Coronary Artery Disease

Question 1

Which 3 meds (& their doses) can be used as anti-platelets?

not ASA

Answer 1

1. clopidogrel (75mg PO QD)
2. Ticagrelor (90mg PO BID)
3. Prasugrel (10mg PO QD)

Question 2

when to use clopidogrel & ticagrelor anti-platelets?

Answer 2

1. Clopidogrel: generic, first choice
2. Ticagrelor: pts w/ DM

Question 3

contraindication of prasugrel?

Answer 3

previous stroke

Question 4

Coronary Vasospasm

describe

Answer 4

• angina pain usually at rest with no change in exercise function
• non-exertional chest pain
• “charlie horse in the heart”

Question 5

Coronary Vasospasm

risk factors

4

Answer 5

1. women > 50 y/o
2. exposure to cold
3. emotional stress
4. vasoconstricting meds

Question 6

Coronary Vasospasm

usually involves which artery?

Answer 6

right coronary artery

Question 7

Coronary Vasospasm

what will you see on EKG?

Answer 7

ST segment elevation

Question 8

Coronary Vasospasm

what you use to dx

Answer 8

coronary angiography

Question 9

Coronary Vasospasm

what do you see on coronary angiography?

Answer 9

no lesions with poss spasm

Question 10

Coronary Vasospasm

tx

Answer 10

1. calcium channel blockers and/or nitrates
2. avoidance of nicotine, caffeiene, cocaine, ergot’s

Question 11

CAD

modifiable risk factors for CAD

10

Answer 11

1. HTN
2. DM
3. Hyperlipidemia
4. CKD/proteinuria
5. autoimmune
6. HIV
7. Obesity
8. Smoking
9. Environmental/Pollution
10. Elevated CAC, CRP, Lp(a)

Question 12

CAD

non-modifiable risk factors for CAD

Answer 12

1. family hx
2. age
3. sex

Question 13

CAD

primary vs secondary prevention

general

Answer 13

Primary
* does not yet have dx of ASCVD but has risk factors
* wants to prevent the first event

Secondary
* has a dx of ASCVD or equivalent
* wants to prevent a second event

Question 14

CAD

Primary Prevention- lifestyle interventions

Answer 14

1. no smoking
2. daily exercise
3. target BMI

Question 15

CAD

Primary Prevention- goal for risk reduction

of BP, LDL, A1C

Answer 15

1. BP goal: < 130/80
2. LDL goal: < 100
3. A1C goal: < 7.0

Question 16

CAD

Medications for Secondary Prevention

4

Answer 16

1. Anti-platelet (ASA or other)
2. Statin (mod to high intensity)
3. If DM: GLP-1
4. If CKD: ACE/ARB, SGLT2-Inhibitor

Question 17

CAD

Secondary Prevention- goal for risk reduction

of BP, LDL, A1C

Answer 17

1. BP goal: < 130/80
2. LDL goal: < 55
3. A1C goal: < 7.0

Question 18

CAD Spectrum

good to bad

Answer 18

1. stable angina
2. unstable angina
3. NSTEMI
4. STEMI

Question 19

Stable Angina

pathophys

Answer 19

1. occurs when myocardial oxygen demand exceeds oxygen supply
2. most commonly caused by atherosclerotic obstruction of 1+ coronary arteries

Question 20

Stable Angina

Sx

3 componeents

Answer 20

• pressure, pain, squeezing, tightness, heaviness
• exertional or relieved with rest
• < 20 min in duration

Question 21

Stable Angina

how may pts with DM present?

general statement, 8 sx

Answer 21

with atypical sx
* dyspnea
* indigestion
* arm/jaw pain
* exertional SOB
* nausea
* diaphoresis
* fatigue
* without pain

Question 22

Stable Angina

Lab findings

Answer 22

neg troponin/CK-MB

Question 23

Stable Angina

EKG findings

Answer 23

• resting EKG normal
• EKG during pain: ST depression, T wave flat or inverted (reverses when pain is gone)

Question 24

Stable Angina

tests to evaluate perfusion

2

Answer 24

• Stress test (w/ or w/out imaging)
• Cardiac CTA

Question 25

# Stable Angina what to do if stress test is pos?

Answer 25

heart cath

Question 26

# Stable Angina First Line Treatments | 1

Answer 26

1. beta blocker 2. ASA (81mg PO QD) or clopidogrel (75mg PO QD)

Question 27

# Stable Angina beta blockers are the only meds which actually do what?

Answer 27

prolong life

Question 28

# Stable Angina Which secondary meds can be used? | 3

Answer 28

* long acting nitrates * ranolazine * calcium channel blockers

Question 29

# Unstable Angina sx

Answer 29

* new or worsening sx of myocardial ischemia (pain/squeezing/tightness) * unstable angina may come on during rest or with minimal exerction * can last > 30 min in duration

Question 30

# Unstable Angina lab findings

Answer 30

troponin neg

Question 31

# Unstable Angina EKG findings

Answer 31

usually ST depression

Question 32

# NSTEMI sx

Answer 32

new or worsening sx of myocardial ischemia

Question 33

# NSTEMI lab findings?

Answer 33

troponin pos

Question 34

# NSTEMI EKG findings

Answer 34

no ST elevation

Question 35

# Unstable Angina/NSTEMI Treatment in hosp

Answer 35

* MONA-BAS * CCB if cocaine induced * Fibrinolytics have been found to be harmful

Question 36

# Unstable Angina/NSTEMI what is MONA-BAS?

Answer 36

* M: morphine * O: oxygen * N: nitroglycerides * A: aspirin * B: beta blocker * A: anti-platelet * S: statin

Question 37

# Unstable Angina/NSTEMI meds prescribed upon discharge?

Answer 37

* beta blocker * ASA +/- anti-platelet * Statin * cardiac rehab

Question 38

# STEMI pathophys

Answer 38

acute episode of chest discomfort that results from an occlusive coronary thrombus at the site of a pre-existing atherosclerotic plaque

Question 39

# STEMI sx

Answer 39

* depend on severity * chest pain * can cause sudden death and arrhythmias

Question 40

# STEMI lab findings?

Answer 40

pos troponin I/T or CK-MB

Question 41

# STEMI why is it important to trend cardiac enzymes?

Answer 41

they elevate at different times. If pt comes in early after pain onset, may not be pos yet. Trending will let you repeat 3/6 hrs later and see changes

Question 42

# STEMI EKG findings

Answer 42

* peaked, hyperacute T waves * ST segment elevation * Q wave development * T wave inverstion * new LBBB * loss of R wave progression

Question 43

# STEMI what is indicative of STEMI until proven otherwise? | NOT ST ELEVATION BUT YES THAT TOO

Answer 43

New LBBB

Question 44

# STEMI which leads will you best see anterior wall MI?

Answer 44

V2, V3, V4

Question 45

# STEMI which leads will you best see inferior wall MI?

Answer 45

II, III, aVF

Question 46

# STEMI in which leads will you best see lateral wall MI?

Answer 46

I, aVL, V5, V6

Question 47

# STEMI tx

Answer 47

* MONA-BAS * anti-coag (heparin) * fibrinolytic

Question 48

# STEMI within which timeframe must a fibrinolytic ideally be started?

Answer 48

first dose 30 min from arrival/ekg ideally within 3 hrs of sx onset

Question 49

# STEMI when is a fibrinolytic therapy always indicated?

Answer 49

* if > 90 min wait for in house labs * > 2 hr wait for transfer

Question 50

# STEMI turn around time goal for reperfusion therapy?

Answer 50

90 min or less from first medical contact

Question 51

# STEMI fibrinolytic absolute contraindications | 5

Answer 51

1. previous hemorrhagicc stroke or strokes within 1 yr 2. known intracranial neoplasm 3. recent head trauma 4. active internal bleeding 5. suspected aortic dissection

Question 52

# STEMI what to give after immediate reperfusion therapy?

Answer 52

* ASA * Statin * BB * ACE * Aldosterone Antagonists if EF < 45%

Question 53

# STEMI post reperfusion therapy no-no's | 2

Answer 53

* calcium channel blockers * non-steroidal anti-inflammatory agents

Question 54

# STEMI post-MI complications | 8

Answer 54

1. arrhythmia 2. CHF 3. tamponade/thromboembolic 4. rupture 5. aneurysm 6. pericarditis 7. infection 8. death/dresslers