Clinical Cardiac Part 1 Flashcards
What is definition of stable angina?
Chest pain or pressure for at least 2 months duration that is precipitated by exertion or emotional stress and have no appreciably worsened
What are the three types of acute coronary syndrome?
1) Unstable angina
2) NSTEMI
3) STEMI
What is the definition of unstable angina?
New onset angina
Angina with minimal exertion
Angina at rest
Angina with accelerating frequency/severity
Are there ST segment depression and T wave inversions with unstable angina?
Maybe
Are the cardiac enzymes abnormal with unstable angina?
No
What is the EKG finding with NSTEMI?
ST depression
T wave inversion
Are the cardiac enzymes abnormal with NSTEMI?
Yes
What are the EKG findings with STEMI?
ST elevation
New LBBB
Posterior MI
Are the cardiac enzymes abnormal with STEMI?
Yes
What is the leading cause of death in the US?
Coronary artery disease
What are the modifiable risks for coronary artery disease?
HTN Hyperlipidemia Diabetes Overweight Cigarette smoking Physical inactivity Unhealthy diet Stress
What are the atherogenic risk factors for CAD?
Low HDL <40 mg/dL
High LDL
High Non-HDL
What are non-modifiable risk factors for CAD?
Male
Age (men 45, women 55)
Family history of premature CAD (men 55, women 65)
Ethnicity (black, hispanic, asian)
What are non-traditional risk factors for CAD?
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
Which inflammatory states are risk factors for CAD?
HIV
Rheumatoid arthritis
Psoriasis
What is the clinical presentation of acute coronary syndrome?
Typical chest pain/discomfort Dyspnea Nausea/vomiting Diaphoresis Fatigue
In which populations are acute MIs painless?
Elderly
Women
Diabetics
What are the Diamond-Forrester criteria for chest pain?
1) Substernal chest pain or discomfort
2) Provoked by exertion or emotional stress
3) Relieved by rest and/or nitroglycerin
Typical angina CP has how many Diamond-Forrester criteria?
3
Atypical angina CP has how many Diamond-Forrester criteria?
2
Non-angina CP has how many Diamond-Forrester criteria?
Less than or equal to 1
What are the three ways to diagnose stable angina?
Resting EKG
Cardiac stress test
Invasive coronary angiography
When do you do cardiac stress testing?
Patients with intermediate pretest probability of CAD
What do you order if a patient has a positive stress test?
Invasive coronary angiography
What are examples of stress tests?
Exercise stress test
Dobutamine stress ECHO
Myocardial perfusion imaging (vasodilators)
How is an exercise stress test typically done?
Treadmill
Stationary bike
Which vasodilators are used to stress the heart?
Adenosine
Dipyridamole
Regadenoson
Why do vasodilators stress the heart?
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
Which inotropes and chronotropes stress the heart?
Dobutamine
What can’t be used to assess stress in patients with baseline EKG changes?
Stress ECG
What are you looking for with stress ECHO?
Regional wall motion abnormalities
LV dilation
What are you looking for in MPI?
Perfusion defects between rest and stress using technetrium or thallium
Cardiac viability
LV systolic function
What is defined as intermediate pretest probability?
10% and 90% or between 25% and 75%
What regional wall abnormalities point towards ischemia in a dobutamine stress ECHO?
Hypokinesis
Akinesis
Dyskinesis
What percentage has to be blocked in coronary angiography for it to be considered significant stenosis?
Greater than 70%
What do you do to diagnose acute coronary artery syndrome?
Resting EKG
Cardiac biomarkers
Invasive coronary angiography
What are ST-elevation equivalents?
New LBBB Posterior MI (tall R waves and ST depression V1-V3)
When can you diagnose a STEMI on EKG?
ST segment elevation > 2mm in continuous leads
OR
New LBBB
Can you diagnose a STEMI in the setting of known or old LBBB?
No
What are the NSTEMI EGC criteria?
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
NSTEMI leads to what type of infarction?
Subendothelial infarction
STEMI leads to what type of infarction?
Transmural
What is a Type I AMI?
Infarction due to coronary artherothrombosis
What is a Type II AMI?
Infarction due to supply-demand mismatch not the result of acute atherothrombosis
What is a Type III AMI?
Infarction causing sudden death without the opportunity for biomarker of ECG confirmation
What is a Type 4a AMI?
Infarction related to percutaneous coronary intervention
What is a Type 4b AMI?
Infarction related to thrombosis after coronary stent
What is a Type 4c AMI?
Infarction related to restenosis after stent placement or balloon angioplasty
What is a Type 5 AMI?
Infarction related to coronary artery bypass grafting (CABG)
What are lifestyle modifications to treat stable angina?
Smoking cessation Weight loss Exercise BP control Diabetes control
What medications can be started for stable angina?
Aspirin
Statin
Anti-anginal drugs
What are the chronic anti-anginal drugs?
Beta-blockers
Calcium channel blockers
Long-acting nitrates
Ranolazine
What are is the acute anti-anginal drugs?
Short-acting nitrates
What is the first line therapy for chronic anginal prevention?
Beta-blockers
How do beta-blockers help with angina?
Decrease heart rate and contractility
How do CCB help with angina?
Coronary artery vasodilation and reduce cardiac contractivity
How do long-acting nitrates help with angina?
Coronary vessel and systemic vasodilation
Decrease cardiac preload
What is ranolazine reserved for?
Refractory angina
What is the mechanism of action for ranolazine?
Inward sodium channel blocker
Decreases myocardial oxygen consumption
What is the dosing for nitroglycerin?
0.5mg every 5 minutes
Max 3 does
When is a CABG indicated?
3 vessel disease with greater than 70% stenosis
Left main disease
LV dysfunction
What is external enhanced counterpulsations therapy?
35 daily outpatient treatments
Compression devices put on LE and inflate during diastole
What if you have continued stable angina symptoms after 1st line therapies then what?
Increase dose of beta-blocker
Add CCB or long-acting nitrate
If stable angina persists after 1st line therapies + CCB/nitrates then what?
Long acting nitrates
Beta-blocker
CCB
Consider ranolazine
If stable angina persists after 1st line therapies + CCB/nitrates + ranolazine then what?
Refer for angiography
If a patient with stable angina is not a candidate for surgical revascularization what should be done?
External enhanced counterpulsation
What is the initial management of all patients with unstable angina, NSTEMI, or STEMI?
MONA
What does MONA stand for?
Morphine (pain control)
Oxygen (oxygen carrying capacity)
Nitrates (pain control)
Aspirin (antiplatelet)
What is DAPT?
Dual Antiplatelet Therapy
What two drugs are part of dual antiplatelet therapy?
Aspirin
P2Y12 inhibitors
What is glycoprotein IIb/IIIa inhibitors reserved for?
NSTE-ACS patients undergoing PCI and at high risk and if used only typically for 18-24 hours
What anticoagulation should be prescribed for patients with unstable angina, NSTEMI, or STEMI?
Unfractionated heparin
Subcutaneous enoxaparin
What does unfractionated heparin/subcutaneous enoxaparin do?
Binds to anti-thrombin III and accelerates its inhibition of thrombin and Xa
What should be used in patients with HITT?
Bivalirudin
Fondaparinux
What is the MOA of bivalirudin?
Direct thrombin inhibitor
What is the MOA of fondaparinux?
Direct Xa inhibitor
What are two percutaneous coronary interventions?
Drug eluting stents
Bare metal stents
What are two revascularization therapies?
Percutaneous coronary intervention (PCI)
Coronary artery bypass grafting (CABG)
Thrombolytics should only be used in what ACS?
STEMI
What are long-term therapies for all ACS?
Aspirin ACEi or ARB P2Y12 inhibitors Beta-blockers Statins SL nitroglycerin PRN
What are drugs shown to improve mortality in MI?
Aspirin
Beta-blockers
ACEi
What does aspirin block?
Cyclooxygenase 1
Cyclooxygenase 2
What are P2Y12 inhibitors?
Ticlopidine Clopidrogrel Prasugrel Cangrelor Ticagrelor
What do P2Y12 inhibitors block?
ADP
*platelet recruitment and activation
What are GPIIb/IIIA inhibitors?
Abciximab
Eptifibatide
Tirofiban
What do GPIIb/IIIA inhibitor block?
Platelet aggregation
How quickly should a patient with a STEMI get to the cath lab?
Less than 90 minutes
How quickly should a patient with a STEMI get transferred to a hospital with a cath lab?
120 minutes or less
What should a patient be given if they can’t get to a cath lab?
Thrombolytics within 30 minutes then cath lab
What does the TIMI score predict?
Risk of 14 day death
Recurrent MI
Urgent revascularization
What do you do for high risk TIMI?
Early invasive strategy
Antiplatelet therapy
Antigoagulant
Coronary angiography
What do you do for intermediate risk TIMI?
Delayed invasive strategy
Antiplatelet therapy
Angicoagulant therapy
Maybe coronary angiography
What do you do for low risk TIMI?
Antiplatelet therapy
Anticoagulant therapy
Stress test
What is the initial treatment for unstable angina/NSTEMI?
Aspirin
Beta-blockers
Nitrates
Statins
Which leads show can inferior MI?
II
III
aVF
Which leads show septal MI?
V1-V2
Which leads show anterior MI?
V2-V4
Which leads show lateral MI?
V5-V6
I
aVL (high lateral)
Which leads show posterior MI?
Tall R waves
ST depression V1-3
Which coronary artery causes inferior MI?
RCA
Which coronary artery causes septal MI?
LAD
Which coronary artery causes anterior MI?
LAD
Which coronary artery causes lateral MI?
Left circumflex
Which coronary artery causes posterior MI?
Right dominant: PDA from RCA
Left dominant: PDA from LCx
Co-dominant: PDA from RCA and LCx
What is dressler syndrome?
Immunologically based syndrome typically occurs within weeks to months after MI
How does Dressler syndrome manifest?
Pericarditis
What are complications of MI?
Embolism Cardiogenic shock CHF Cardiac tamponade Arrhythmias
Differential diagnosis of acute MI?
Aortic dissection
Pulmonary embolism
What are the two classification system for thoracic aortic dissections?
Debakey
Stanford
What are the two types of Stanford criteria?
Type A: ascending
Typer B: descending
What is the mortality rate of ascending aortic dissection?
1-2% per hours after symptom onset
In what populations is aortic dissection most common?
Old men
Which type of aortic dissection is most common?
Ascending
Which type of aortic dissection has higher mortality?
Ascending
What are lifestyle risk factors for aortic dissection?
Long-term arterial HTN
Smoking
Dyslipidemia
Cocaine, crack cocaine, amphetamine use
Which connective tissue disorders increase risk for aortic dissection?
Marfan syndrome
Loeys-Dietz syndrome
Ehler-Danlos syndrome
Turner syndrome
Which hereditary vascular diseases increase risk for aortic dissection?
Bicuspid aortic valve
Coarctation of the aorta
Which vascular inflammation increases risk for aortic dissection?
Giant-cell arteritis Takayasu arteritis Bechet disease Ormond disease Syphilis Tuberculosis
What deceleration traumas increase risk for aortic dissection?
MVC
Fall from height
What are younger patient risk factors for aortic dissection?
Marfan syndrome
Syphilis
Cocaine/methamphetamine
Trauma
Where is the tear in aortic dissection?
Intima
What is the risk if an aortic dissection propagates backwards?
Aortic regurg -> cardiac tamponade
What are the three types of acute aortic syndromes?
Aortic dissection
Intramural hematoma
Penetrating aortic ulcer
What is the classic clinical presentation with aortic dissection?
Sudden onset of chest pain “tearing or ripping” which radiates to the back
HTN (hypotension also seen)
What are cardiac complications with aortic dissection?
Myocardial infarction
Aortic regurgitation (widen pulse pressure)
BP asymmetry between arms
Cardiac tamponade
Syncope
Aortic rupture with exsanguination an death
What are neurologic complications with aortic dissection?
Stroke or TIA
Ischemic neuropathy
Paraplelgia (anterior spinal cord perfusion defect)
Horner syndrome (cervical sympathetic chain injury, ptosis, miosis, anhidrosis)
What are GI complications with aortic dissection?
Mesenteric ischemia
GI bleeding from aortenteric fistula
What are pulmonary complications with aortic dissection?
Hemothorax
What are renal complications with aortic dissection?
Acute renal failure
What are limb complications with aortic dissection?
Pulse deficit (weak peripheral pulse) Upper and lower extremity ischemia
How do you diagnose aortic dissection?
ECG and cardiac biomarkers (rule out MI)
CXR (rule out pneumothorax, look for widened mediastinum)
CT angiography
Transesophageal ECHO (TEE)
What is most commonly used to diagnose aortic dissection patients?
CT angiography
When is a TEE used for diagnosing aortic dissection?
Hemodynamically unstable patient
Which lumen is typically smaller on CT angiography?
Smaller lumen
What is the acute medical management of aortic dissection?
Anti-impulse therapy
Opiates
What does anti-impulse therapy do?
Lowers HR and diminishes the force of LV ejection, thus reducing shear stress on initma
What is the goal for BP and HR in patients with aortic dissection?
BP < 120 mmHG
HR < 60
What is the first line therapy in anti-impulse therapy?
IV labetalol or esmolol
If first line anti-impulse therapy doesn’t work what do you add?
Nicardipine (CCB)
Nitroprusside
How can you manage aortic dissection surgically?
Open surgery
Endovascular stenting
What is the open surgery for aortic dissection?
Section of aorta is replaced with synthetic vascular graft (Dacron)
Does medical management or surgical management have worse outcomes for treatment with type A aortic dissection?
Medical management
Does medical management or surgical management have worse outcomes for treatment with type B aortic dissection?
Surgical management
Which management for type B aortic dissection has the highest survival?
Endovascular management
