Coronary Artery Disease Flashcards
Which 3 meds (& their doses) can be used as anti-platelets?
not ASA
- clopidogrel (75mg PO QD)
- Ticagrelor (90mg PO BID)
- Prasugrel (10mg PO QD)
when to use clopidogrel & ticagrelor anti-platelets?
- Clopidogrel: generic, first choice
- Ticagrelor: pts w/ DM
contraindication of prasugrel?
previous stroke
Coronary Vasospasm
describe
- angina pain usually at rest with no change in exercise function
- non-exertional chest pain
- “charlie horse in the heart”
Coronary Vasospasm
risk factors
4
- women > 50 y/o
- exposure to cold
- emotional stress
- vasoconstricting meds
Coronary Vasospasm
usually involves which artery?
right coronary artery
Coronary Vasospasm
what will you see on EKG?
ST segment elevation
Coronary Vasospasm
what you use to dx
coronary angiography
Coronary Vasospasm
what do you see on coronary angiography?
no lesions with poss spasm
Coronary Vasospasm
tx
- calcium channel blockers and/or nitrates
- avoidance of nicotine, caffeiene, cocaine, ergot’s
CAD
modifiable risk factors for CAD
10
- HTN
- DM
- Hyperlipidemia
- CKD/proteinuria
- autoimmune
- HIV
- Obesity
- Smoking
- Environmental/Pollution
- Elevated CAC, CRP, Lp(a)
CAD
non-modifiable risk factors for CAD
- family hx
- age
- sex
CAD
primary vs secondary prevention
general
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
CAD
Primary Prevention- lifestyle interventions
- no smoking
- daily exercise
- target BMI
CAD
Primary Prevention- goal for risk reduction
of BP, LDL, A1C
- BP goal: < 130/80
- LDL goal: < 100
- A1C goal: < 7.0
CAD
Medications for Secondary Prevention
4
- Anti-platelet (ASA or other)
- Statin (mod to high intensity)
- If DM: GLP-1
- If CKD: ACE/ARB, SGLT2-Inhibitor
CAD
Secondary Prevention- goal for risk reduction
of BP, LDL, A1C
- BP goal: < 130/80
- LDL goal: < 55
- A1C goal: < 7.0
CAD Spectrum
good to bad
- stable angina
- unstable angina
- NSTEMI
- STEMI
Stable Angina
pathophys
- occurs when myocardial oxygen demand exceeds oxygen supply
- most commonly caused by atherosclerotic obstruction of 1+ coronary arteries
Stable Angina
Sx
3 componeents
- pressure, pain, squeezing, tightness, heaviness
- exertional or relieved with rest
- < 20 min in duration
Stable Angina
how may pts with DM present?
general statement, 8 sx
with atypical sx
* dyspnea
* indigestion
* arm/jaw pain
* exertional SOB
* nausea
* diaphoresis
* fatigue
* without pain
Stable Angina
Lab findings
neg troponin/CK-MB
Stable Angina
EKG findings
- resting EKG normal
- EKG during pain: ST depression, T wave flat or inverted (reverses when pain is gone)
Stable Angina
tests to evaluate perfusion
2
- Stress test (w/ or w/out imaging)
- Cardiac CTA
Stable Angina
what to do if stress test is pos?
heart cath
Stable Angina
First Line Treatments
1
- beta blocker
- ASA (81mg PO QD) or clopidogrel (75mg PO QD)
Stable Angina
beta blockers are the only meds which actually do what?
prolong life
Stable Angina
Which secondary meds can be used?
3
- long acting nitrates
- ranolazine
- calcium channel blockers
Unstable Angina
sx
- 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
Unstable Angina
lab findings
troponin neg
Unstable Angina
EKG findings
usually ST depression
NSTEMI
sx
new or worsening sx of myocardial ischemia
NSTEMI
lab findings?
troponin pos
NSTEMI
EKG findings
no ST elevation
Unstable Angina/NSTEMI
Treatment in hosp
- MONA-BAS
- CCB if cocaine induced
- Fibrinolytics have been found to be harmful
Unstable Angina/NSTEMI
what is MONA-BAS?
- M: morphine
- O: oxygen
- N: nitroglycerides
- A: aspirin
- B: beta blocker
- A: anti-platelet
- S: statin
Unstable Angina/NSTEMI
meds prescribed upon discharge?
- beta blocker
- ASA +/- anti-platelet
- Statin
- cardiac rehab
STEMI
pathophys
acute episode of chest discomfort that results from an occlusive coronary thrombus at the site of a pre-existing atherosclerotic plaque
STEMI
sx
- depend on severity
- chest pain
- can cause sudden death and arrhythmias
STEMI
lab findings?
pos troponin I/T or CK-MB
STEMI
why is it important to trend cardiac enzymes?
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
STEMI
EKG findings
- peaked, hyperacute T waves
- ST segment elevation
- Q wave development
- T wave inverstion
- new LBBB
- loss of R wave progression
STEMI
what is indicative of STEMI until proven otherwise?
NOT ST ELEVATION BUT YES THAT TOO
New LBBB
STEMI
which leads will you best see anterior wall MI?
V2, V3, V4
STEMI
which leads will you best see inferior wall MI?
II, III, aVF
STEMI
in which leads will you best see lateral wall MI?
I, aVL, V5, V6
STEMI
tx
- MONA-BAS
- anti-coag (heparin)
- fibrinolytic
STEMI
within which timeframe must a fibrinolytic ideally be started?
first dose 30 min from arrival/ekg
ideally within 3 hrs of sx onset
STEMI
when is a fibrinolytic therapy always indicated?
- if > 90 min wait for in house labs
- > 2 hr wait for transfer
STEMI
turn around time goal for reperfusion therapy?
90 min or less from first medical contact
STEMI
fibrinolytic absolute contraindications
5
- previous hemorrhagicc stroke or strokes within 1 yr
- known intracranial neoplasm
- recent head trauma
- active internal bleeding
- suspected aortic dissection
STEMI
what to give after immediate reperfusion therapy?
- ASA
- Statin
- BB
- ACE
- Aldosterone Antagonists if EF < 45%
STEMI
post reperfusion therapy no-no’s
2
- calcium channel blockers
- non-steroidal anti-inflammatory agents
STEMI
post-MI complications
8
- arrhythmia
- CHF
- tamponade/thromboembolic
- rupture
- aneurysm
- pericarditis
- infection
- death/dresslers
