Coronary Artery Disease Flashcards
What is arteriosclerosis?
- 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
What happens when the vessel walls are weakened?
Arteriosclerosis
there is a loss of elasticity leading to dilation, rupture, occlusion
What happens to diastolic and systolic in arteriosclerosis?
diastolic increases; systolic decreases
What is atherosclerosis?
- inflammatory process that results in patchy, nodular, lipid laden lesions in large and medium arteries
- major cause of death
What is the inflammation process of atherosclerosis?
lesion occurs –> thin fibrous cap covering lipid rich core ruptures –> release of cytokines –> stimulates platelets –> thrombus occurs –> vasoconstriction of vessel
What can atherosclerosis lead to in coronary arteries?
- unstable angina myocardial ischemia
- myocardial infarction/myocardial cell death
What terminologies are associated with atherosclerosis?
- fatty streaks (early)
- fibrous plaques
- complicated lesions
- “soft” lesions
Where does atherosclerosis commonly occur?
abdominal aorta
Who is affected w/ CAD?
- probably all older adults have some degrees of CAD
- asymptomatic until it ruptures and there is a thrombosis occurring
What is a marker for CAD?
-LDH
What is myocardial infarction?
RESULT of:
plaque from atherosclerotic lesion causes a break in the coronary artery –> thrombus forms –> stopping blood flow –> MYOCARDIAL CELL DEATH!
What is angina?
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
What is unstable angina?
blood flow is greatly obstructed cxing pain at rest & exercise
What is acute coronary syndrome (ACS)?
- 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
What are the risk factors for CAD?
- 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
How can you REDUCE RISK of CAD?
-control glucose
-tx HTN
-incr lipid
–diet
–drugs/meds
-STOP smoking
-wt loss
-exercise regime
LIFE STYLE CHANGES
What is % mortality and survivors of MI?
- 30% mortality
- even if you survive there is increased risk of death w/in 1st yr of survival
What ECG changes are w/MI?
STEMI (ST elevation Myocardial Infarction) non STEMI (non ST elevation myocardial infarction)
What is STEMI?
- indicates there’s tissue dying
- MI is happening now
What is non STEMI?
- lower amounts of tissue dying
- POSITIVE troponin is required for non STEMI (or else it’s ischemia)
What is inferior MI age indeterminent?
MI is happened in the past or happening now
PE of MI?
-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
Classic PE of MI?
elephant crushing my chest (substernal chest pain) running down (radiation) to left elbow and jaw)
DDx for MI?
- acute aortic dissection
- acute pericarditis
- GI pain (cholecystitis, esophageal spasm)
- pulmonary pain (pleurisy, PE)
- musculoskeletal related pain (costchondritis)
Initial impression of MI?
- acute MI: anxious
- large area is involved: listless, weak, confused, comatose (d/t poor CO)
- pallor, sweat, nausea, vomiting (diaphoretic)
Vita signs of MI?
- low BP (than normal)
- -lower BP = larger myocardial infarction
- pulses: weak, thready, irregular
- “anterior MI”: tachycardia, HTN
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)
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!
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
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
ECG for MI? - ischemia
- ST depression (same as infarction)
- TALL POSITIVE T WAVES
- inversion/flat T waves (same as infarction)
ECG for MI? - rhythm abnromalities
- PVC
- VT
- VF
- PAC
- A flutter and A fib
- heart blocks
ECG for MI? -serial EKG
- you need SERIAL EKGs to dx (NOT ONE)
- COMPARISON IS VERY HELPFUL
CXR for MI?
- LVH/RVH
- HF
- mediastinal widening (d/t acute aortic dissection)
- tumor, infiltration, fracture, suspicion of pericardial effusion
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
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
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
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
What is the goal of getting patient into cath lab?
90 min upon arrival of the ER
What is cardiac catherization?
- PTCA
- Coronary Stent placement
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)
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)
Post MI management?
- modify risk factors
- medication
- Reperusion
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)
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
Post MI management? -reperfusion
- CABG
- PTCA
What is stable angina?
- when sx of pain decrease w/ rest after exertion
- NO myocardial cell death
What is unstable angina?
-rest does not relieve pain and sx
Stable angina: Hx?
- provokers: physical activity, stress, LARGE MEALS
- relievers: REST (goes away in 3-5 min)
- tightness, radiating
- -dyspnea
Stable angina: PE?
usually normal OR:
- nicotine stained fingers
- HTN
- AV nicking/copper wire
- arterial bruit
- OTHER EVIDENCE OF ATHEROSCLEROSIS
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
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
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
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
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
How to group TMI scores?
- low (0-2%)
- int (3-4%)
- high (5-7%)
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
Tx Prinzmetal Angina?
- nitrates
- CCB
