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Internal Medicine pt.1 > Coronary Artery Disease > Flashcards

Coronary Artery Disease Flashcards

1
Q

What is the difference between stable & unstable angina?

A

Stable: on exertion -> increased oxygen demand
Unstable: supply is decreased -> oxygen demand is unchanged

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2
Q

What is the criteria for typical angina?

A
  • retrosternal chest pain
  • provoked by exertion
  • relieved by rest or nitroglycerin

atypical: 2 of the above
nonanginal: one or non of the above

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3
Q

What is the most common cause of CAD?

A

atherosclerosis

1- stable atherosclerotic plaque 
2- vascular stenosis 
3- increased resistance to blood flow in coronary arteries 
4- decreased myocardial blood flow 
5- myocardial ischemia
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4
Q

What is Poiseuille’s law?

A

vascular stenosis increases vascular resistance

- 50% reduction in the radius -> 16-fold increase in resistance

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5
Q

What is coronary steal syndrome?

A

blood flow to ischemic area is decreased

blood flow to normal areas are increased significantly

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6
Q

What are the clinical features of stable angina?

A
  • retrosternal chest pain -> may be absent in geriatric, women, or diabetics
  • dyspnea
  • dizziness, palpitations
  • restlessness, anxiety
  • autonomic symptoms -> diaphoresis, nausea, vomiting, syncope
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7
Q

What is the best initial test for angina?

A

ECG

  • usually normal in stable CAD
  • Q waves -> prior MI
  • ST-segment depression
  • T wave inversion or T wave flattening
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8
Q

When should a stress test be done?

A

in case of TYPICAL ANGINA

  • women < 60 years
  • men < 40 years

in case of ATYPICAL ANGINA

  • women > 50
  • men of all ages

in case of NON-ANGINAL PAIN

  • men > 40 years
  • women > 60 years
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9
Q

How should a stress test be preformed?

A

target 85% of maximal heart rate -> stress induced ischemia

maximum heart rate = 220 - age

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10
Q

When should a stress test be terminated?

A
  • diagnostic endpoint -> symptoms appear, signs of ischemia (ST), abnormal HR, abnormal BP
  • after reaching target HR
  • significant arrhythmias
  • patient inability to continue
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11
Q

What is the gold standard method of investigation for CAD?

A

CARDIAC CATHETERIZATION
indicated in
- positive stress test
- noninvasive tests are non diagnostic/contraindicated
- angina occurs inspite of medical therapy
- acute MI with intent of perforating angiogram & PCI

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12
Q

What are the other non-invasive tests for CAD?

A
  • coronary CT angiography (CCTA)

- coronary artery calcium (CAC) scoring

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13
Q

How should CAD be managed?

A

ALL PATIENTS -> pharmacotherapy

  • secondary prevention of CAD + management of comorbidites
  • antianginal medication

SELECT PATIENTS -> revascularization

  • percutaneous coronary intervention (PCI)
  • coronary artery bypass grafting (CABG)
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14
Q

What are the types of medical therapy for CAD?

A

ANTIANGINAL -> second line

  • nitrates
  • CCB
  • metabolic modulators

SECONDARY PREVENTION & ANTIANGINAL
- Beta blockers -> first line

SECONDARY PREVENTION

  • ACEi or ARBs -> patients with HTN, DM, LVEF <40%, & chronic kidney disease
  • lipid lowering agents -> statins first then PCSK9 inhibitors
  • anti platelet agents -> aspirin, clopidogrel
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15
Q

What are the acute coronary syndromes?

A
  • unstable angina -> no troponins
  • NSTEMI -> positive troponin without ST elevation
  • STEMI -> positive troponin & ST elevation
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16
Q

What are the clinical features of unstable angina?

A
  • dull squeezing pressure
  • precipitated by stress
  • dyspnea
  • pallor
  • nausea
  • vomiting
  • diaphoresis, anxiety
  • dizziness, lightheadedness, syncope
17
Q

What is seen with right ventricular infarction?

A
  • hypotension
  • elevated JVP
  • clear lung fields

DO NOT GIVE NITRATES

18
Q

What should be preformed as soon as ACS is suspected?

A

1- ECG -> repeat every 15-30 mins in first hour
2- if ST elevation is present -> D2B 90 minutes or D2N 30 minutes
3- troponin is most sensitive
4- CK-MB for reinfarction

19
Q

What are the ECG changes that occur in STEMI?

A

tomb-stone appearance

  • ST-elevation in V1 - V2 -> anterior -> LAD
  • ST-elevation in V3 - V4 -> anterior -> distal LAD
  • ST elevation in I, aVL -> lateral -> lateral circumflex
  • ST elevation in II, III, aVF -> inferior -> right coronary artery
  • left bundle branch block
  • QRS duration > 120ms
  • dominant S wave in V1
  • broad monophasic R wave in lateral leads -> I, aVL
20
Q

What is the fibrinolytic therapy used in STEMI?

A

D2N 30 mins

  • tenecteplase
  • alteplase
  • reteplase
  • streptokinase
21
Q

How should NSTEMI & STEMI be managed?

A

MONA BASHC

  • Morphine
  • Oxygen
  • Nitrates
  • ASA
  • Beta blockers -> if not at risk for HF or shock
  • ACEi
  • Statin
  • Heparin
  • Clopidogrel
22
Q

What are the ECG changes in NSTEMI?

A
  • no ST elevation

- nonspecific signs of ischemia -> ST depression & T wave inversion

23
Q

What are the indications for urgent revascularization in NSTEMI?

A
  • hemodynamic instability
  • life-threatening arrhythmias
  • refractory ischemic pain despite medical treatment
  • acute heart failure
  • mechanical complications
24
Q

What are the complications of MI?

A

0 - 24hrs post infarction

  • arrhythmias
  • sudden cardiac death
  • acute left heart failure
  • cardiogenic shock

1 - 3 days
- acute pericarditis

3 - 14 days

  • papillary muscle rupture
  • free wall rupture -> tamponade
  • ventricular septal rupture
  • left ventricle pseudo aneurysm

2 weeks to months

  • post myocardial infarction syndrome (Dressler syndrome)
  • atrial & ventricular aneurysms
  • arrhythmias
  • HF
25
Q

What type of angina is caused by transient coronary spasm?

A

Prinzmetal angina

  • not affected by exertion & can occur at rest
  • typically early morning
  • in young women
  • cigarette smoking, stress, hyperventilation, & exposure to cold precipitates it
26
Q

How is Prinzmetal angina managed?

A
  • smoking cessation
  • calcium channel blockers -> verapamil, diltiazem, nifedipine

BETA BLOCKERS CONTRAINDICATED because they cause vasoconstriction

Internal Medicine pt.1 (33 decks)

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