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Medicine SHELF > Cardiovascular System > Flashcards

Cardiovascular System Flashcards

1
Q

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

A
  1. Diabetes (worst one)
  2. Hyperlipidemia
  3. Hypertension
  4. Cigarette smoking
  5. Age
  6. FHx of CAD or MI
  7. Low levels of HDL
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2
Q

Below what EF leads to increased mortality risk in CAD?

A

EF <50%

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3
Q

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

A
  1. LMCA - supplies ~2/3 of heart

2. 2 or 3-vessel involvement

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4
Q

What are the clinical features of stable angina?

A
  1. Chest pain / substernal pressure sensation <10-15m, usually more pressure than sharp, gradual onset
  2. Worse with exertion / increased oxygen demands
  3. Relieved with rest / NG
  4. No change with position / breathing / chest wall tenderness
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5
Q

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

A

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

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6
Q

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

A

ST-segment or T-wave abnormalities

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7
Q

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?

A

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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8
Q

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

What happens if the exam is positive?

A
  • 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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9
Q

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

A

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

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10
Q

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

A
  • 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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11
Q

What is the most definitive test for CAD?

A

Coronary catheterization with coronary angiography

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12
Q

When is a stress test considered to be positive?

A
  1. ST-Depression
  2. Chest pain
  3. Hypotension
  4. Significant arrhythmias
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13
Q

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

A
  1. Metabolic Syndrome X: 1+ HCh, HTG, impaired glucose tolerance, DM, hyperuricemia, HTN
  2. 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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14
Q

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

A

Aspirin

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15
Q

What medications are indicated in the treatment of ACS?

A
  1. Aspirin
  2. Lipid-lowering agents
  3. B-blockers
  4. Nitrates
  5. CC-blockers
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16
Q

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

A
  1. 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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17
Q

When is revascularization indicated?

A

Stable angina refractory to medical therapy and symptom control

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18
Q

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

A

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

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19
Q

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

A
  1. Patients with chronic angina with increasing frequency, duration, intensity of chest pain
  2. Patients with new onset angina that is severe + worsening
  3. Patients with angina at rest
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20
Q

What is the difference between unstable angina and NSTEMI?

A

Cardiac enzymes; NSTEMI has elevated troponin or CK-MB

21
Q

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

A
  1. Duel anti-platelet therapy (aspirin + P2Y12 inhibitor - clopidogrel, ticagrelor, prasugrel) x9-12 mo
  2. Heparin (LMWH)
  3. BB unless CI
22
Q

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

A
  1. Aspirin
  2. Heparin
  3. P2Y12 inhibitor
  4. BB
  5. Nitrates
  6. Glycoprotein IIb/IIIa inhibitors as adjuncts
  7. High-intensity statin
  8. Oxygen
  9. Replace electrolytes (K+, Ca+)
  10. Morphine
23
Q

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

A
  1. After patient responds to medical therapy and a stress test is complete
  2. If sx persist after medications and/or ECG continues to show signs of ischemia >48h
  3. Hemodynamic instability, ventricular arrthymias, new MR, new septal defect
24
Q

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?

A

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

25
Q

What is the most common cause of myocardial infarction?

A

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

26
Q

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

A 
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
27
Q

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

A

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

28
Q

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

A
  • Contraindicated in RV wall infarct with inferior lead changes - HPN, elevated JVP, hepatomegaly, clear lungs
  • May lead to cardiovascular collapse
29
Q

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

A
  1. Aspirin
  2. Ticagrelor
  3. BB
  4. ACEi
30
Q

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)
A

ECG changes in ischemia

  1. Anterior infarct
  2. Posterior infarct
  3. Lateral infarct
  4. Inferior infarct
31
Q

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

A

Ticagrelor

32
Q

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

A

BB

33
Q

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

A

Atorvastatin

34
Q

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

A

Venodilation to reduce oxygen demand on the heart through reduced preload

35
Q

Which BB shows the greatest decreased in MI mortality?

A

Carvedilol

36
Q

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

A

Heparin

37
Q

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

A
  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
38
Q

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

A
  • (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
39
Q

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

A
  1. Pump failure (CHF)
  2. Arrhythmias
  3. Recurrent infarction
  4. Mechanical/anatomical
  5. Acute pericarditis
  6. Dressler syndrome
40
Q

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

A

CHF

  • treat mild cases with medications (ACEi, diuretic)
  • severe cases may lead to cardiogenic shock
41
Q 
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
A

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

42
Q

How is recurrent MI within 24h treated?

A

Repeat thrombolysis or urgent catheterization and PCI; continue medical management

43
Q

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

A

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

44
Q

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?

A

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)

45
Q

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

A 
Ventricular pseudoaneurysm (surgical emergency): incomplete free wall rupture - contained by pericardium, likely to become full free wall rupture
Ventricular aneurysm: medical management
46
Q

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?

A

Dressler syndrome; immunological

Tx: aspirin, ibuprofen

47
Q

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

A
  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)
48
Q

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?

A

More likely: relieved with nitroglycerin

Less likely: pain is positional, pleuritic, reproduced with chest wall palpation

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