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Clinical Medicine Lecture - Professor Kramer > Cradio ppt. 1 - Exam 6 > Flashcards

Cradio ppt. 1 - Exam 6 Flashcards

1
Q

Angina Types

A

Stable angina - w/ exertion

Unstable angina - @ rest

Coronary spasm:
Prinzmetal angina

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2
Q

Angina Patho? Atherosclerosis

A
  • Atherosclerosis
  1. Lipid deposition
  2. Atheroma
  3. 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.

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3
Q

Angina Patho? Coronary spasm

A

Spasm of coronary vessels

Cocaine or Prinzmetal

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4
Q

What is the most common cause of death in US and world?

A

Atherosclerosis - angina, MI

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5
Q

Atherosclerosis /MI is _x higher in men than women?

A

4

By age 70, 1:1 male/female ( normalizing as men start to die)

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6
Q

Atherosclerosis /MI risk factors?

A

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

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7
Q

Common comorbidities with Atherosclerosis / MI ?

A

Hypertension
PAD
Aortic disease

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8
Q

You need three of more of what for Metabolic syndrome? risk factor to angina and MI

A

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

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9
Q

Angina / MI social Hx?

A

Alcohol

Cocaine vasospasm

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10
Q

Angina / MI Hx?

A

Chest pressure (squeezing) - “elephant on my chest “

Impending death - “ i feel like im going to die “

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11
Q

Chest pressure location for angina / MI?

A

midsternal or left chest (retrosternal)

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12
Q

Chest pressure location of radiation for angina and MI?

A

radiates by vertebral nerves

and to the JAW, SHOULDER, arms, wrists, back of hand

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13
Q

Stable angina history?

A

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

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14
Q

Unstable angina history?

A

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

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15
Q

Prinzmetal angina history?

A

More common in females and in the morning

issues in the heart and vessels but the pathophys is different

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16
Q

Angina Physical exam findings?

A

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

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17
Q

Diagnostic Studies for angina ?

A

Screening - EKG

Provocative screening - stress test

Gold standard test - Coronary angiography

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18
Q

Options studies for angina ( definitive) ?

A

Myocardial perfusion scintigraphy

Radionuclide angiography

Echocardiography

Positron emission tomography

CT Angiography

MRI with gadolinium

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19
Q

Angina EKG findings?

A

25% normal

  1. ST segment depression
  2. T wave inversion
  3. Nonspecific T wave abnormalities

get any of these and we have to move on to more testing

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20
Q

What angina diagnostic test is the most useful and cost effective and noninvasive?

A

Exercise stress test

may be done with medications like Dobutamine

high risk - chest pain, stenosis = no stress test here we go right to angiography

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21
Q

Angina - Exercise stress test positive findings?

A

1mm depression or greater

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22
Q

For angina, which test is selectively used because of cost and invasiveness?

A

Coronary angiography

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23
Q

When is coronary angiography selected ?

A

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

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24
Q

Coronary angiography is the definitive test for what?

A

CAD

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25
Q

<50% stenosis on coronary angiography indicates?

A

Mild

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26
Q

> 50% stenosis on coronary angiography indicates?

A

Clinical significance

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27
Q

> 70% stenosis on coronary angiography indicates?

A

Very significant - like to cause ischemia - stent is indicated

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28
Q

Optional test for angina that involve stress?

A

Myocardial perfusion scintigraphy

Radionuclide angiography

Echocardiography

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29
Q

Optional test for angina that is looking for perfusion and metabolism?

A

Positron emission tomography

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30
Q

Optional test for angina that is not for low risk individuals and will show a low likelihood of significant CAD to rule out disease?

A

CT angiography

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31
Q

What optional test is used to evaluate degree of damages for angina?

A

MRI with gadolinium

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32
Q

Angina prognosis?

A

1-25% mortality per year

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33
Q

Angina complications?

A

MI

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34
Q

Stable and Unstable angina tx for acute episode?

A

Nitroglycerin ( fast acting, sublingual)

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35
Q

Stable and Unstable angina tx for chronic management?

A
  1. Aspirin- decrease chance of MI, improves mortality
  2. Long acting nitrates - decreases episodes during day, but they become less affective over time (periods of break to keep affetc)
  3. Beta blocker - improves mortality
  4. Ranolazine- SCB - improves exercise capability - help with ability to exercise but still be careful cause it prolongs QT (liver disease)
  5. Comorbidities ( treat these!)
    Statin - high cholesterol (low, moderate or high potency - for high risk)
    ACEI - for coronary disease + HTN
  6. Revascularization - after trying all these above and still symptomatic at rest
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36
Q

Prinzmetal tx for acute episode?

A

Nitroglycerin

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37
Q

Prinzmetal tx for chronic management?

A

CCB - amlodipine

38
Q

Patient education with angina?

A

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

39
Q

Patient education diet LOW in what with angina?

A

Low saturated fat
Low cholesterol
Low trans fat

40
Q

Patient education diet HIGH in what with angina?

A

Fiber
Vegetables
Fruits
Whole grains

41
Q

What treatment medication is most important long term and decreases mortality?

A

Beta blockers , along with ASA

42
Q

When are ACE inhibitors indicated ?

A

Unstable angina

CHF - cormobid

43
Q

What medication do you want to avoid in CHF?

A

CCB

44
Q

When are CCB indicated?

A

In place of BB or have already been maximized

Dihydropyridine or nondihydropyridines - ejection fraction indicating CHF then avoid CCBs

45
Q

When are CCB contraindicated?

A

with CHF

46
Q

Platelet inhibitors example treatment for angina?

A

ASA

Clopidogrel

significant reduction in infarctions

47
Q

What class is Ranolazine and when is it indicated?

A

it is a sodium channel blocker and it is used to help increase exercise tolerance

48
Q

Revascularization options for angina?

A

PCI - percutaneous intervention

CABG - coronary bypass bypass graft

49
Q

Indications for PCI?

A

Unacceptable symptoms despite tx

Unstable angina with ischemia despite tx

Post-MI w/ continue angina

50
Q

Indications for CABG?

A

Left main coronary stenosis >50%

Three vessel disease w/ LV dysfunction ( EF <50%) - signs of heart failure from disease

Restenosis of PCI

51
Q

What is PCI?

A

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

52
Q

What is CABG?

A

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.

53
Q

MI patho?

A

Plaque rupture

Thrombus

Death of myocardial tissue

54
Q

Types of MI?

A

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

55
Q

MI hx?

A

last longer than 30 min

most common during early morning

56
Q

Elderly sx of MI?

A

generalized weakness

syncope

altered mental status

57
Q

Atypical MI symptoms?

A

Diaphoresis - sweaty

Dyspnea

Nausea/ vomiting

Weakness

Anxiety/restlessness

light-headedness

Syncope

Cough

Orthopnea

abdominal bloating

58
Q

History of “silent MI” and occurrence?

A

1/3 of MI

minor pain, often thought to be GI

common if females and elderly

59
Q

MI PE?

A

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

60
Q

MI PE if severe?

A

Hypotension

Arrhythmia - V- fib

Heart failure: JVD,
Pulmonary edema

61
Q

PE after MI?

A

Low grade fever

Dressler syndrome : Pericardial friction rub

62
Q

MI diagnostic studies - primary evaluation?

A
  1. EKG
  2. Troponin I
  3. CXR
  4. Coronary angiography - always with STEMI
63
Q

Diagnostic studies to consider with MI?

A

Ck and CK-MB 9 creatine kinase - myoglobin

Myoglobin

Echocardiography

64
Q

MI EKG findings with STEMI?

A

ST dement elevation 1mm or higher in 2 contiguous leads

New LBBB

65
Q

MI EKG findings with UA or NSTEMI?

A

ST-segement depression

66
Q

What is the POST- MI progression on an EKG?

A

ST-segement elevations leads to Q-waves which leads to T-wave inversions

develops over hours to days

frowny face - convexity

67
Q

STEMI in leads II, III, AVF, where is the MI location?

A

inferior

68
Q

STEMI in leads V1 and V2, where is the MI located?

A

Posterior, anteroseptal

69
Q

STEMI in leads V1 and V2, where is the MI located?

A

Anterospetal, posterior

70
Q

STEMI in leads V2, V3 and V4, where is the MI located?

A

Anterior

71
Q

STEMI in leads V5 and V6, where is the MI located?

A

Anterolateral

72
Q

Troponin onset, peak and duration?

A

onset: 3-12 hours
peak: 18-24 hours
duration: 10 days

73
Q

CK- MB onset, peak and duration?

A

onset: 3-12 hours
peak: 18-24 hours
duration: 36-48 hours

74
Q

LDH onset, peak and duration?

A

onset: 6-12 hours
peak: 24-48 hours
duration: 6-8 days (5-10days)

75
Q

Myoglobin onset, peak and duration?

A

onset: 1-4 hours
peak: 6-7 hours
duration: 24 hours

76
Q

MI echo findings?

A

wall motion abnormality

mitral regurgitation

77
Q

MI CXR findings?

A

Likely normal

screen for other conditions

complications - Pulmonary edema

78
Q

Gold standard for MI?

A

Coronary angiography

79
Q

What is the most sensitive test to quantify the extent of MI?

A

MRI with gadolinium contrast

80
Q

What measures severity of MI?

A

TIMI score - Thrombolysis In Myocardial Infarction

81
Q

What are the factors of TIMI score to get a point?

A

> 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

82
Q

What is considered high risk from TIMI score?

A

3 or more

83
Q

MI prognosis?

A

20% mortality

84
Q

MI complications?

A

Dressler syndrome - pericarditis after MI

CHF

85
Q

MI - STEMI plan: starting treatment?

A

MONA - consider M later

  1. Oxygen NC 4L
  2. ASA: 160-325 mg po
  3. Nitroglycerin SUBL
  4. Morphine IV - lower anxiety and vasodilation effect
86
Q

Primary goal of MI- STEMI tx?

A

PCI within 90 min

87
Q

Consider which medications for MI - STEMI? Me 2 medicines.

A

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

88
Q

MI - NSTEMI and UA conservative tx?

A

ASA

clopidogrel

Anticoagulation - LMWH

Monitor for progression

89
Q

For MI - NSTEMI and UA consider what treatments?

A

IV glycoprotein IIb/IIIa inhibitors like : Eptifibatide, Tirofiban

90
Q

MI - NSTEMI and UA invasive treatment?

A

conservative plus….

cardiac catheterization

91
Q

STEMI reperfusion tx?

A

Immediate angiography <90 min

PCI better than thrombolysis

92
Q

When do we use thrombolysis for STEMI? and what is it?

A

we only consider it when PCI is unavailable

and it is Tissue plasminogen activator - alteplase, streptokinase

Clinical Medicine Lecture - Professor Kramer (28 decks)

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