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CVA/CAD Flashcards

1
Q

Atherosclerosis Facts

A
  • Includes: CAD, ischemic stroke, renal artery stenosis, and PVD
  • Dynamic process
  • Fat, cholesterol, and other substances build up on arterial walls and form plaques
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2
Q

Risk factors: Atherosclerosis

A
  • Smoking
  • Obesity
  • HLD
    • High LDL, Low HDL
  • HTN
  • DM
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3
Q

CHD Risk Equivalents

A
  • PAD
  • AAA
  • Coronary artery stenosis (>50%)
  • DM
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4
Q

CVA Risk factors: Non-modifiable

A
  • Age
  • Gender: M>W
  • Race: > in young/middle aged AA (SAH/ICH)
  • Low birth weight
  • Family Hx: inherited coagulopathies, intracranial aneurysms
  • Previous CVA or TIA
  • Fibromuscular dysplasia
  • Patent foramen ovale
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5
Q

CVA Risk Factors: Modifiable

A
  • HTN
  • Smoking
  • A-fib
  • ETOH
  • Physical inactivity
  • Obesity
  • SCD
  • Post-menopausal HRT
  • Poor diet
  • Atherosclerosis/carotid stenosis
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6
Q

CHADS 2 Score

A
  • CHF +1
  • HTN +1
  • Age >75yo +1
  • DM +1
  • CVA/TIA +2
    • Low risk = 0-1
    • Moderate risk = 2
    • High risk = >2
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7
Q

Transient Ischemic Attack (TIA)

A
  • Brief episodes of neurologic dysfunction resulting from focal cerebral ischemia
  • No permanent effects
  • No time limit
  • – Usually minutes to hours
  • – No changes on brain imaging
  • – Like chest pain for an MI=Warning sign
  • – 40% of patients with TIA will have CVA
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8
Q

Warfarin goal for A-fib

A

INR = 2-3

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9
Q

ABCD2 Algorithm score for TIA

A
  • Age: >60 +1
  • Blood pressure: >140/90 +1
  • Clinical features:
  • – Unilateral weak +2
  • – Speech dist only +1
  • Duration of symptoms:
  • – >=60min +2
  • – 10-59min +1
  • – <10min 0
  • Diabetes: +1
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10
Q

ABCD2 Calculation for risk of stroke after TIA

A
  • 0-3 = 1%
  • 4-5 = 4%
  • 6-7 = 8%
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11
Q

Management of TIA

A
  • Head CT/MRI shows changes with CVA, not with TIA
  • Angiogram, CT/MRI Angiogram: blood vessel blockage or bleeding
  • Echo: Evaluate heart for clot
  • Carotid duplex: carotid artery stenosi
  • EKG: A-fib
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12
Q

Medical/Lifestyle management of TIA

A
  • Treat the risk factors
  • Educate regarding lifestyle changes
  • Anti-platelet therapy
  • – Plavix if ASA allergy
  • – Persantine and ASA superior
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13
Q

Framingham CVA Risk profile

A
  • Evaluates risk of stroke within 10 years
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14
Q

CVA Causes

A
  • Hemorrhagic: Aneurysm, AVM

- Ischemic: Thrombotic, embolic

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15
Q

Cardiac conditions that can cause stroke

A
  • Endocarditis/vegetations
  • Atrial arrhythmias/LA thrombus
  • DVT with ASD
  • Primary cardiac tumors/myxoma
  • Prosthetic heart valves
  • Cardiac procedures
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16
Q

What percent of carotid blockage requires intervention?

A

70% is hemodynamically significant

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17
Q

Stroke symptoms

A
  • May be sudden
  • HA: Sudden & severe; Associated with hemorrhagic
  • vomiting (Hemorrhagic)
  • AMS
  • Lethargy
  • Loss of balance
  • Change in hearing
  • Unilateral muscle weakness
  • Personality/mood changes
  • Difficulty speaking
  • Dizziness
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18
Q

7 D’s of stroke survival

A
  • Detection: Recognize
  • Dispatch: 911
  • Delivery: transport
  • Door: ED triage
  • Data: Eval
  • Decision
  • Drug
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19
Q

Cincinnati Stroke Scale

A

1) Facial Droop
2) Arm drift
3) Speech

20
Q

Differential for Stroke Mimics

A
  • Migraines
  • Hypoglycemia
  • Seizures
  • Syncope
  • Metabolic: ARF, Hepatic insufficiency, drug OD
21
Q

Management of stroke: Acute phase

A
  • Minimize brain injury
  • Treat medical complications
  • Treat severe HTN (>220/120) or other co-morbid conditions
  • BP needs to be <185/110 to treat with lytic therapy
22
Q

Acute BP treatment in CVA

A
  • **Labetalol: DOC
  • NTG
  • Nipride
  • Nicardipine
23
Q

Thrombolytic therapy

A
  • Exclusion: head trauma within 3mo, ICH, Major surgery w/i 14d, GI/GU bleeding w/i 21d, Dabigitran w/i 2d, INR >1.7, PLT <100K
  • Inclusion: Ischemic stroke, w/i 4.5hr
24
Q

Acute Coronary Syndrome (ACS): Definition

A
  • Rest angina that persists >20min
  • New onset angina that greatly limits physical activity
  • Increasing angina, more frequent, longer duration, occurs with less exertion
25
Unstable angina
- Ischemic symptoms suggestive of ACS, but no elevation in troponin - +/- EKG changes... ST segment depression, transient elevation, or new T-wave inversion
26
NSTEMI
- Same presentation as UA, but have elevation in CK-MB (6hr), and troponin (10-14hr)
27
UA / NSTEMI
- Assess patient for abnormal VS, arrhythmia, new murmur, crackles/pulmonary edema - EKG - 911 - -- Ideal: Treat w/i 20min, ASA, O2, NTG, Morphine - -- Beta-blocker, Antiplatelet therapy, anticoagulation, D/C all NSAIDs
28
UA / NSTEMI: Interventions
- Early intervention for: - -- Extent of ST depression - -- Elevated cardiac markers - -- Hemodynamic instability - -- Persistent CP despite medical therapy
29
TIMI (Thrombolysis in MI) Score
- Age >64 - At least 3 risk factors: CHD, HTN, DM, Dyslipidemia, smoking, Fam Hx - Hx of coronary stenosis >50% - ST deviation on EKG - 2+ anginal episodes in previous 24hrs - +serum cardiac markers - Use of ASA in last 7d - -- Low risk 0-1 - -- Intermediate risk 2-3 - -- High risk 4-7
30
Chronic Stable Angina
- Angina from myocardial ischemia - Coronary blood supply cannot meet myocardial oxygen demand - Occurs predictably - Relieved with NTG or rest
31
Stable angina: goals of therapy
- Prevent/minimize ischemia - Improve survival - Improve/maintain functionality
32
Describing Angina
- Typical or definite angina: Substernal chest pain with characteristic quality and duration; brought on by exertion or stress; relieved with rest/NTG - Atypical or Probable Angina: Chest discomfort with 2 of the above typical angina characteristics - Noncardiac chest pain: One or none of the above typical angina characteristics
33
When to stress test
- Low risk of CAD: 90% Cath
34
Exercise treadmill test
- Initially developed to assess functional capacity in patients with CHD and valve disorders - Patient needs to walk with increasing incline and speed - Goal if 85% redicted heart rate - Reproducible CP, arrhythmias, change in BP or HR, or declining functional capacity is significant - Higher false positive in women - CP and 1mm ST depression has 90% predictive value for CAD - 2mm ST depression and CP = CAD
35
Stress Echo
- resting echo - The echo after exercise or dobutamine - Looks at LV size/function, global/regional wall motion and thickening, ischemic threshold - Body habitus may limit quality of image - Contraindications: CP at rest, Frequent arrhythmia, Known severe LM disease, severe symptomatic valve disorder, decompensated heart failure
36
Stress Myocardial Perfusion Imaging
- EXPESIVE - More accurate for Dx of obstructive CAD - Looking for wall motion abnormalities under stress/LVEF - Adenosine or dobutamine used for chemical stress
37
Cardiac CT
- Low false positive rate - Helpful to exclude CAD - Ideal candidates: Patients with equivocal noninvasive stress test - Good for assessing anatomy of coronary arteries
38
Cardiac Rehab: Recent ACS, revascularization, or CHF
- reduce your overall risk of dying, the risk of future heart problems, and the risk of dying from MI - Decrease the pain and the need for meds to treat heart or CP - Lessen the chance that you'll have to go back to hospital or ED - Improve overall health by reducing risk factors - Improve your QOL and make it easier for you to work, socialize, and exercise
39
Pharmacologic Therapy for CAD: Goal
1) Alleviate angina 2) reduce plaque progression 3) Restore functional capacity
40
ACE / ARB
- Lower risk patients with normal to slightly reduced LVEF, well controlled risk factors, and Hx of revascularization - ACE #1 - ARB if ACE intolerant - ACE + ARB for HF due to LV systolic dysfunction - Aldosterone blockade: Post-MI without significant renal dysfunction or high K; Already on ACE and Beta; LVEF <40%, DM
41
Beta-Blockers (Hx of MI, LV dysfunction, ACS, or HF)
- Decreases myocardial O2 demand by decreasing HR and contractility - Essential for patient with stable angina or Hx of MI or depressed LVEF - Long acting cardioselective: Metoprolol, atenolol - CI: Severe asthma, heart block/bradycardia, severe symptomatic PVD
42
Calcium-channel blockers
- Diltiazem: Decreases HR and increases coronary blood supply - Verapamil: Decreases HR and decreases myocardial O2 demand - Use in combo with beta or when beta CI
43
Ranexa (Ranolazine)
- Inhibits cardiac late sodium channel - Decreases angina frequency - Does NOT improve survivability
44
ASA Therapy
- Reduces vascular events by 30% in patients with SA
45
Plavix
- Use in patients with CI to ASA

N810 (18 decks)

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