and reduce risk of MI?

Aspirin

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What medications are indicated in the treatment of ACS?

Aspirin
Lipid-lowering agents
B-blockers
Nitrates
CC-blockers

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What (2) types of lipid-lowering agents are used in ACS treatment and why?

HMG-CoA reductase inhibitors (statins) lower LDL

2. PCSK9 inhibitors lower LDL even more; use in conjunction with statins for LDL level >70

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When is revascularization indicated?

Stable angina refractory to medical therapy and symptom control

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What is the pathophysiology of unstable heart angina? What happens to oxygen demand?

Unchanged oxygen demand; decreased oxygen supply due to reduced resting coronary flow

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What are the (3) types of patients who may have unstable angina?

Patients with chronic angina with increasing frequency, duration, intensity of chest pain
Patients with new onset angina that is severe + worsening
Patients with angina at rest

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What is the difference between unstable angina and NSTEMI?

Cardiac enzymes; NSTEMI has elevated troponin or CK-MB

What are the mortality-lowering medications used in the treatment of unstable angina?

Duel anti-platelet therapy (aspirin + P2Y12 inhibitor - clopidogrel, ticagrelor, prasugrel) x9-12 mo
Heparin (LMWH)
BB unless CI

What other medical management is indicated in the treatment of unstable angina?

Aspirin
Heparin
P2Y12 inhibitor
BB
Nitrates
Glycoprotein IIb/IIIa inhibitors as adjuncts
High-intensity statin
Oxygen
Replace electrolytes (K+, Ca+)
Morphine

What are the indications for revascularization in unstable angina after evaluation?

After patient responds to medical therapy and a stress test is complete
If sx persist after medications and/or ECG continues to show signs of ischemia >48h
Hemodynamic instability, ventricular arrthymias, new MR, new septal defect

What angina classically appears at night, at rest, and are associated with ventricular arrhythmias? What is the pathophysiology? How is it diagnosed? How is it treated?

Variant (Prinzmetal) angina - transient vasospasm on top of atherosclerotic lesions
Dx: transient ST-elevation on ECG when chest pain occurs, coronary angiography shows vasospasm after IV ergonovine or acetylcholine administration to provoke vasoconstriction
Tx: vasodilators (CCB, nitrates), RF modifications

What is the most common cause of myocardial infarction?

Acute coronary thrombosis: atheromatous plaque ruptures into vessel lumen, thrombus forms, leads to occlusion

What are the common clinical symptoms of myocardial infarction? What about other symptoms?

``` Most common: - Intense substernal chest pain, crushing - Radiation to neck, jaw, arms, back, occasional epigastric - May not respond to NG **may be asymptomatic in ~33% of patients (women, elderly, post-op, diabetic) Other: - dyspnea - sweating - weakness/fatigue - n/v - sense of impending doom - fainting ```

How is a myocardial infarction diagnosed? What is seen on the diagnostic tests and what do they indicate?

ECG: - peaked T waves: occur early on, may be missed - ST-segment elevation: transmural injury, acute infarct - Q waves: necrosis, occurs later - T-wave inversion: nonspecific - ST-segment depression: subendocardial injury Cardiac Enzymes: - troponins: (+) 3-5h, peak 12-24h, normalize 5-14d; repeat Q6H for 18-24h **may be falsely elevated in renal failure, must trend - CK-MB: (+) 4-8h, peak 24h, normalize 48-72h; repeat Q8H for 24h

When are nitrates and diuretics contraindicated in myocardial infarction? Why?

- Contraindicated in RV wall infarct with inferior lead changes - HPN, elevated JVP, hepatomegaly, clear lungs - May lead to cardiovascular collapse

What are the only (4) medications that have been shown to reduce mortality in treatment of MI?

1. Aspirin 2. Ticagrelor 3. BB 4. ACEi

What do the following ECG changes indicate about the location of a myocardial infarct? 1. V1-V4: ST elevation (acute), Q waves (late) 2. V1,V2: large R wave, ST depression, prominent T 3. I, aVL: Q waves (late) 4. II, III, aVF: Q waves (late)

ECG changes in ischemia 1. Anterior infarct 2. Posterior infarct 3. Lateral infarct 4. Inferior infarct

Which medication used in the ACS treatment combination has a common side effect of dyspnea?

Ticagrelor

Which medication used in the ACS treatment combination reduces remodeling of the heart post-MI?

Which statin gives the best results as shown in the PROVE IT-TIMI 22 trial?

Atorvastatin

What is the mechanism of action of nitrates when used in ACS treatment?

Venodilation to reduce oxygen demand on the heart through reduced preload

Which BB shows the greatest decreased in MI mortality?

Carvedilol

Which medication is used in unstable angina and STEMI/NSTEMI, but not used in stable angina?

Heparin

What are the (3) methods of revascularization? Within how long of ACS presentation should they be initiated?

1. Percutaneous Coronary Intervention (PCI): 90 min **preferred method of treatment 2. Thrombolytic therapy: 6 hrs up to 24hrs 3. Coronary Artery Bypass Grafting (CABG): used in multi-vessel disease

When are thrombolytics indicated? Which is the best? What are absolute contraindications?

- (Alteplase) Indicated if ST elevation in 2+ contiguous leads with pain onset <6h prior, not responsive to NG - CI: trauma (head or CPR), previous stroke, recent invasive surgery, dissecting aortic aneurysm, active bleeding/ bleeding diarrhea

What are the (6) main categories of complications after acute MI?

1. Pump failure (CHF) 2. Arrhythmias 3. Recurrent infarction 4. Mechanical/anatomical 5. Acute pericarditis 6. Dressler syndrome

What is the most common cause of in-hospital mortality after acute MI? How is it treated?

CHF - treat mild cases with medications (ACEi, diuretic) - severe cases may lead to cardiogenic shock

``` How are the following arrhythmias that may present after an acute MI managed and treated? PVC AFib VTach VFib PSVT Sinus tach Sinus brady Asystole AV block ```

PVC: observation AFib: ? VTach: antiarrhythmic (stable), electrical cardioversion (unstable) VFib: immediate defibrillation + CPR PSVT: ? Sinus tach: treat underlying cause (pain, anxiety, fever, etc.) Sinus brady: observation, consider atropine if severe Asystole: treat as VFib unless obvious; transcutaneous pacing AV block: 2 degree anterior - emergent pacemaker, 2D inferior - IV atropine or temporary pacemaker

How is recurrent MI within 24h treated?

Repeat thrombolysis or urgent catheterization and PCI; continue medical management

What mechanical complications after acute MI occur on the following timeline? What are their treatments? 1-4d to 2wk Within 10d

1-4d: free wall rupture - hemodynamic stabilization, pericardiocentesis (due to hemopericardium and cardiac tamponade), surgical repair <10d: IV septum rupture - emergent surgery

What mechanical complication has most likely occurred if a patient presents with a new murmur after an acute MI? How do you diagnosis it? How is it treated?

Papillary muscle rupture -> acute MR Dx: immediate ECHO Tx: emergent surgery with mitral valve replacement, sodium nitroprusside to decrease afterload, intra-aortic balloon pump (IABP)

What ventricular mechanical complications may occur after acute MI? When is surgery indicated?

``` Ventricular pseudoaneurysm (surgical emergency): incomplete free wall rupture - contained by pericardium, likely to become full free wall rupture Ventricular aneurysm: medical management ```

What is the likely diagnosis if a patient presents weeks to months after an acute MI with fever, malaise, pericarditis, leukocytosis, and pleuritis? What is the pathophysiology? What is the treatment?

Dressler syndrome; immunological | Tx: aspirin, ibuprofen

What are the main steps in evaluating a patient presenting with chest pain?

1. Rule out life threatening causes (ACS, aortic dissection, pericarditis w/cardiac tamponade, PE, tension pneumothorax, esophogeal rupture) 2. Assess vitals 3. Focused history (OLDCARTS) 4. Focused physical exam 5. Ancillary tests (ECG, cardiac enzymes, CXR, PE r/o) 6. DDx (CV, Pulm, GI, MSK, Psych, Drugs)

In evaluation for chest pain, what factor makes it more likely to be cardiac in nature? What factors make it less likely to be cardiac origin?

More likely: relieved with nitroglycerin | Less likely: pain is positional, pleuritic, reproduced with chest wall palpation