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Coronary Artery Disease Flashcards

1
Q

What is arteriosclerosis?

A
  • overtime (age) there accumulation of phospholipid and cholesterol –> symmetric thickening and hardening of the arterial wall (lumen) –> narrowed –> vessel walls are weakened*
  • there is not “plaque” involved, it is only the WALLS that are getting big that narrows the lumen
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2
Q

What happens when the vessel walls are weakened?

Arteriosclerosis

A

there is a loss of elasticity leading to dilation, rupture, occlusion

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3
Q

What happens to diastolic and systolic in arteriosclerosis?

A

diastolic increases; systolic decreases

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4
Q

What is atherosclerosis?

A
  • inflammatory process that results in patchy, nodular, lipid laden lesions in large and medium arteries
  • major cause of death
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5
Q

What is the inflammation process of atherosclerosis?

A

lesion occurs –> thin fibrous cap covering lipid rich core ruptures –> release of cytokines –> stimulates platelets –> thrombus occurs –> vasoconstriction of vessel

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6
Q

What can atherosclerosis lead to in coronary arteries?

A
  • unstable angina myocardial ischemia

- myocardial infarction/myocardial cell death

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7
Q

What terminologies are associated with atherosclerosis?

A
  • fatty streaks (early)
  • fibrous plaques
  • complicated lesions
  • “soft” lesions
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8
Q

Where does atherosclerosis commonly occur?

A

abdominal aorta

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9
Q

Who is affected w/ CAD?

A
  • probably all older adults have some degrees of CAD

- asymptomatic until it ruptures and there is a thrombosis occurring

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10
Q

What is a marker for CAD?

A

-LDH

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11
Q

What is myocardial infarction?

A

RESULT of:
plaque from atherosclerotic lesion causes a break in the coronary artery –> thrombus forms –> stopping blood flow –> MYOCARDIAL CELL DEATH!

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12
Q

What is angina?

A

the RESULT of the narrowing of the coronary artery d/t plaque in coronary artery –> decrease of radius –> COULD stop blood flow and ischemia when oxygen delivery is needed (exercise) –> PAIN occurs –> NOT MYOCARDIAL CELL DEATH

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13
Q

What is unstable angina?

A

blood flow is greatly obstructed cxing pain at rest & exercise

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14
Q

What is acute coronary syndrome (ACS)?

A
  • unstable angina is the primary syndrome for ACS

- a broad descriptor that is used for the range of myocardial ischemia from unstable angina to myocardial infarction

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15
Q

What are the risk factors for CAD?

A
  • males (women are “protected” during menstruation; become equal after menopause)
  • -hypoestrogenemia
  • -elevated C protein/homocysteine
  • old age
  • family hx (dad/brother < 55yo; mom/sister <65 yo)
  • DM
  • HTN
  • lipid elevation
  • smoking
  • not active
  • abdominal visceral obesity (apple vs pear-apple)
  • hypercoagulability
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16
Q

How can you REDUCE RISK of CAD?

A

-control glucose
-tx HTN
-incr lipid
–diet
–drugs/meds
-STOP smoking
-wt loss
-exercise regime
LIFE STYLE CHANGES

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17
Q

What is % mortality and survivors of MI?

A
  • 30% mortality

- even if you survive there is increased risk of death w/in 1st yr of survival

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18
Q

What ECG changes are w/MI?

A 
STEMI (ST elevation Myocardial Infarction)
non STEMI (non ST elevation myocardial infarction)
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19
Q

What is STEMI?

A
  • indicates there’s tissue dying

- MI is happening now

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20
Q

What is non STEMI?

A
  • lower amounts of tissue dying

- POSITIVE troponin is required for non STEMI (or else it’s ischemia)

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21
Q

What is inferior MI age indeterminent?

A

MI is happened in the past or happening now

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22
Q

PE of MI?

A

-pain (see classic)
-asymptomatic common in DIABETIC, OLDER WOMEN
(“mom can’t get over cold”)
– sudden breathlessness
– dyspnea
– fatigue
– weakness
– “brain freeze” headache
-early morning presentation
-triggers (physical/emotional, surgery (intubated: pt can’t tell you where they’re hurting - THINK)
-denial in men (delay’s help)
-xanthoma/tuberous xanthomas (fluid fat building up in the eye/body)
-AV nicking (d/t HTN)
-papilledema
-diabetic retinopathy/cotton wool
-copper wire (d/t reflection of lipid to make it look “silver”)
-erectile dysfunction

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23
Q

Classic PE of MI?

A

elephant crushing my chest (substernal chest pain) running down (radiation) to left elbow and jaw)

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24
Q

DDx for MI?

A
  • acute aortic dissection
  • acute pericarditis
  • GI pain (cholecystitis, esophageal spasm)
  • pulmonary pain (pleurisy, PE)
  • musculoskeletal related pain (costchondritis)
25
Initial impression of MI?
- acute MI: anxious - large area is involved: listless, weak, confused, comatose (d/t poor CO) - pallor, sweat, nausea, vomiting (diaphoretic)
26
Vita signs of MI?
- low BP (than normal) - -lower BP = larger myocardial infarction - pulses: weak, thready, irregular - "anterior MI": tachycardia, HTN
27
Cardiac exam of MI?
- abnormal systolic pulsation - -part of heart bulges out (dyskinetic bulge) - rate and rhythm assessment - heart sounds may be normal OR: - - S2 - - S3 (HEART FAILURE) - - murmur - - jugular cannon wave vein (d/t papillary m. dysfunction; papillary m. is ischemic --> AV valve doesn't close very well aka acute ventricular failure = MURMUR - - pericardial friction rubs d/t transmural infarction (STEMI: pericardium gets irritated and rubs like sandpaper instead of smooth glass)
28
Pulm exam of MI?
-rales = HF d/t blood being pulled to lower lung than higher --> if more prominent signs on upper lobe --> tissue gets boggy --> RALES!
29
Labs for MI?
- routine labs (CBC/CHEM 20) - - high WBC - - high myoglobin - - increase AST - - high LDH1 (norm: low LDH1/ LDH2; MI: high LDH1/LDH2) - - high CK: MB band (heart), MM (heart), BB (brain) - HIGH TROPONIN (gold standard) - - 1-3 days is high and remains high 5-7 days - SERIAL TESTS of cardiac enzymes (4-6 hrs) - total quantity of cardiac enzymes released = size of infarct
30
ECG for MI? - infarction
-ST elevation/depression -Q waves -abnormal T waves -decreased R wave CLASSIC PATTERN: normal ECG > peaked T waves > ST elevation > Q wave > T wave inversion/flat
31
ECG for MI? - ischemia
- ST depression (same as infarction) - TALL POSITIVE T WAVES - inversion/flat T waves (same as infarction)
32
ECG for MI? - rhythm abnromalities
- PVC - VT - VF - PAC - A flutter and A fib - heart blocks
33
ECG for MI? -serial EKG
- you need SERIAL EKGs to dx (NOT ONE) | - COMPARISON IS VERY HELPFUL
34
CXR for MI?
- LVH/RVH - HF - mediastinal widening (d/t acute aortic dissection) - tumor, infiltration, fracture, suspicion of pericardial effusion
35
Echocardiography for MI?
- VERY SENSITIVE but NOT specific (can't tell if MI is happening NOW or happened years ago: scar) - abnormal wall motion - can asses for ventricular aneurysm, pericardial effusion, valvular dysfunction, ejection fraction
36
Imaging for MI?
Radionuclide imaging - Thallium 201: reveals "cold" spot by concentrating at VIABLE myocardium --> NOT GOOD FOR ACUTE MI (cannot distinguish between old and new MI) - Tc99: reveals "hot" spot by localizing MI and sizing --> GOOD FOR ACUTE MI - SPECT: 3D image for 'stressed' myocardium and 'resting' myocardium
37
MI management?
``` ACUTE: -Nitrate (NOT in hypotensive or right ventricular infarction) -O2 -Beta blockers -Anti platelet and thrombo -ACE -Analgesia -Aspirin IV access for easy access (D5) Cardiac Catherization before Cath lab if pt stable: -Beta blockers ACE inhibitors (NOT IN HYPOTENSIVE) lipid lowering (aggressive) pump failure mangement Reperfusion ```
38
MI management w/ ST segment elevation?
``` tPA NON STEMI= NO tPA; ONLY IF NEW best w/in 3-12 hrs -limits infarct size and mortality -AltePLASE, retePLASE, tenectePLASE -streptokinase (only give ONCE d/t allergic rxn risk is high) -anticoagulation w/ hep after tPA ```
39
What is the goal of getting patient into cath lab?
90 min upon arrival of the ER
40
What is cardiac catherization?
- PTCA | - Coronary Stent placement
41
What is pump failure management in MI?
-monitoring -inotropes (excitatory and inhibitory actions on the heart and vascular smooth muscle) -IABC (intra aortic balloon counter pulsation)
42
What is reperfusion in MI management?
- tPA - -Streptokinase (only once d/t allergic rxn) - -heparin - PTCA (percutaneous transluminal coronary angioplasty) - CABG (coronary artery bypass graft)
43
Post MI management?
- modify risk factors - medication - Reperusion
44
Post MI management? - modify risk factors
LIFESTYLE MANAGEMENT - stop smoking - control lipids - control diabetes - wt loss - start cardiac rehab exercise (more for support in case pts are scared to start walking again)
45
Post MI management? -meds
-antiplatelet medication -ACE inhibitors -lipid lowering meds -Beta blockers ADJUNCTIVE meds: -digoxin (inotrope) -nitrates (for angina symptoms) -CCB AVOID NSAIDS --> RECURRENT/MORTALITY RISK INCR
46
Post MI management? -reperfusion
- CABG | - PTCA
47
What is stable angina?
- when sx of pain decrease w/ rest after exertion | - NO myocardial cell death
48
What is unstable angina?
-rest does not relieve pain and sx
49
Stable angina: Hx?
- provokers: physical activity, stress, LARGE MEALS - relievers: REST (goes away in 3-5 min) - - tightness, radiating - -dyspnea
50
Stable angina: PE?
usually normal OR: - nicotine stained fingers - HTN - AV nicking/copper wire - arterial bruit - OTHER EVIDENCE OF ATHEROSCLEROSIS
51
Stable angina: work up?
- routine labs: diabetes, renal dz, lipid abnormalities, glucose, thyroid fxn - CXR: LVH/ CHF - EKG: MI, LVH - CARDIAC STRESS TEST 1) Exercise stress test 2) echo: wall motion abnormality 3) coronary angiogram: gold standard
52
Stable angina: Tx?
``` LIFESTYLE CHANGES: -reduce risk factors for CAD -physical conditioning Meds (not everyone can get surgery) -- Antiplatelet -- Nitrates (if they know what triggers angina, take it before) -- Beta blockers (decrease contractility = decrease myocardial O2) -- CCB Revascularization: - PTCA - CABG ```
53
How to Dx unstable angina?
1) NEW onset (less than 2 mo) 2) had stable but develops more FREQUENT, SEVERE, PROLONGED angina or angina happens w/ LESS exertion aka Accelerate angina 3) ANGINA AT REST
54
Tx for unstable angina?
- asprin - coronary care unit ASAP / cath lab - RULE OUT MI via EKG, serial cardiac enzymes - Cardaic Cath/Revascularzation URGENT for: 1) persistant chest pain AND EKG changes w/in 1hr 2) recurring ischemia w/ AGGRESSIVE THERAPY 3) responds to meds but has ischemia w/ min activity
55
What are TMI scores?
- 65 yo+ -prior coronary stenosis - ST segment deviation -2+ angina/day -3 risk factors for CAD (family hx, male, HTN, high lipids, DM, smoking, obesity) -incr serum cardia markers
56
How to group TMI scores?
- low (0-2%) - int (3-4%) - high (5-7%)
57
What is Prinzmetal Angina?
- ischemic pain at rest WITH transient ST elevation - d/t transient coronary vasospasm - YOUNGER and FEW coronary risks (but they smoke) - area of spasm is ADJACENT to plaque
58
Tx Prinzmetal Angina?
- nitrates | - CCB

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