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
2
Q
Risk factors: Atherosclerosis
A
- Smoking
- Obesity
- HLD
- High LDL, Low HDL
- HTN
- DM
3
Q
CHD Risk Equivalents
A
- PAD
- AAA
- Coronary artery stenosis (>50%)
- DM
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
5
Q
CVA Risk Factors: Modifiable
A
- HTN
- Smoking
- A-fib
- ETOH
- Physical inactivity
- Obesity
- SCD
- Post-menopausal HRT
- Poor diet
- Atherosclerosis/carotid stenosis
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
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
8
Q
Warfarin goal for A-fib
A
INR = 2-3
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
10
Q
ABCD2 Calculation for risk of stroke after TIA
A
- 0-3 = 1%
- 4-5 = 4%
- 6-7 = 8%
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
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
13
Q
Framingham CVA Risk profile
A
- Evaluates risk of stroke within 10 years
14
Q
CVA Causes
A
- Hemorrhagic: Aneurysm, AVM
- Ischemic: Thrombotic, embolic
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
16
Q
What percent of carotid blockage requires intervention?
A
70% is hemodynamically significant
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
18
Q
7 D’s of stroke survival
A
- Detection: Recognize
- Dispatch: 911
- Delivery: transport
- Door: ED triage
- Data: Eval
- Decision
- Drug
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
Q
Unstable angina
A
- Ischemic symptoms suggestive of ACS, but no elevation in troponin
- +/- EKG changes… ST segment depression, transient elevation, or new T-wave inversion
26
Q
NSTEMI
A
- Same presentation as UA, but have elevation in CK-MB (6hr), and troponin (10-14hr)
27
Q
UA / NSTEMI
A
- 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
Q
UA / NSTEMI: Interventions
A
- Early intervention for:
- – Extent of ST depression
- – Elevated cardiac markers
- – Hemodynamic instability
- – Persistent CP despite medical therapy
29
Q
TIMI (Thrombolysis in MI) Score
A
- 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
Q
Chronic Stable Angina
A
- Angina from myocardial ischemia
- Coronary blood supply cannot meet myocardial oxygen demand
- Occurs predictably
- Relieved with NTG or rest
31
Q
Stable angina: goals of therapy
A
- Prevent/minimize ischemia
- Improve survival
- Improve/maintain functionality
32
Q
Describing Angina
A
- 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
Q
When to stress test
A
- Low risk of CAD: 90% Cath
34
Q
Exercise treadmill test
A
- 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
Q
Stress Echo
A
- 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
Q
Stress Myocardial Perfusion Imaging
A
- EXPESIVE
- More accurate for Dx of obstructive CAD
- Looking for wall motion abnormalities under stress/LVEF
- Adenosine or dobutamine used for chemical stress
37
Q
Cardiac CT
A
- Low false positive rate
- Helpful to exclude CAD
- Ideal candidates: Patients with equivocal noninvasive stress test
- Good for assessing anatomy of coronary arteries
38
Q
Cardiac Rehab: Recent ACS, revascularization, or CHF
A
- 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
Q
Pharmacologic Therapy for CAD: Goal
A
1) Alleviate angina
2) reduce plaque progression
3) Restore functional capacity
40
Q
ACE / ARB
A
- 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
Q
Beta-Blockers (Hx of MI, LV dysfunction, ACS, or HF)
A
- 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
Q
Calcium-channel blockers
A
- 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
Q
Ranexa (Ranolazine)
A
- Inhibits cardiac late sodium channel
- Decreases angina frequency
- Does NOT improve survivability
44
Q
ASA Therapy
A
- Reduces vascular events by 30% in patients with SA
45
Q
Plavix
A
- Use in patients with CI to ASA
