CHD Flashcards
Left main artery
aka left coronary
branches to left anterior descending (LAD) and circumflex
right coronary artery
RCA
to base and anterior wall
RA and RV
LAD
left anterior descending
LA- front and septum
circumflex
from left coronary
LA and LV- back and side
CHD
athersclerosis - endothelial injury causes smooth m. proliferation, inflammatory cell recruitment and lipid deposition within the vessel
plaque progressively narross the coronary artery lumen impacting blood flow
unstable plaque ruptures and exposes throbogenic core of lipid and necrotic material to platelets that adhere and aggregate causing ACS
10 yr risk of CHD event > 20%
noncoronary artheroscerotic disease - carotid artery disease, PAD, AAA
DM
CKD
CHD: risk factors
Fhx - MI/death of 1st degree relative 45 (M), >55 (F) gender- men, women after menopause Elevated hs-CRP metabolic syndome obesity elevated blood homocysteine levels low intake fruit/vegetables/fiber and high intake of red meat/glycemi index foods physical inactivity psychosocial factors - stress, depression estrogen deficiency oral contraceptives cocaine
framingham risk calculator
uses age, gender, SBP, cholesterol, HDL, BP meds, smoking status
CHD symptoms
often asymptomatic CP/angina arm, shoulder, neck, back of jaw pain dyspnea w/ or w/o exertion syncope or presyncope weakness dizziness/lightheadedness fatigue palpatations/ arrhythmias SCD HF - dyspnea, orthopnea, wt gain, edema
CHD PE
often normal
may have bruits - PVD
abnormal ABI/ weak lower extremity pulses - PAD
HF - peripheral edema, S3, ascites, rales, JVD, HJR
Stable angina pectoris
usually causes by CHD, oxygen demand exceeds supply
CP- heavy, pressure, squeezing, burning, fullness, elephant on chest, may radiate to shoulder, arm, neck, jaw
does not change w/ position or inspiration
palpatation causes no additional discomfort
Also - SOB, nausea, diaphoresis, lightheaded, fatigue
discomfort occurs w/ activity and resolves w/ rest
same discomfort every episode
nitroglycerin shortens or aborts attack
stable angina pectoris PE
incr. in HR, BP - sympathetic activation
S3, S4, paradoxical splitting of S2
New/changed murmur- papillary m. dysfcn
stable angina pectoris tests
Labs - lipid, CMP, CBC, TSH
troponin/ CK-MB
CXR- should be no findings
resting EKG - not sensitive or specific but during anginal episode, characteristic ST depression
echocardiogram
ultrasound
ability to evaluate cardiac anatomy and function
evaluate LVEF - +50% normal
can show wall motion abnormalities indicative of S/P MI or active ischemia
exercise stress test
evaluate continue EKG w/ exercise
look for ST depression of 1 mm or greater
ability to monitor BP, functional capacity, monitor for exercise-induced symptoms and arrhythmias
cannot use for abnormal resting EKG - ST depression, NSST changes, LBBB or paced
no radiation
stress echocardiogram
provides an ultrasound evaluation of cardiac function pre- and post-exercise
normal study - hypercontractility of all walls post exercise
abnormal - one area has poor movement or hypokinetic
difficult on pts with large body habitus
no radiation
dobutamine stress echocardiogram
increases contractility of the heart (+ inotropic agent)
ordered only for pts unable to exercise and have significant COPD/ asthma with active wheezing
highly symptomatic - feel like having heart attack - CP, dyspnea, palpitations, HA, nausea
Nuclear stress test
visualize radiopharmaceutical pre and post exercise
can calculate LVEF
can tell if viability fixed (post MI) or reversible (active ischemia)
modest radiation exposure, high cost
may see balanced perfusion in 3 vessel disease but generally fairly accurate
chemical nuclear stress test
for pts that cannot exercise to target HR, lexiscan used
contraindications - pregnancy, AV blocks (not 1st), sinus node dysfcn, active wheezing, BP <90/60
common SE - bronchoconstriction, hypotension, dyspnea, CP, nausea, flushing, abd pain, HA, dizziness (usually brief)
Stress Test contraindications
acute MI, unstable angina pectoris
uncontrolled arrhythmias causing hemodynamic compromise symptoms
symptomatic sever vavlular stenosis - aortic esp.
uncontrolled, symptomatic HF
active endocarditis, acute myocarditis, pericarditis
aortic dissection
PE or systemic emboli
acute disorders that exercise may aggravate
pregnancy - nuclear/pharm only
stress test info
exercise to target HR - 85% of max for age (220-age*.85)
LBBB or paced rhythm should be pharm testing only
drop in SBP indicates stenosis including left main disease
be prepared for the worst - staff and equipment
consider radiation exposure if done often
CCTA
coronary CT angiogram
non-invasive test to assess coronary artery anatomy and stenosis
irregular heart rhythms, severe coronary artery calcification, stents can interfere with the quality of images
segments with diameter <60
utilized when stress test results inconclusive
radiation exposure, contrast dye and kidneys, insurance
Left Heart Catherization
catheter inserted in the femoral/ radial artery, threaded up to coronary arteries
contrast dye injects to allow visualization of stenotic lesion
low risk of complications, substational radiation and risk of contrast-induced nephropathy
gold standard to determine info about atherosclerosis
antiplatelets
ASA +/- P2Y12 receptor blockers
P2Y12 - clopidogrel, prasugrel, ticagrelor
all pts w/ CHD should be treated with ASA
dual for post-PCI and ACS only
ASA inhibits thromboxane A2
P2Y12 block ADP binding -> no GP IIb/IIIa binding or aggregation
statins
reduce serum LDL
atherosclerosis regression, plaque stabilization, inflammation reduction, reverse endothelial dysfunction, decrease thrombogenicity, CRP reduction
proven survival benefit -primary and secondary
beta blockers
1st line anginal episodes, improve exercise tolerance
reduce heart oxygen demand by dec. HR and contractility
prevents reinfarct and S/P MI survival
SE: fatigue, diziness, sexual dysfcn, bronchoconstriction
contraindications: bradycardia, active bronchospasm, >1st degree block, hypotension, pulmonary edema, HF
ACEIs/ ARBs
don’t reduce angina
improve LV fcn and decrease mortality S/P MI
CCBs
decr. contractility
coronary and peripheral vasodilation
used when BBs contraindicated, SE or not sufficient
Nitrates
decrease myocardial oxygen demand- system vasodilation
SL nitre - tx of choice in acute anginal episodes
chronic tx for recurrent angina
nitro tolerance is an issue
SE: HA, flushing, hypotension
contraindicated: RV infarct, HCM, phosphodiesterase-5 w/in 24 hrs, severe asthma
ranolazine
chronic angina
reduces angina and incr. exercise capacity
late sodium channel blocker
minimal effects on BP and HR, can prolong QT
many drug interactions
PCI
stents, reduces restenosis and acute vessel closure
done during diagnostic cath
only lesions +70%
FFR and IVUS used to asses size of intermediate coronary lesions
not done- diffuse disease, chronic total occlusions, left main
stent use shoudl be discussed prior to procedue
<1% adverse risk - MI, stroke, death
complications - contrast nephropathy, retroperitoneal bleed, hematoma, AV fistula, pseudoaneurysma, contract rcn
PCI - Bare metal vs. DES
DES - decreased risk of restenosis, require 1 year S/P PCI dual anti-platelet therapy
Bare metal - 30 days anti-platelet, vessles >4mm, pts can’t afford dual platelet therapy, non-compliance likeley, durg alcohol abuse, needed surgical procedure in <1 yr
S/P PCI thrombosis
usually due to discontinuation of antiplatelets - high rate of MI and death
never stop post PCI antiplatelets w/o consulting their cardiologist first
CABG
coronary artery bypass graft
diffuse disease, total chronic occlusion, left main disease, 3 vessel disease, etc.
graft patency higher w/ IMA vs. saphenous vein graft
elective <1% death, most 2-5% risk of death
complications - graft occlusion, perioperative MI, atrial and ventricular arrhythmia, pericarditis, pericardial effusion, tamponade, infection, bleeding, acute kidney injury, DVT, PE, pleural effusion, atelectasis, neuro problems
afib in up to 40% of early postoperative period
CHD screening
diabetics who want to start exercising
multple risk factors for CHD
jobs w/ high cardiovascular performance required
men over 45, women +55, w/ multiple risks starting vigorous exercise
pts at high risk for CHD
EBCT w/ >75th percentile
ACS
acute coronary syndromes
unstable angine, NSTEMI, STEMI
sudden, reduced blood flow to the heart
plaque disruption, platelet plug, coronary thrombosis
CHD signs and symptoms + nausea, diaphoresis, anxiety, incr. angina, symptoms at rest, in early am, brady/tachycardia+ arrythmias, HTN/ hypotension, respiratory distress
UA
unstable angina
rest angina, new onset, increasing angina - frequency, time, exertion
EKG may or may not be suggestive - ST depression, T wave
no troponin or CK-MB
NSTEMI
troponin or CK-MB+
EKG - ST depression, T wave, nothing
STEMI
ST elevation or new LBBB
biomarkers not needed
classic evolution - peaked T wave, ST elevation, Q wave development, T-wave inversion
ACS: ER management
ABC Hx and PE 12-lead EKG CXR resuscitation equipment bedside cardiac monitor, O2 IV + labs - CMP, CBC< cardiac biomarkers, coag indices, lipids bedside echo
ACS: Rx
ASA: 325 mg chewed STAT
Nitro: .4 mg Q5 min until 3 doses given, may be IV
Morphine - 2-4 mgs Q15 min for persistant pain PRN
BBs
Statin
dual antiplatelet, angicoagulant, GP IIb/IIIa - cardiologist
UA and STEMI revascularization
no fibrinolysis
use TIMI Score to determine timing of angiography - age, risks, known CAD, aprin use, sever angina, cardiac markers, ST elevation
STEMI tx
PCI - door to balloon time of < 4 hrs, utilized w/in 12 hours
contraindications: ICH, known intracracranial issues, strokes, aortic dissection, active bleeding, significant closed-head trauma
Post ACS Car
dual antiplatelet statin BBs ACEIs aldosterone antagonist Nitro PRN cardiac rehab risk factor modification - include diet and exercise
Variant angina
aka prinzmetal angina
angina pectoris due to coronary artery vasospasn - high grade obstruction w/o CHD normally
50+ yo Japanese women that uses tobacco, cocaine, has other vasospastic disorders
recurrent CP - at rest, at night, 5-15 min
result - MI, aryrhthmias - palpitations, syncope, SCD
- AV block - RCA, Vtach (LAD)
transiet ST elevation during discomfort
tx: avoid stimulation, nitro, chronic: CCVs, long-acting nitrates, ICD
SCD
hemodynamic collapse due to Vfib w/in 1 hr of symptoms
usually CHD, HF, cardiomyopathy, LVH, myocarditis, HCM, cogenital anomalies, conduction - Brugada, long QT, Wolff-Parkinson-White, triggers- electolytes, drugs, commotio cordis
P2Y12 receptor blockers
clopidogrel, prasugrel and ticagrelor- ACS only
BBs
-lol
ACEIs
-pril
ARBs
-sartan
CCBs
-ipine, diltiazem, verapamil
nitrates
nitroglycerin, isosorbide
anticoagulants
heparin, enoxaprin, bivalirudin, fondaprinux
GP IIb/ IIIa
abciximab, eptifibatide, tirofiban
