case selection Flashcards
for cabg questions will you need to calc a complex score for the boards (ie TIMI, Syntax)
No
Dr Whites Key point re PCI and CABG?
suspend reality. Need to do what evidence suggests not what you would do.
Things that favor CABG
good targets, high complexity, med-high syntax score, insulin dependent DM, poor dapt compliance, coexisting valve dz, less comorbidiy
What is class I indication for revasc of SIHD? What is class IIa?
stenosis > 50% with limiting angina > 50% unresponsive to OMT. Stenosis > 50% with dypnes or CHF and > 10% LV ischemia
In SIHD what percentage of LV ischemia is signficant?
>10%
What is considered prognostically signficant disease if stable angina or silent ischemia
- Left main > 50% 2. Any LAD > 50% with documented ischemia or FFR <0.8 3. 2VD or 3 VD with LV dysfunction with ischemia or FFR < 0.80 4. Large area of ischemia > 10% 5. Remaining patent vessel > 50% with ischemia or + FFR
What is class III for revasc?
1VD, no LAD > 50%, no ischemia
When CABG based on the guidleines by bonow?
1VD pLAD, 2VD with PLAD 3VD syntax <22 CABG is I and PCI is IIa 3VD syntax > =22and Syntax > =22 then CABG class I and PCI class III LM isolated CABG class I (PCI IIa) LM + 2VD or 3VD Syntax < 32 CABG class I and PCI IIb, if syntax >=33 then pci falls to class III
Only time PCI gets a higher class rec then CABG
1VD or 2VD non prox LAD (CABG IIb and PCI I
3VD syntax score that matters LM syntax care
>=22 however PCI in 3vd is IIb so PCI is pretty much not going to be a choice you want to take <33 or >=33 (although again if additonal lesions you are going to want to choose cabg (only real time you are good is isolated LM dz)
PCI ____ symptoms but doesnt improve ____ in SIHD
reduces, surivival
PCI may ____ short term risk of MI, and does note ____ the long term risk of MI in SIHD
increase, lower
Medical therapy on the exam
you will have to acknowledge that medical therapy will be a key component of this.
what is higher in cabg than pci (2)
stroke and HD
what drives MACE post PCI compared to CABG
TVR, and MI
What 2 trials show the CABG is better than PCI in pts with insulin treated DM with CABG
Freedom (18.7% vs. 26.6% 5 years)and Syntax (5 year MACE PCI 46.5 and CABG 29.0%),
Culprit Shock showed what
higher frequency of mort and RRT
SAFARI STEMI trial
fem vs. Radial
No difference in 30 d mor, no difference in bleeding
STEMI going to cath lab what do gl say to do before
asa 162 to 325 asa
P2?Y12 - Plavix 600, PRasugrel 60, Ticag 180
Heparin or bival
Algorhytm for presenting to non pci capable
will the transfer to device time be less than 120 min then tx
if > then lyse
Need a regional system of stemi care rec I
When dont watn to lyse even if expected door to tx time >120 min (%)
Cardiogenic shoc
high ris features:CHF
? ant mi
Later presetnters > 4 hrs
CI
- what is goal to give fibrinolytic if decide to do so]
- post fibrinolysis tx?
30 min
always need tx for an angio
- no reperfusion or reocclusion urgent
- transfer for angio & revasc 3-24 hours
GL recs for rescue PCI
class I, 3x mort if didnt do this.
What antiplts to support pci after fibrinolyisis/
< 24 hours 300 mg and > 24 hours 600 , can also give prasugrel 60 mg if > 24 hours and fibrin specific and 48 hours if fibrin nonspe adgent
Can you give prasugrel after TPA per the guidelines
YEs if PCI is 24 hours after with fibrin spe adgent or 48 hours after with non fibrin specific agent
300 or 600 mg post lysis with pci
300 mg if PCI within 24 hours and 600 mg if PCI after 24 hours (note see prior card on age for adjuncitve inital antiplts 75 give 75 and if younger give 300 mg). This shit is so fucking dumb
can you do CABG for STEMI
GL say class I for stemi and not amenable to PCI
also class I for repeair fo mechanical defects
Hypotheremia protocol recs
Out of hospital arrest and shocable rhythm
In hospital arrest and nonshockable
targeted temp between 32-36
goal is 24 hours
class III for prehosp cooling with rapid infusions of cold saline
ACC/AHA guideline update for people with CAD 5 things needs
antiplt with asa 81 and plavix, ticag, prasgurel 1 year post ACS
lipid lowering therapy to decrease LDL by 50% or to < 70 for very high risk
Anti HTN for bp goal < 130/80
ACE inhibitor (if htn or LV dysfunction)
BB preferably coreg
Metabolic syndrome
5 compontents
Hallmark is abd obesity
Men
Wait > 40 and Women > 35
TAG >=150 men and women
HDL-C men < 40 women < 50
BP >= 130/85 for men and women
FBG >=100
if have DM with metabolic syndrome risk?
doubles
what did the diabetes prevention program show
showed meformin decreased progression to DM by 31% and lifestyle cahnges by 58% (no metformin)
Hople trial showed what
ramipril had a reduction in DM (25-30%) reduction
Dr. LAvie prefers ARBs due to recent increased risk of CAncer
HTN GL change why did they change
Sprint trial (goal was to get it to <120/80 got it to 121/80)
intesive bp mangement had a 23% reduction so GL recd 130/85 goal
**2017 GL on antihtn
4 stages and treatments
4 cat
nomral <120 or < 80
elevated 120-129/80
HTN
stage 1 130-139/80-89
stage 2 >= 140 or >=90
ASCVD risk calc overestimates and underestimates in what groups
over hisp and asians
under in American indians
So how do we use the categories of bp now with the ASVD calc
BP stage I 130-139/80-90, and risk calculator 10 year risk >=10% ortherise start 140 over 90
6 livestyle interventions to reduce bp
- reduce salt
- DASH diet
- Exerices
- Avoid high etoh
- increase potassium
- reduce and maintain weight
<130/80 goal 2x need to start meds (what comorbid) 2 exceptins where can go with 140/90 goal
130/80 trheshold
- DM
- Ckd and CKD with renal txplt
- CHF
- Stable ischemic heart dz
- stroke prevention (lacunar onlu
- PAD
140/90 threshold ASCVD risk score <10% and do not have one of the above comorbiditis.
and hx of CVA (non lacunar
What is counted as ASCVD
ASCVD
angina
stroke/TIA
revasc for CAD
(in new ris score atheroon cath doesnt count as ascvd, 50% lesion for example but I would also a ca score of a 1000%
Secondary prevention guideline algo
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high does statin
crestor 20/40
lipitor 40/80
What is very high risk ASCVD (4)
What does this do?
Need 2 of these or 1+ High risk condition
recent ACS <12 mo
Hx of MI in addition to current event
history of ischemic strok
Symptomatic pad
High risk conditions: (everyeone)
age >65, hetero hyperchol, CABG or CAD outside of current events
HTN, DM, CKD GFR < 60, smoing, LDL >=100
CHF
Need LDL < 70 mg /dl
Who needs LDL <=70 secondary prevention
High risk ASCVD
-note I feel this should be < 50
<20 yo primaryprevention need statin
only for FH or LDL >190 need high intesity statin
Primary prevention for statin 40-75nyears old
ASCVD >7.5 or between 5-7.5 +risk enhanancers
reimary prevention for statin use algothrym
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when do you do CAC
40-55 with 10 year risk 5-7.5 with ris enhanceing factors to better understand risk
Men 55-80 and women 60-80 with low burgen of risk factors who wonder if would benefit
Zetia reduciton in LDL
PCSK9% lowering
15-20%
60% lower even on statin –> can reduce plaque (evoluquiamb) on us
aliroucamab amazing hting
mortality reduction
High TAG and low HLD?
Reduce it - EPA in reduce it 25% reduction and 20% reduciton
asa primry prvention
low dose asa 81 only high risk patients for ASCVD age 40-70
No routine use of asa ofr those <40 or >70 and leave to clnincaian
What is the CAC score lavine consideres high ris
top 25% for age
or > 200ish
In gereral ACS/UA need these meds
BB
ACE
Statin
ASA + Statin
What does lavine consider a high tAG
200
PCSk9 Eving house trial
2 years evolucamab <25, those with
Firstine rx of HTN these 3 medications
HCTZ/ACE,ARB or CCB