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Coronary Artery Disease and Acute Coronary Syndrome Flashcards

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1
Q

Coronary Artery Disease

A

Definition: atherosclerosis of the intima of the coronary arteries

Statistics:
- #1 cause of death in the US*
- Men > women; after age 70 -> same risk for both genders
- estrogen protection stops after menopause
-18.2 million adults
- MI every 40 seconds

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2
Q

Atherosclerosis and progression

A

Atherosclerosis: accumulation of plaque in the intima of any artery
1) Lipid deposition (LDL)
2) fibrosis
3) calcification
4) plaque formation
- eventually plaque ruptures

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3
Q

Cardiovascular disease and its subbranches

A

Cardiovascular disease: atherosclerosis of the arterial circulation

  • Peripheral arterial disease (PAD)
  • Carotid artery disease
  • Cerebral artery disease:
    CVA, TIA
  • Coronary artery disease (CAD) -> Ischemic heart disease: same ds and can lead to MI
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4
Q

Coronary Artery Disease
Risk Factors:

A

Tobacco use**
Diabetes mellitus *
Metabolic syndrome
- Three of more of the following:
- 1) Triglycerides > 150 mg/dL
- 2) HDL cholesterol < 40 mg/dL men, <50 mg/dL women
- 3) Fasting blood glucose > 110mg/dL
- 4) Abdominal obesity
- 5) HTN

Hypertension
Hyperlipidemia
Family hx of CAD
Obesity

“HDL = happy lipids; LDL = loser lipids”

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5
Q

Hyperlipidemia def + types

A

Definition: increased levels of lipids (triglycerides + cholesterol) in the blood

Types:
- Mixed hyperlipidemia: cholesterol and triglycerides
- Hypercholesterolemia: high cholesterol
- Hypertriglyceridemia: high triglycerides

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6
Q

Hyperlipidemia: risk factors

A

Risk factors:
- Diet: alcohol + saturated fats
- Age
- Sedentary lifestyle
- Family history
- Men > Women
- Genetic mutations: Familial hypercholesterolemia

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7
Q

Hyperlipidemia: clinical features

A
  • Asymptomatic
  • Xanthoma = hard yellowish plaque/nodule of tendons and skin-> Severe hyperlipidemia
  • Pancreatitis with hypertriglyceridemia
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8
Q

Hyperlipidemia: Fasting lipid panel goals:

A

Cholesterol < 200 mg/dL

LDL (MOST IMPORTANT FOR CAD RISK) **
- < 100 mg/dL
- < 70 for patient with DM, CAD

HDL : Protective factor; happy!!!
- > 40 mg/dL men
- > 50 mg/dL women

Triglycerides:
- < 150 mg/dL

“LDL is double HDL and men less than women bc they more at risk”

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9
Q

Statins (HMG-CoA reductase inhibitors): what is their use, MOA

A
  • Most potent to lower LDLs***
  • put atherosclerotic pts on statins even if they dont have high cholesterol -> stabilizes plaque

MOA:
- Inhibit cholesterol synthesis by inhibiting the enzyme HMG-CoA reductase
- Increase LDL receptors -> promotes LDL clearance
-Reduce PROGRESSION of plaque and reduce MORTALITY rates from cardiovascular disease
- stabilizes plaque, lowers cholesterol

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10
Q

Statins: ADR, drug names

A

ADR:**
- Myalgia, arthralgia (common)
- rhabdomyolysis: muscle injury that releases myoglobin into bloodstream
- elevated ALT/AST - need routine lfts

Examples: “-statins”
- Rosuvastatin (Crestor)
- atorvastatin (Lipitor)
- simvastatin (Zocor)
- pravastatin (Pravachol)

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11
Q

PSK9 inhibitors: MOA, indications, ADR, drug names

A

MOA:
- Inhibit DEGRADATION of LDL receptors -> increase LDL clearance

Indications:
-Familial hypercholesterolemia
- CAD

ADR:
-Headaches
- diarrhea
- URI symptoms

Drugs: “-CUmab”
- Alirocumab (Praluent)
- evolocumab (Repatha)

“Saiki K - CUsuo -> CUmab”
- saiki taking this med because hes sick with URI, diarrhea, headache

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12
Q

Hyperlipidemia all medication tx

A

-statins: most potent to lower LDL
- PSK9 inhibitors: lowers LDL
- Niacin: lowers triglycerides, increases HDL
- Fenofibrates(ex: gemfibrozil): lowers triglycerides
- bile acid binding resins (rarely used): lowers LDL

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13
Q

Bile acid binding resins

A

Other hyperlipidemia tx: rarely used

Bile acid binding resins:
- lowers LDL
- no change on triglycerides
- ADR: GI side effects
- drugs: Cholestyramine, Colestipol, Colesevelam (Welchol)

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14
Q

Niacin

A

Niacin: Other hyperlipidemia tx
- lowers triglycerides
- increases HDL
- ADR: flushing, pruritis, nausea/vomiting

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15
Q

Fenofibrates

A

Other hyperlipidemia tx
Fenofibrates (ex: gemfibrozil)
- lowers triglycerides
- ADR: nausea vomiting, ab pain

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16
Q

Differential Diagnosis of Chest Pain: cardiac

A

Angina pectoris
Acute MI
Aortic dissection
Arrythmias
Heart failure
Pericarditis
Valvular heart disease
Myocarditis

“AAAA- HPV-M”
“Always Ask About Aches, Heart Problems Vary Much”

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17
Q

Differential Diagnosis of Chest Pain: non-cardiac

A

Anxiety
Cholecystitis
Costochondritis
GERD
PUD
PE
Pneumothorax
Musculoskeletal disease

“A- CCG-PPP- M”

“Anxious Cats Craft Great Plans, Pondering Pneumatic Mysteries” -> MOCHA HAD ATYPIC CHEST PAIN

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18
Q

Angina Pectoris

A

Definition:
- chest pain caused by inadequate tissue perfusion of the myocardium (heart muscle)
- Imbalance in cardiac demand and tissue perfusion
- MC cause: CAD*

Sx:
- Chest pain that originates from the heart
- Can have typical and atypical chest pain

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19
Q

typical chest pain

A

Typical
- Men
- Mid-sternal or left sided
- Squeezing, tightness, pressure
- “elephant sitting on chest”
- Levine sign – clenches fist over sternum
- Radiation: Left arm

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20
Q

atypical chest pain

A

Typical
- Men
- Mid-sternal or left sided
- Squeezing, tightness, pressure
- “sitting on chest”
- Levine sign – clenches fist over sternum
- Radiation: Left arm

Atypical
- Females
- elderly
- diabetes/ immunocompromised
- pain: jaw, right shoulder; may not be in chest
- Radiation:
- Right or bilateral arms
- Back

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21
Q

Prinzmetal Angina

A
  • Vasospasm of coronary artery at REST
  • MC in females
  • 75% w/ atherosclerotic lesion (+/-)
  • Early morning
  • Exercise capacity is preserved
  • Can be induced via cocaine

Tx: calcium channel blockers

“elderly female in early morning hours presents with chest pain who is addicted to exercise and cocaine”

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22
Q

Stable Angina

A

Predictable chest pain:
- ex: i walk 2 blocks, 5 sec it goes away consistently
- always 2 blocks
Lasts <3 mins

Exacerbated by:
- activity
- emotion

Relieved by:
- rest
- sublingual nitroglycerin (immediate)

first line tx: beta blockers

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23
Q

Unstable Angina

A

Grouped w/ acute coronary syndrome
Angina that WORSENS (not consistent, not typical or predictable)

One of the following:
- Angina at rest
- New onset of angina symptoms
- increasing pain in stable pts

Less responsive to sublingual nitroglycerin
Indicates stenosis that has enlarged

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24
Q

Angina Pectoris
Causes:

A

CAD: MC **

Embolus
Arteritis
Dissection
Congenital abnormality
Vasospasm
- Cocaine
- Prinzmetals

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25
Coronary Artery Disease Diagnosis: EKG
Normal in 25% of patients Horizontal or down sloping depression ST-segments Non-specific changes Flattening or inversions of T-waves T-wave changes in Lead III can be diaphragmatic
26
Coronary Artery Disease Diagnosis: what are all the dx tests
- CARDIAC CATHETERIZATION/coronary angiography: definitive dx** - EKG - exercise stress test - echocardiogram "CEEE u got CAD"
27
Coronary Artery Disease Diagnosis: Exercise stress testing
- Non-invasive testing - ST depressions of 1mm in two leads = POSITIVE test - More specific with single-photon emission computed topography (SPECT) - Nuclear exercise stress testing allows imaging for extent and location of disease - Can use pharmacologic stress testing if patient is unable to exercise
28
Coronary Artery Disease Diagnosis: Echocardiogram
Echocardiogram: - Wall motion abnormalities - Decreased LVEF
29
Coronary Artery Disease Diagnosis: Cardiac catheterization
Cardiac catheterization (coronary angiography) is the DEFINITITE DIAGNOSIS - Selective due to invasiveness - can be dx and tx
30
Coronary Artery Disease Treatment: Risk factor modification
STOP SMOKING!!* Treat comorbidities: - Hypertension - Hyperlipidemia - Diabetes Lifestyle changes: - Exercise and dietary modification - Weight reduction - quit smoking!!!
31
Antiangina meds:
1) Beta blockers – first line for patient with stable angina * - NOT FOR VASOSPASTIC ANGINA (prinzmetal angina) 2) Calcium channel blocks (diltiazem, verapamil) - Second-line if beta-blockers fail or contraindicated - first line tx: prinzmetal angina 3) Nitrates (nitroglycerin, isosorbide, hydralazine) - Angina that persists with monotherapy - first line tx: acute MI Additional therapy: - Ranolazine (Ranexa): late sodium channel blocker
32
Beta blockers - angina tx; indication and MOA
Beta blockers =first line tx for pt with STABLE ANGINA - DO NOT USE FOR VASOSPASTIC ANGINA* MOA: - Increase oxygenation by decreasing heart rate -> prolongs diastole - Prevents reinfarction
33
Calcium channel blockers: antiangina tx; indication, MOA, drug names
Indication: - Second-line tx: use if beta-blockers fail or contraindicated - First-line tx: Prinzmetal’s angina MOA: - Vasodilation Drug names: - diltiazem - verapamil
34
Nitrates - antiangina tx; indication, MOA, drug names
Indication: - angina that persists with monotherapy MOA: - vasodilation Immediately effective: - Sublingual nitroglycerin Long acting: - isosorbride - hydralazine
35
Nitrates - antiangina; ADR
ADR: *** - headache - fascial flushing - orthostatic hypotension - syncope
36
Coronary Artery Disease: Treatment - Percutaneous coronary intervention
1) Balloon angioplasty - small balloon at the tip of the catheter that is inflated to compress plaque against artery walls 2) Drug eluding stents: slowly releases meds that prevent blocakge - requires dual antiplatelet therapy for 12 months to prevent clots forming in stent - Aspirin 81 mg - Clopidogrel 75 mg (Plavix) 3) Bare metal stents: 1 month of dual antiplatelet therapy; no med release
37
Coronary Artery Disease: Treatment - Coronary artery bypass grafting (CABG)
Indication: - 1) 3 vessel disease with >70% stenosis of each vessel - 2) Left main coronary disease > 50% stenosis surgery to bypasses stenosis
38
Acute Coronary Syndrome Symptoms:
Typical or atypical chest pain* Diaphoresis: excess sweating * Shortness of breath/dyspnea Nausea/vomiting Dizziness/lightheadedness Syncope Anxiety
39
Acute Coronary Syndrome - Signs
Hypertension Hypotension Tachycardia Bradycardia/heart block - inferior wall MI Murmur Lungs: Friction rub (pericardial effusion) Bibasilar rales "both hypo/hyper; tachy/brady + heart murmurs + block"
40
Acute Coronary Syndrome: Definition
Umbrella term that includes: 1) Unstable angina 2) Non-ST segment myocardial infarction (NSTEMI) - Partial thickness necrosis (endocardial muscle) 3) ST segment myocardial infarction (STEMI) - Full thickness necrosis "basically acute coronary syndrome = any unstable angina, NSTEMI, STEMI"
41
Myocardial Infarction: definition and important facts
Definition: - necrosis of the myocardium due to interruption of blood supply to the myocardium - 1 in 5 of MIs are silent** - MCC: thrombosis - plaque ruptures -> thrombus -> occlusion
42
Myocardial Infarction: MC cause + typical presentation
MC cause: thrombosis - Ruptured atherosclerotic plaque → thrombus formation (clot) → occlusion (artery blocked) MC: pts present w atypical sx (right arm, back, odd age) - Atypical chest pain** - Fatigue - Weakness - Abdominal pain - they will often think they have a stomach bug
43
Acute Coronary Syndrome Diagnosis
12 lead EKG *STEMI: - ST segment elevation > 1mm in two contiguous leads - ST elevation: Ischemia = "tombstoning" - Q wave: infarction NSTEMI and UA: - ST depressions or T wave inversions - Positive cardiac enzymes = NSTEMI
44
Cardiac Enzymes
cardiac enzymes = Gold standard diagnosis for NSTEMI!!! - Release with necrosis of myocardial tissue - serve as markers for diagnosing myocardial injury - Three sets on enzymes every 6 hours Troponin T and I most specific** - Increases 4-8 hours - Peaks 12-24 hours - Normalizes 5 to 14 days Others: - CK-MB: normalizes faster (2-3 days) - Myoglobin: increases (4h), peaks(4h), normalizes faster (1 day)
45
Acute Coronary Syndrome: MI Treatment
"MONAB" *Morphine: use when pain is not adequately controlled by NTG *Oxygen *Nitroglycerin (NTG): *Aspirin *Beta Blocker *Statins: - reduce risk of further coronary events *Unfractionated heparin or low molecular weight heparin (LMWH) - both: reduce clot formation - unfractionated heparin: inactivate thrombin (factor 2) -> no clot formation/activation of fibrin (factor 1) - LMWH: inactivates factor Xa by potentiating anti-thrombin III
46
Aspirin allergy alternative
Adenosine diphosphate receptor inhibitors *Inhibits ADP mediated platelet aggregation -> anti-platelet agent *Caution if bleeding of planned CABG within seven days Drugs: "-grel" -Clopidogrel (Plavix) - Prasugrel (Effient) - Ticlopidine (Ticlid)
47
Inferior MI: what EKG leads and corresponding artery?
II,III, aVF Right Coronary Artery
48
Posterior MI: what EKG leads and corresponding artery?
V1, V2, V3 Posterior descending artery
49
Septal MI: what EKG leads and corresponding artery?
V1, V2 Left anterior descending
50
Anterior MI: what EKG leads and corresponding artery?
V3, V4 Left anterior descending
51
Lateral MI: what EKG leads and corresponding artery?
I, avL,V5,V6 Left anterior descending or circumflex
52
Acute Coronary Syndrome: STEMI reperfusion
STEMIs need IMMEDIATE REPERFUSION First line: percutaneous transluminal coronary angioplasty (PCI) -> better than thrombolysis - can be performed fast: DOOR TO CATH TIME = 90 min!!! - wantto treat pts asap, less than 90 minutes 1) Drug eluding stents (DES): release meds to help prevent artery from becoming blocked again - require dual anti-platelet therapy x 12 months 2) Bare metal stents: dual anti-platelet therapy x 1 month
53
Acute Coronary Syndrome: STEMI reperfusion - thrombolytic therapy
Used when PCI cannot be performed within recommended time; not as good tx - goal door to cath time: 30 min - reduces mortality and infarction by using meds to dissolve clots TPA Agents (-"plase": activate tissue plasminogen to dissolve clots - alteplase - reteplase - tenecteplase
54
Absolute contraindications to thrombolytic therapy
CVA within the last year Intracranial neoplasm Major surgery < 2 weeks Active internal bleeding Suspected aortic dissection Previous hemorrhagic CVA Trauma <2 wks ---------- Thrombolytic -> A (big) IMPACT: - AORTIC DISSECTION - intracranial hemorrhage - major surgery 2 wks - previous CVA HEMORRHAGIC - active internal bleeding -CVA in the last year - trauma 2 wks
55
Relative contraindications to thrombolytic therapy - weight risk vs benefit
"2 BP DR PANda + CPR" need to consider risk vs benefit of thrombolytic therapy 2 wks: trauma + surgery Bleeding Diathesis: unusual susceptibility to bleeding- platelet disorders, coagulation factor deficiencies, etc. Pressure: BP over 180/110 Diabetic retinopathy Recent internal bleed PUD + Pregnant Anticoagulation use Noncompressible vascular puncture + CPR (prolonged or traumatic)
56
Acute Coronary Syndrome: MI Complications
Ventricular tachycardia Ventricular fibrillation Ventricular aneurysm/rupture Cardiogenic shock Sudden death Heart failure Pericarditis Papillary muscle rupture Dressler syndrome
57
Acute Coronary Syndrome Unstable angina - tx
Unstable angina needs management strategy !!! Risk stratification scales: - TIMI scale – identifying the likelihood of death, new or recurrent MI - GRACE: Global Registry of Acute Coronary Events GRACE: - Low score = conservative treatment - Antiplatelet therapy - Anticoagulation therapy - High score = invasive treatment - Cardiac angiogram/angioplasty Low risk pts: - conservative tx - antiplatelet therapy - anticoagulation therapy High score: - invasive tx - cardiac angiogram/angioplasty
58
Cocaine Induced Myocardial Infraction definition
Definition: - Coronary artery vasospasm - secondary to cocaine activation of SNS nervous system and alpha 1 receptors - Cocaine causes vasoconstriction of coronary arteries
59
Cocaine Induced Myocardial Infraction dx, tx, contraindication
Diagnosis: - 12 lead EKG: transient diffuse ST elevations + troponins + Utox Treatment: - Calcium channel blockers and nitrates - ASA and Heparin/LMWH until CAD is rule out Contraindication: - beta- blockers: risk of vasospasm
60
TIMI Risk Score
- score calculates risk of death and ischemic events in patients with unstable angina or NSTEMI Points: - Age ≥ 65: 1 point - ≥ 3 CAD risk factors (such as family history, hypertension, high cholesterol, diabetes, and being a smoker): 1 point - Known CAD with stenosis ≥ 50%: 1 point - ASA use in the past 7 days: 1 point - Recent (≤24h) severe angina: 1 point - Elevated cardiac markers (such as troponins): 1 point - ST deviation ≥ 0.5 mm: 1 point

Cardiology (6 decks)

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