Cradio ppt. 1 - Exam 6 Flashcards
Angina Types
Stable angina - w/ exertion
Unstable angina - @ rest
Coronary spasm:
Prinzmetal angina
Angina Patho? Atherosclerosis
- Atherosclerosis
- Lipid deposition
- Atheroma
- Calcification / fibrosis
Fat gets stucky and sits on the surface and accumulates -
HTN usually involved so we have high pressure hitting this hunk of lipids and it can rupture or embolism and then there is a tear in the endothelial and then body is going to repair ir and then platelets come in and try and fix it and then the entire vessel gets narrowed completely THAT IS WHY IT IS IMPORTNAT TO GIVE THESE PEOPLE ASA.
Angina Patho? Coronary spasm
Spasm of coronary vessels
Cocaine or Prinzmetal
What is the most common cause of death in US and world?
Atherosclerosis - angina, MI
Atherosclerosis /MI is _x higher in men than women?
4
By age 70, 1:1 male/female ( normalizing as men start to die)
Atherosclerosis /MI risk factors?
Age
Smoking
Total cholesterol >200 - elevated
Family history - did anyone in your family die a sudden
death ?
Diabetes mellitus - coronary
disease, PAD to coronary vessels
Obesity
Common comorbidities with Atherosclerosis / MI ?
Hypertension
PAD
Aortic disease
You need three of more of what for Metabolic syndrome? risk factor to angina and MI
abdominal obesity - central
obesity - waste circumference - >47 cm
triglycerides greater than 150 mg/dL
high-density lipoprotein (HDL) less than 40 mg/dL for men and less than 50 mg/dL for women
fasting glucose greater than 110 mg/dL
HTN
Angina / MI social Hx?
Alcohol
Cocaine vasospasm
Angina / MI Hx?
Chest pressure (squeezing) - “elephant on my chest “
Impending death - “ i feel like im going to die “
Chest pressure location for angina / MI?
midsternal or left chest (retrosternal)
Chest pressure location of radiation for angina and MI?
radiates by vertebral nerves
and to the JAW, SHOULDER, arms, wrists, back of hand
Stable angina history?
occurs only with activity
lasts less than 3 minutes
Nitroglycerine significantly improves
sits down and goes away - hit them with nitro and then they have improvement - probably has like 30% occlusion
Unstable angina history?
occurs at rest
lasts more than 30 minutes
Nitroglycerin improves, but not significantly
started stable but it got worse - atheroma is not about 50% - more an issue - nitro wont help as much
Prinzmetal angina history?
More common in females and in the morning
issues in the heart and vessels but the pathophys is different
Angina Physical exam findings?
May be normal
Levine sign - clenching chest
Hypertension
Tachycardia
Xanthelasma - fatty yellow deposits - indicating high cholesterol
always watch a patient VITALS! - do not ignore them - which risk management ( young can get toasted if you did not address abnormal vitals) - tachycardia does not just happen… it is trying to compensate for something - you always want to normalize the vitals if and before you send them home or to ED
Diagnostic Studies for angina ?
Screening - EKG
Provocative screening - stress test
Gold standard test - Coronary angiography
Options studies for angina ( definitive) ?
Myocardial perfusion scintigraphy
Radionuclide angiography
Echocardiography
Positron emission tomography
CT Angiography
MRI with gadolinium
Angina EKG findings?
25% normal
- ST segment depression
- T wave inversion
- Nonspecific T wave abnormalities
get any of these and we have to move on to more testing
What angina diagnostic test is the most useful and cost effective and noninvasive?
Exercise stress test
may be done with medications like Dobutamine
high risk - chest pain, stenosis = no stress test here we go right to angiography
Angina - Exercise stress test positive findings?
1mm depression or greater
For angina, which test is selectively used because of cost and invasiveness?
Coronary angiography
When is coronary angiography selected ?
Life-limiting stable angina despite tx
Unstable angina
Aortic valve disease
Suspected MI
Recurrent symtpoms after revascularization
Unknown cause of chest pain
Survivors of sudden death
Coronary angiography is the definitive test for what?
CAD
<50% stenosis on coronary angiography indicates?
Mild
> 50% stenosis on coronary angiography indicates?
Clinical significance
> 70% stenosis on coronary angiography indicates?
Very significant - like to cause ischemia - stent is indicated
Optional test for angina that involve stress?
Myocardial perfusion scintigraphy
Radionuclide angiography
Echocardiography
Optional test for angina that is looking for perfusion and metabolism?
Positron emission tomography
Optional test for angina that is not for low risk individuals and will show a low likelihood of significant CAD to rule out disease?
CT angiography
What optional test is used to evaluate degree of damages for angina?
MRI with gadolinium
Angina prognosis?
1-25% mortality per year
Angina complications?
MI
Stable and Unstable angina tx for acute episode?
Nitroglycerin ( fast acting, sublingual)
Stable and Unstable angina tx for chronic management?
- Aspirin- decrease chance of MI, improves mortality
- Long acting nitrates - decreases episodes during day, but they become less affective over time (periods of break to keep affetc)
- Beta blocker - improves mortality
- Ranolazine- SCB - improves exercise capability - help with ability to exercise but still be careful cause it prolongs QT (liver disease)
- Comorbidities ( treat these!)
Statin - high cholesterol (low, moderate or high potency - for high risk)
ACEI - for coronary disease + HTN - Revascularization - after trying all these above and still symptomatic at rest
Prinzmetal tx for acute episode?
Nitroglycerin
Prinzmetal tx for chronic management?
CCB - amlodipine
Patient education with angina?
Stop smoking
treat comorbidity’s like DM, HTN and hypercholesterolemia
Lose weight if overweight :
BMI <25
waist circumference <40 in males and <35 in females
Aerobic exercise
Patient education diet LOW in what with angina?
Low saturated fat
Low cholesterol
Low trans fat
Patient education diet HIGH in what with angina?
Fiber
Vegetables
Fruits
Whole grains
What treatment medication is most important long term and decreases mortality?
Beta blockers , along with ASA
When are ACE inhibitors indicated ?
Unstable angina
CHF - cormobid
What medication do you want to avoid in CHF?
CCB
When are CCB indicated?
In place of BB or have already been maximized
Dihydropyridine or nondihydropyridines - ejection fraction indicating CHF then avoid CCBs
When are CCB contraindicated?
with CHF
Platelet inhibitors example treatment for angina?
ASA
Clopidogrel
significant reduction in infarctions
What class is Ranolazine and when is it indicated?
it is a sodium channel blocker and it is used to help increase exercise tolerance
Revascularization options for angina?
PCI - percutaneous intervention
CABG - coronary bypass bypass graft
Indications for PCI?
Unacceptable symptoms despite tx
Unstable angina with ischemia despite tx
Post-MI w/ continue angina
Indications for CABG?
Left main coronary stenosis >50%
Three vessel disease w/ LV dysfunction ( EF <50%) - signs of heart failure from disease
Restenosis of PCI
What is PCI?
Angioplasty OR
Stent
Stent - angioplasty plus a metal wiring that keeps it open - risk of collapse or showing a clot ( plane metal wiring = 30% restenosis) 10% with eluents on the wiring
Plan = ASA + Clopidogrel once a month
What is CABG?
redirect another graft artery from mammalian (saphenous vein straight to the heart)
the left internal thoracic artery (left internal mammary artery or “LIMA”) is diverted to the left anterior descending (LAD) branch of the left main coronary artery.
MI patho?
Plaque rupture
Thrombus
Death of myocardial tissue
Types of MI?
NSTEMI - (Non ST segment elevation myocardial infarction) - hard to catch - why we admits these patients
STEMI - (ST segment elevation myocardial infarction) - EKG within 10 min
MI hx?
last longer than 30 min
most common during early morning
Elderly sx of MI?
generalized weakness
syncope
altered mental status
Atypical MI symptoms?
Diaphoresis - sweaty
Dyspnea
Nausea/ vomiting
Weakness
Anxiety/restlessness
light-headedness
Syncope
Cough
Orthopnea
abdominal bloating
History of “silent MI” and occurrence?
1/3 of MI
minor pain, often thought to be GI
common if females and elderly
MI PE?
May be normal
Levine sign
Diaphoresis - more likely in someone with extremous - tells us something bad is going on
Hypertensive
Tachycardia
Bradycardia
New gallop (S3, S4 - stiff heart - chronic HTN, LVH)
Mitral regurgitation ( mr. ass, ms. ard)
these can all indicate extremous
MI PE if severe?
Hypotension
Arrhythmia - V- fib
Heart failure: JVD,
Pulmonary edema
PE after MI?
Low grade fever
Dressler syndrome : Pericardial friction rub
MI diagnostic studies - primary evaluation?
- EKG
- Troponin I
- CXR
- Coronary angiography - always with STEMI
Diagnostic studies to consider with MI?
Ck and CK-MB 9 creatine kinase - myoglobin
Myoglobin
Echocardiography
MI EKG findings with STEMI?
ST dement elevation 1mm or higher in 2 contiguous leads
New LBBB
MI EKG findings with UA or NSTEMI?
ST-segement depression
What is the POST- MI progression on an EKG?
ST-segement elevations leads to Q-waves which leads to T-wave inversions
develops over hours to days
frowny face - convexity
STEMI in leads II, III, AVF, where is the MI location?
inferior
STEMI in leads V1 and V2, where is the MI located?
Posterior, anteroseptal
STEMI in leads V1 and V2, where is the MI located?
Anterospetal, posterior
STEMI in leads V2, V3 and V4, where is the MI located?
Anterior
STEMI in leads V5 and V6, where is the MI located?
Anterolateral
Troponin onset, peak and duration?
onset: 3-12 hours
peak: 18-24 hours
duration: 10 days
CK- MB onset, peak and duration?
onset: 3-12 hours
peak: 18-24 hours
duration: 36-48 hours
LDH onset, peak and duration?
onset: 6-12 hours
peak: 24-48 hours
duration: 6-8 days (5-10days)
Myoglobin onset, peak and duration?
onset: 1-4 hours
peak: 6-7 hours
duration: 24 hours
MI echo findings?
wall motion abnormality
mitral regurgitation
MI CXR findings?
Likely normal
screen for other conditions
complications - Pulmonary edema
Gold standard for MI?
Coronary angiography
What is the most sensitive test to quantify the extent of MI?
MRI with gadolinium contrast
What measures severity of MI?
TIMI score - Thrombolysis In Myocardial Infarction
What are the factors of TIMI score to get a point?
> 65 years
three or more risk factors for
CAD
use of aspirin within the last 7 days
known CAD with stenosis 50% or greater
more than one episode of rest angina within the last 24 hours
ST-segment deviation
elevated cardiac markers
What is considered high risk from TIMI score?
3 or more
MI prognosis?
20% mortality
MI complications?
Dressler syndrome - pericarditis after MI
CHF
MI - STEMI plan: starting treatment?
MONA - consider M later
- Oxygen NC 4L
- ASA: 160-325 mg po
- Nitroglycerin SUBL
- Morphine IV - lower anxiety and vasodilation effect
Primary goal of MI- STEMI tx?
PCI within 90 min
Consider which medications for MI - STEMI? Me 2 medicines.
Heparin
Clopidogrel
GIIb/IIIa inhibitors
Thrombolytics
Beta blockers debated ( not in acute phase, they decrease blood flow, BB are important AFTER acute phase)
GET THESE PEOPLE TO THE CATH LAB. STENT! within 90 min
MI - NSTEMI and UA conservative tx?
ASA
clopidogrel
Anticoagulation - LMWH
Monitor for progression
For MI - NSTEMI and UA consider what treatments?
IV glycoprotein IIb/IIIa inhibitors like : Eptifibatide, Tirofiban
MI - NSTEMI and UA invasive treatment?
conservative plus….
cardiac catheterization
STEMI reperfusion tx?
Immediate angiography <90 min
PCI better than thrombolysis
When do we use thrombolysis for STEMI? and what is it?
we only consider it when PCI is unavailable
and it is Tissue plasminogen activator - alteplase, streptokinase
