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NURS 503 > CVD and Chest Pain > Flashcards

CVD and Chest Pain Flashcards

1
Q

What is the single most important factor in assessing CAD?

A

Collect a thorough history and physical exam that includes:

  • Prior medical history of MI or CAD
  • Presenting symptoms: angina, radiating pain, tingling, numbness
  • Family history of CAD
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2
Q

What additional diagnostic tools would be helpful in diagnosing CAD?

A
  • Immediate ECG
  • Lab biomarkers (e.g. troponin)
  • Cardiac catheterization indicated if ECG findings and biomarkers indicate acute MI
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3
Q

What is the NPs role in managing CAD?

A

Reduce risk factors

  • Smoking cessation
  • Manage HTN, DM, hyperlipidemia
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4
Q

What is the first line diagnostic test for CAD?

A

Exercise tolerance test/stress test

  • Most common and least invasive
  • Detects CAD in patients with chest pain or DOE
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5
Q

What non-invasive tests and biomarkers can be collected to evaluate CAD?

A
  • Labs: CRP, IL-6, monocyte-macrophage colony stimulating factor
  • Coronary artery calcium score (CACS)
    • Directly related to plaque burden
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6
Q

What are imaging adjuncts to the exercise tolerance test (ETT)?

A
  • Myocardial perfusion imaging (MPI)
  • Cardiac ultrasound imaging (2DE)
  • Exercise echocardiography
  • 3D and doppler flow echocardiography
  • Cardiac MRI and ultrafast CT scans
  • Pharmacologic stress testing
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7
Q

What diagnostic testing considerations will need to be made when assessing women?

A
  • Women are more likely to have non obstructive or single vessel disease
  • Limited evidence to suggest the most appropriate CV diagnostic test for women
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8
Q

How does myocardial ischemia present in women?

A
  • Dyspnea
  • Indigestion
  • Nausea
  • Numbness in UE
  • Fatigue
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9
Q

What is carotid stenosis (CS)?

A

Atherosclerotic narrowing of the extra cranial arteries

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10
Q

Carotid stenosis (CS) symptoms

A

Manifests as focal neurological dysfunction

  • TIA, ischemic stroke, confusion, etc.
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11
Q

What is the difference between a TIA and stroke?

A

TIA → acute neurological dysfunction referable to the distribution of a single brain artery and characterized by symptoms that resolves in <24 hours without permanent neurological deficit

Ischemic stroke → neurological deficit that persists >24 hours

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12
Q

True/false: If stenosis in the carotid artery is 70-90% occluded, the patient will require invasive interventions

A

True - should undergo CEA

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13
Q

Symptomatic manifestations of carotid stenosis (CS)

A
  • Visual disturbances
  • Monocular blindness (amaurosis fugax)
  • Weakness or numbness of contralateral arm, leg, and/or face
  • Dysarthria
  • Aphasia
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14
Q

Asymptomatic manifestations of carotid stenosis (CS)

A
  • Dizziness
  • Generalized weakness
  • Syncope or near syncopal episodes
  • Blurred vision
  • Transient visual phenomena (“floaters”, “stars”)
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15
Q

What two findings on fundoscopic examination indicate significant CS?

A
  • Amaurosis fugax
  • Hollenhorst plaques
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16
Q

Modifiable risk factors for CS (or any atherosclerotic disorder)

A
  • High blood pressure
  • Smoking
  • Hyperlipidemia
  • DM
  • Hyperhomocysteinemia
  • Obesity
  • Nutrition
  • Physical inactivity
  • CKD
  • Heavy alcohol consumption
  • Sleep apnea
  • Depression
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17
Q

Physical exam components for CS

A

Perform a complete CV and neurologic exam

  • Include palpation of all bilateral peripheral pulses and auscultation for bruits
  • BP of bilateral UE in the lying and sitting position
  • Neurologic exam → MS, cranial nerves, fundoscopic, motor and sensory function
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18
Q

What is the first line diagnostic study for CS?

A

Duplex ultrasound

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19
Q

Other than a duplex ultrasound, what other diagnostic studies (imaging and labs) are indicated for CS?

A
  • Catheter-based angiography (criterion standard)
  • MRA + CTA (adjunct to duplex ultrasound)
  • Labs: CBC, BMP, lipid panel, coagulation studies
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20
Q

How would the NP manage CS?

A
  • Medication therapy + carotid revascularization (CEA)
  • Carotid angioplasty and stenting + medication therapy
  • Smoking cessation
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21
Q

What medications should be prescribed for patients with CS?

A
  • ASA and/or clopidogrel (if symptomatic)
  • Statins
  • Antihypertensives
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22
Q

How long should patients be on antiplatelet therapy (ASA + clopidogrel) for after CEA for CS?

A

At least 4 weeks

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23
Q

When is noninvasive imaging indicated in patients with CS?

A
  • All patients who present with amaurosis fugax, TIA, stoke to determine extent of CS
  • Patients with carotid bruit or other nonspecific symptoms (e.g. dizziness)
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24
Q

Coronary heart disease (CHD) is an umbrella term. What conditions does this include?

A
  • Acute MI
  • Angina pectoris
  • Atherosclerotic CV disease
  • All forms of chronic ischemic heart disease
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25
Q

Chest pain - What is chronic stable angina?

A
  • Precipitated by exertion
  • Relieved by rest and NTG
  • Lasts <5 minutes
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26
Q

Chest pain - What is silent myocardial ischemia?

A

Asymptomatic coronary heart disease

  • Objective evidence of ischemia in the absence of symptoms
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27
Q

Chest pain - What is microvascular angina (syndrome X)?

A
  • Chest discomfort with exercise
  • Positive stress test
  • Angiography reveals no obstruction
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28
Q

Chest pain - What is variant angina (coronary artery spasm, prinzmetal angina)?

A

Coronary vasospasm can cause chest discomfort at rest AEB by ST elevation or depression on ECG

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29
Q

Chest pain - What is unstable angina and NSTEMI?

A
  • Chest pain lasta >10 minutes
  • Not relieved by rest or NTG
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30
Q

Chest pain - What is acute STEMI?

A

Atherosclerotic plaque ruptures and serves as nidus for thrombus formation with resultant coronary artery occlusion, ischemia, myocyte necrosis, infarction, death

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31
Q

Chest pain - What is MINOCA?

A

Acute MI without an obvious cause (no obstruction)

  • Consider MINOCA as working diagnosis while evaluating for treatable underlying causes with MRI, provocative testing, and evaluating for thrombophilia
32
Q

What is the Levine sign?

A

Patient places clenched fist over their sternum → sign of chronic stable angina

33
Q

Chronic stable angina clinical presentation

A

Occur with predictable frequency, severity, duration, and provocation

  • Dyspnea
  • Paroxysmal nocturnal dyspnea
  • Orthopnea
  • Diaphoresis
  • N/V/D
  • Eructations (belching)
  • Fatigue
  • Levine sign: clenched fist over sternum
34
Q

Angina equivalents clinical presentation

A

Myocardial ischemia may present as…

  • Dyspnea
  • Indigestion
  • Nausea
  • Numbness in UE
  • Fatigue

Rather than chest pressure/tightness (especially for women)

35
Q

Microvascular angina clinical presentation

A
  • Generally more intense chest pain, lasts for longer periods of time, does not go away with rest
  • Unpredictable and occurs with rest, routine physical activity, or stressful events
36
Q

Vasospastic angina clinical presentations

A

History of spontaneous or unprovoked episodes of typical angina

37
Q

Unstable angina and NSTEMI clinical presentation

A

Most important factors from initial history that increase likelihood of patient experiencing episode of ischemia are…

  • Nature of symptoms
  • Prior history of CAD
  • Age >65 years
  • Number of risk factors for CAD
38
Q

Physical exam components for chest pain and CAD

A
  • HEENT - funduscopic (diabetic retinopathy), neck JVD
  • Periorbital → xanthomas or early arcus senilis may indicate elevated cholesterol
  • Cardiac → PMI (may be displaced), palpate carotid upstroke, auscultate for murmurs, gallops, pericardial friction rub, bruits
  • Lungs → adventitious breath sounds
  • Thorax → vesicles or rashes (herpes zoster), edema, lesions
39
Q

Diagnostic studies for CAD and chest pain

A
  • ECG
  • Echocardiography
  • Exercise tolerance test/stress test
  • Coronary CT angiography
  • Labs: hgb/hct, electrolytes, magnesium, TSH, serial cardiac troponin, CRP, BNP
40
Q

How would the NP manage chronic stable angina with medication?

A
  • Antihypertensives (beta blockers, ACE inhibitors or ARBs)
  • Nitrates
  • ASA
  • Anticoagulants
41
Q

True/false: Patients with comorbidities (DM, SLE) and chest pain/CAD should be referred to cardiology

A

True

42
Q

What should the NP do for patients with an acute STEMI?

A

Need to be transported to ED within 90 minutes to a facility with PCI capability

  • If transport is to non-PCI capable hospital, or when anticipated time of transfer is >120 minutes, give fibrinolytic therapy within 30 minutes
43
Q

What is heart failure (HF)?

A

Inability of the heart to meet the body’s metabolic demands

  • Clinical diagnosis
  • Results from any structural/functional cardiac disorder that impairs the ventricles ability to fill or eject blood properly
44
Q

What is the most common cause of heart failure?

A

Cardiomyopathy

45
Q

What is HFrEF?

A

Reduced EF <40%

  • Reduction in contractility of the LV (systolic) → reduced CO
  • Symptomatic
46
Q

What is HFpEF?

A

Preserved EF >50%

  • Associated with impairment of ventricular filling and relaxation (diastolic)
  • Results in reduced SV with exertion causing symptoms
47
Q

What is the most common cause of HFrEF and HFpEF?

A

HFrEF → CAD

HFpEF → HTN, atrial fibrillation, DM

48
Q

HF clinical presentation

A
  • Cardinal symptoms → dyspnea, fatigue
  • LE edema, JVD
  • Paroxysmal nocturnal dyspnea, orthopnea
  • SOB with exertion or at rest
  • Persistent coughing, wheezing, bronchospasm
  • Lack of appetite, nausea
49
Q

NY Heart Association Functional Classification for HF

A
50
Q

ACC/AHA HF stages

A
51
Q

What two medications make HF worse?

A

CCB and NSAIDs

52
Q

HF physical exam components

A
  • Assess perfusion and volume status
    • Narrow pulse pressure
  • Signs of fluid overload, reduced CO, enlarged heart and arrhythmia
    • JVD, displaced PMI, S3 gallop, murmurs, adventitious lung sounds, edema
  • Hepatomegaly, RUQ tenderness, ascites
  • Cool extremities
53
Q

What is the best imaging modality for HF?

A

Echocardiogram

54
Q

Labs that should be ordered for patients with HF

A
  • BNP or pro-BNP
  • CBC
  • CMP
  • Lipid panel
  • TSH
  • HIV
  • UA
55
Q

Imaging tests that should be ordered for patients with HF?

A
  • Echocardiography
  • Chest x-ray
  • EKG
  • Cardiac catheterization
  • Cardiac MRI
  • PET/CT
  • Exercise tolerance testing
56
Q

HF management → stage A (high risk, no structural abnormalities, no symptoms)

A
  • ACE inhibitor or ARB to control DM
  • Smoking cessation, salt restriction (2-3 g), avoid drug use, limit alcohol, exercise
  • Treat HTN, DM, dyslipidemia
57
Q

HF management → stage B (structural heart disease, no symptoms)

A
  • ACE inhibitors or ARBs
  • Beta blockers
  • Screening BNP
58
Q

HF management → stage C (known structural disease, previous or current symptoms)

A
  • ACE inhibitors and beta blockers for all patients
  • Sodium restriction, daily weights
  • Diuretics, digoxin, aldosterone antagonists
  • Avoid NSAIDs and CCBs
59
Q

HF management → stage D (refractory symptoms requiring special intervention)

A
  • ACE inhibitors or ARBs, beta blockers
  • Inotropes
  • Consider palliative care, hospice
  • VAD, transplantation
60
Q

What are some potential causes of myocarditis?

A
  • Infectious → viral, bacterial, protozoal, spirocheten, rickettsial, fungal
  • Toxins → ethanol and certain chemo agents, drug-induced allergies (PCN allergy), autoimmune diseases (SLE)
61
Q

Myocarditis symptoms - mild

A
  • Fever
  • Atypical chest pain
  • Fatigue
  • Palpitations
  • Transient ECG changes
62
Q

How do moderate/severe symptoms of myocarditis present?

A

Lead to symptoms similar to LV dysfunction

  • DOE, fatigue, orthopnea, paroxysmal nocturnal dyspnea
  • Pleuritic chest pain
63
Q

Myocarditis physical examination findings/components

A
  • Resting tachycardia with an exaggerated chronotropic response to any exertion
  • Mild cases → low grade fever, tachycardia
  • LVH (S3, S4, pulmonary rales)
  • Mitral regurgitation, pericardial friction rub, elevated JVD
  • RUQ tenderness
  • Pedal edema
64
Q

What is the gold standard diagnostic test for myocarditis?

A

Endomyocardial biopsy

65
Q

Myocarditis diagnostic tests/labs

A
  • Based on clinical presentation
  • ECG, echocardiogram, endomyocardial biopsy
  • Labs: ESR, CRP, biomarkers (troponin, CRP, BNP), IgM and IgG
66
Q

True/false: Immediate specialist referral is indicated for all causes of suspected myocarditis

A

True

67
Q

Non pharmacological management of myocarditis

A
  • Bed rest
  • Avoid stimulants (alcohol, caffeine, nicotine)
  • Avoid exercise (no exercise for 6 months from date of symptom onset)
68
Q

Pharmacologic management of myocarditis

A

Same meds used for HF

  • ACE inhibitors or ARBs
  • Loop diuretics (furosemide or torsemide)
  • Beta blockers
  • Anticoagulation with heparin/warfarin if afib or severe LV dysfunction
  • Antiviral therapy
  • IVIG
69
Q

What is peripheral arterial insufficiency?

A

Insufficient blood flow to the extremities

  • More likely to occur in LE, although use of catheter interventions has made the incidence of UE problems more common
70
Q

Peripheral arterial insufficiency risk factors

A
  • Older than 65 years
  • Ages 50-64 years with history of DM, HTN, hyperlipidemia, smoking, family history of PAD
  • <50 years who have DM and another risk factor for atherosclerosis (smoking, dyslipidemia, HTN, hyperhomocysteinemia)
  • Known atherosclerotic disease in another vascular bed (coronary, carotid, subclavian, renal), mesenteric artery stenosis, AAA
71
Q

What are causes of peripheral arterial insufficiency?

A

Involve more than one artery

  • Atherosclerosis
  • Arteritis
  • Connective tissue disease
  • Marfan’s syndrome
72
Q

Peripheral arterial insufficiency clinical presentation

A
  • Exertional leg symptoms → fatigue, aching, numbness, pain (“tiredness”, “giving way”, “soreness”) - claudication
  • Abnormalities of LE pulses
  • Pain at rest in lower leg or feet
  • Poor wound healing in legs or feet
  • Impaired walking function
73
Q

Peripheral arterial insufficiency physical exam components

A
  • Assess BP, palpate pulses for quality and amplitude
  • Assess abdominal aortic pulsation
  • Auscultate femoral and carotid bruits
  • Full foot exam → assess for tissue loss, dependent rubor or pallor
  • Absence of hair in LE
  • Assess for limb wasting
74
Q

Diagnostic studies for peripheral arterial insufficiency

A
  • Resting ankle-brachial index
  • Duplex ultrasound
75
Q

Conservative management of peripheral arterial insufficiency

A
  • Smoking cessation
  • Treat HTN, hyperlipidemia, DM
  • Compression stockings
  • Toenails cut by podiatrist, wear properly fitting shoes
  • Structured exercise program to relieve claudication
76
Q

Pharmacological management of peripheral arterial insufficiency

A
  • Low dose ASA
  • Antiplatelet therapy (ASA, clopidogrel)
  • Statins
  • Antihypertensives (ACE inhibitors, ARBs)
77
Q

Invasive management of peripheral arterial insufficiency

A

Arteriography to demonstrate extent and location of obstruction → angioplasty (with/without stent placement) or surgery

NURS 503 (10 decks)

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