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CPR 2 Exam 1 > Clinical Cardiac Part 1 > Flashcards

Clinical Cardiac Part 1 Flashcards

1
Q

What is definition of stable angina?

A

Chest pain or pressure for at least 2 months duration that is precipitated by exertion or emotional stress and have no appreciably worsened

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2
Q

What are the three types of acute coronary syndrome?

A

1) Unstable angina
2) NSTEMI
3) STEMI

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3
Q

What is the definition of unstable angina?

A

New onset angina
Angina with minimal exertion
Angina at rest
Angina with accelerating frequency/severity

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4
Q

Are there ST segment depression and T wave inversions with unstable angina?

A

Maybe

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5
Q

Are the cardiac enzymes abnormal with unstable angina?

A

No

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6
Q

What is the EKG finding with NSTEMI?

A

ST depression

T wave inversion

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7
Q

Are the cardiac enzymes abnormal with NSTEMI?

A

Yes

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8
Q

What are the EKG findings with STEMI?

A

ST elevation
New LBBB
Posterior MI

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9
Q

Are the cardiac enzymes abnormal with STEMI?

A

Yes

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10
Q

What is the leading cause of death in the US?

A

Coronary artery disease

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11
Q

What are the modifiable risks for coronary artery disease?

A 
HTN
Hyperlipidemia
Diabetes
Overweight
Cigarette smoking
Physical inactivity
Unhealthy diet
Stress
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12
Q

What are the atherogenic risk factors for CAD?

A

Low HDL <40 mg/dL
High LDL
High Non-HDL

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13
Q

What are non-modifiable risk factors for CAD?

A

Male
Age (men 45, women 55)
Family history of premature CAD (men 55, women 65)
Ethnicity (black, hispanic, asian)

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14
Q

What are non-traditional risk factors for CAD?

A

Chronic kidney disease
Proteinuria
Inflammatory states

Metabolic syndrome
Ankle brachial index
Elevated coronary calcium score
Elevated CRP
Elevated Apolipoprotein B
Elevated Lipoprotein A
Elevated homocysteine levels
Premature menopause 
Atrial fibrillation
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15
Q

Which inflammatory states are risk factors for CAD?

A

HIV
Rheumatoid arthritis
Psoriasis

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16
Q

What is the clinical presentation of acute coronary syndrome?

A 
Typical chest pain/discomfort
Dyspnea
Nausea/vomiting
Diaphoresis
Fatigue
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17
Q

In which populations are acute MIs painless?

A

Elderly
Women
Diabetics

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18
Q

What are the Diamond-Forrester criteria for chest pain?

A

1) Substernal chest pain or discomfort
2) Provoked by exertion or emotional stress
3) Relieved by rest and/or nitroglycerin

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19
Q

Typical angina CP has how many Diamond-Forrester criteria?

A

3

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20
Q

Atypical angina CP has how many Diamond-Forrester criteria?

A

2

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21
Q

Non-angina CP has how many Diamond-Forrester criteria?

A

Less than or equal to 1

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22
Q

What are the three ways to diagnose stable angina?

A

Resting EKG
Cardiac stress test
Invasive coronary angiography

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23
Q

When do you do cardiac stress testing?

A

Patients with intermediate pretest probability of CAD

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24
Q

What do you order if a patient has a positive stress test?

A

Invasive coronary angiography

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25
Q

What are examples of stress tests?

A

Exercise stress test
Dobutamine stress ECHO
Myocardial perfusion imaging (vasodilators)

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26
Q

How is an exercise stress test typically done?

A

Treadmill

Stationary bike

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27
Q

Which vasodilators are used to stress the heart?

A

Adenosine
Dipyridamole
Regadenoson

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28
Q

Why do vasodilators stress the heart?

A

Disease coronary arteries are already maximally dilated as rest to increase flow, they receive relatively less blood flow when the entire coronary system is pharmacologically dilated

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29
Q

Which inotropes and chronotropes stress the heart?

A

Dobutamine

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30
Q

What can’t be used to assess stress in patients with baseline EKG changes?

A

Stress ECG

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31
Q

What are you looking for with stress ECHO?

A

Regional wall motion abnormalities

LV dilation

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32
Q

What are you looking for in MPI?

A

Perfusion defects between rest and stress using technetrium or thallium
Cardiac viability
LV systolic function

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33
Q

What is defined as intermediate pretest probability?

A

10% and 90% or between 25% and 75%

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34
Q

What regional wall abnormalities point towards ischemia in a dobutamine stress ECHO?

A

Hypokinesis
Akinesis
Dyskinesis

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35
Q

What percentage has to be blocked in coronary angiography for it to be considered significant stenosis?

A

Greater than 70%

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36
Q

What do you do to diagnose acute coronary artery syndrome?

A

Resting EKG
Cardiac biomarkers
Invasive coronary angiography

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37
Q

What are ST-elevation equivalents?

A 
New LBBB
Posterior MI (tall R waves and ST depression V1-V3)
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38
Q

When can you diagnose a STEMI on EKG?

A

ST segment elevation > 2mm in continuous leads
OR
New LBBB

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39
Q

Can you diagnose a STEMI in the setting of known or old LBBB?

A

No

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40
Q

What are the NSTEMI EGC criteria?

A

New ST depression > 0.5 mm in two continuous leads
OR
T wave inversions > 1 mm in two continuous leads with prominent R waves for R/S ration >1

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41
Q

NSTEMI leads to what type of infarction?

A

Subendothelial infarction

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42
Q

STEMI leads to what type of infarction?

A

Transmural

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43
Q

What is a Type I AMI?

A

Infarction due to coronary artherothrombosis

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44
Q

What is a Type II AMI?

A

Infarction due to supply-demand mismatch not the result of acute atherothrombosis

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45
Q

What is a Type III AMI?

A

Infarction causing sudden death without the opportunity for biomarker of ECG confirmation

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46
Q

What is a Type 4a AMI?

A

Infarction related to percutaneous coronary intervention

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47
Q

What is a Type 4b AMI?

A

Infarction related to thrombosis after coronary stent

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48
Q

What is a Type 4c AMI?

A

Infarction related to restenosis after stent placement or balloon angioplasty

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49
Q

What is a Type 5 AMI?

A

Infarction related to coronary artery bypass grafting (CABG)

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50
Q

What are lifestyle modifications to treat stable angina?

A 
Smoking cessation
Weight loss
Exercise
BP control
Diabetes control
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51
Q

What medications can be started for stable angina?

A

Aspirin
Statin
Anti-anginal drugs

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52
Q

What are the chronic anti-anginal drugs?

A

Beta-blockers
Calcium channel blockers
Long-acting nitrates
Ranolazine

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53
Q

What are is the acute anti-anginal drugs?

A

Short-acting nitrates

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54
Q

What is the first line therapy for chronic anginal prevention?

A

Beta-blockers

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55
Q

How do beta-blockers help with angina?

A

Decrease heart rate and contractility

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56
Q

How do CCB help with angina?

A

Coronary artery vasodilation and reduce cardiac contractivity

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57
Q

How do long-acting nitrates help with angina?

A

Coronary vessel and systemic vasodilation

Decrease cardiac preload

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58
Q

What is ranolazine reserved for?

A

Refractory angina

59
Q

What is the mechanism of action for ranolazine?

A

Inward sodium channel blocker

Decreases myocardial oxygen consumption

60
Q

What is the dosing for nitroglycerin?

A

0.5mg every 5 minutes

Max 3 does

61
Q

When is a CABG indicated?

A

3 vessel disease with greater than 70% stenosis
Left main disease
LV dysfunction

62
Q

What is external enhanced counterpulsations therapy?

A

35 daily outpatient treatments

Compression devices put on LE and inflate during diastole

63
Q

What if you have continued stable angina symptoms after 1st line therapies then what?

A

Increase dose of beta-blocker

Add CCB or long-acting nitrate

64
Q

If stable angina persists after 1st line therapies + CCB/nitrates then what?

A

Long acting nitrates
Beta-blocker
CCB
Consider ranolazine

65
Q

If stable angina persists after 1st line therapies + CCB/nitrates + ranolazine then what?

A

Refer for angiography

66
Q

If a patient with stable angina is not a candidate for surgical revascularization what should be done?

A

External enhanced counterpulsation

67
Q

What is the initial management of all patients with unstable angina, NSTEMI, or STEMI?

A

MONA

68
Q

What does MONA stand for?

A

Morphine (pain control)
Oxygen (oxygen carrying capacity)
Nitrates (pain control)
Aspirin (antiplatelet)

69
Q

What is DAPT?

A

Dual Antiplatelet Therapy

70
Q

What two drugs are part of dual antiplatelet therapy?

A

Aspirin

P2Y12 inhibitors

71
Q

What is glycoprotein IIb/IIIa inhibitors reserved for?

A

NSTE-ACS patients undergoing PCI and at high risk and if used only typically for 18-24 hours

72
Q

What anticoagulation should be prescribed for patients with unstable angina, NSTEMI, or STEMI?

A

Unfractionated heparin

Subcutaneous enoxaparin

73
Q

What does unfractionated heparin/subcutaneous enoxaparin do?

A

Binds to anti-thrombin III and accelerates its inhibition of thrombin and Xa

74
Q

What should be used in patients with HITT?

A

Bivalirudin

Fondaparinux

75
Q

What is the MOA of bivalirudin?

A

Direct thrombin inhibitor

76
Q

What is the MOA of fondaparinux?

A

Direct Xa inhibitor

77
Q

What are two percutaneous coronary interventions?

A

Drug eluting stents

Bare metal stents

78
Q

What are two revascularization therapies?

A

Percutaneous coronary intervention (PCI)

Coronary artery bypass grafting (CABG)

79
Q

Thrombolytics should only be used in what ACS?

A

STEMI

80
Q

What are long-term therapies for all ACS?

A 
Aspirin
ACEi or ARB
P2Y12 inhibitors
Beta-blockers
Statins
SL nitroglycerin PRN
81
Q

What are drugs shown to improve mortality in MI?

A

Aspirin
Beta-blockers
ACEi

82
Q

What does aspirin block?

A

Cyclooxygenase 1

Cyclooxygenase 2

83
Q

What are P2Y12 inhibitors?

A 
Ticlopidine
Clopidrogrel
Prasugrel
Cangrelor
Ticagrelor
84
Q

What do P2Y12 inhibitors block?

A

ADP

*platelet recruitment and activation

85
Q

What are GPIIb/IIIA inhibitors?

A

Abciximab
Eptifibatide
Tirofiban

86
Q

What do GPIIb/IIIA inhibitor block?

A

Platelet aggregation

87
Q

How quickly should a patient with a STEMI get to the cath lab?

A

Less than 90 minutes

88
Q

How quickly should a patient with a STEMI get transferred to a hospital with a cath lab?

A

120 minutes or less

89
Q

What should a patient be given if they can’t get to a cath lab?

A

Thrombolytics within 30 minutes then cath lab

90
Q

What does the TIMI score predict?

A

Risk of 14 day death
Recurrent MI
Urgent revascularization

91
Q

What do you do for high risk TIMI?

A

Early invasive strategy
Antiplatelet therapy
Antigoagulant
Coronary angiography

92
Q

What do you do for intermediate risk TIMI?

A

Delayed invasive strategy
Antiplatelet therapy
Angicoagulant therapy
Maybe coronary angiography

93
Q

What do you do for low risk TIMI?

A

Antiplatelet therapy
Anticoagulant therapy
Stress test

94
Q

What is the initial treatment for unstable angina/NSTEMI?

A

Aspirin
Beta-blockers
Nitrates
Statins

95
Q

Which leads show can inferior MI?

A

II
III
aVF

96
Q

Which leads show septal MI?

A

V1-V2

97
Q

Which leads show anterior MI?

A

V2-V4

98
Q

Which leads show lateral MI?

A

V5-V6
I
aVL (high lateral)

99
Q

Which leads show posterior MI?

A

Tall R waves

ST depression V1-3

100
Q

Which coronary artery causes inferior MI?

A

RCA

101
Q

Which coronary artery causes septal MI?

A

LAD

102
Q

Which coronary artery causes anterior MI?

A

LAD

103
Q

Which coronary artery causes lateral MI?

A

Left circumflex

104
Q

Which coronary artery causes posterior MI?

A

Right dominant: PDA from RCA
Left dominant: PDA from LCx
Co-dominant: PDA from RCA and LCx

105
Q

What is dressler syndrome?

A

Immunologically based syndrome typically occurs within weeks to months after MI

106
Q

How does Dressler syndrome manifest?

A

Pericarditis

107
Q

What are complications of MI?

A 
Embolism
Cardiogenic shock
CHF
Cardiac tamponade
Arrhythmias
108
Q

Differential diagnosis of acute MI?

A

Aortic dissection

Pulmonary embolism

109
Q

What are the two classification system for thoracic aortic dissections?

A

Debakey

Stanford

110
Q

What are the two types of Stanford criteria?

A

Type A: ascending

Typer B: descending

111
Q

What is the mortality rate of ascending aortic dissection?

A

1-2% per hours after symptom onset

112
Q

In what populations is aortic dissection most common?

A

Old men

113
Q

Which type of aortic dissection is most common?

A

Ascending

114
Q

Which type of aortic dissection has higher mortality?

A

Ascending

115
Q

What are lifestyle risk factors for aortic dissection?

A

Long-term arterial HTN
Smoking
Dyslipidemia
Cocaine, crack cocaine, amphetamine use

116
Q

Which connective tissue disorders increase risk for aortic dissection?

A

Marfan syndrome
Loeys-Dietz syndrome
Ehler-Danlos syndrome
Turner syndrome

117
Q

Which hereditary vascular diseases increase risk for aortic dissection?

A

Bicuspid aortic valve

Coarctation of the aorta

118
Q

Which vascular inflammation increases risk for aortic dissection?

A 
Giant-cell arteritis
Takayasu arteritis
Bechet disease
Ormond disease
Syphilis
Tuberculosis
119
Q

What deceleration traumas increase risk for aortic dissection?

A

MVC

Fall from height

120
Q

What are younger patient risk factors for aortic dissection?

A

Marfan syndrome
Syphilis
Cocaine/methamphetamine
Trauma

121
Q

Where is the tear in aortic dissection?

A

Intima

122
Q

What is the risk if an aortic dissection propagates backwards?

A

Aortic regurg -> cardiac tamponade

123
Q

What are the three types of acute aortic syndromes?

A

Aortic dissection
Intramural hematoma
Penetrating aortic ulcer

124
Q

What is the classic clinical presentation with aortic dissection?

A

Sudden onset of chest pain “tearing or ripping” which radiates to the back
HTN (hypotension also seen)

125
Q

What are cardiac complications with aortic dissection?

A

Myocardial infarction
Aortic regurgitation (widen pulse pressure)
BP asymmetry between arms
Cardiac tamponade
Syncope
Aortic rupture with exsanguination an death

126
Q

What are neurologic complications with aortic dissection?

A

Stroke or TIA
Ischemic neuropathy
Paraplelgia (anterior spinal cord perfusion defect)
Horner syndrome (cervical sympathetic chain injury, ptosis, miosis, anhidrosis)

127
Q

What are GI complications with aortic dissection?

A

Mesenteric ischemia

GI bleeding from aortenteric fistula

128
Q

What are pulmonary complications with aortic dissection?

A

Hemothorax

129
Q

What are renal complications with aortic dissection?

A

Acute renal failure

130
Q

What are limb complications with aortic dissection?

A 
Pulse deficit (weak peripheral pulse)
Upper and lower extremity ischemia
131
Q

How do you diagnose aortic dissection?

A

ECG and cardiac biomarkers (rule out MI)
CXR (rule out pneumothorax, look for widened mediastinum)
CT angiography
Transesophageal ECHO (TEE)

132
Q

What is most commonly used to diagnose aortic dissection patients?

A

CT angiography

133
Q

When is a TEE used for diagnosing aortic dissection?

A

Hemodynamically unstable patient

134
Q

Which lumen is typically smaller on CT angiography?

A

Smaller lumen

135
Q

What is the acute medical management of aortic dissection?

A

Anti-impulse therapy

Opiates

136
Q

What does anti-impulse therapy do?

A

Lowers HR and diminishes the force of LV ejection, thus reducing shear stress on initma

137
Q

What is the goal for BP and HR in patients with aortic dissection?

A

BP < 120 mmHG

HR < 60

138
Q

What is the first line therapy in anti-impulse therapy?

A

IV labetalol or esmolol

139
Q

If first line anti-impulse therapy doesn’t work what do you add?

A

Nicardipine (CCB)

Nitroprusside

140
Q

How can you manage aortic dissection surgically?

A

Open surgery

Endovascular stenting

141
Q

What is the open surgery for aortic dissection?

A

Section of aorta is replaced with synthetic vascular graft (Dacron)

142
Q

Does medical management or surgical management have worse outcomes for treatment with type A aortic dissection?

A

Medical management

143
Q

Does medical management or surgical management have worse outcomes for treatment with type B aortic dissection?

A

Surgical management

144
Q

Which management for type B aortic dissection has the highest survival?

A

Endovascular management

CPR 2 Exam 1 (20 decks)

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