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Clinical Medicine 2 > Exam 1: Ischemic Heart Disease > Flashcards

Exam 1: Ischemic Heart Disease Flashcards

1
Q

Where are atherosclerotic plaques most likely to form?

A

Sites of increased blood turbulence or branching points in the epicardial arteries

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2
Q

What is the definition of IHD?

A

A condition where there is inadequate supply of blood and oxygen to the portion of the myocardium

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3
Q

What is the leading cause of death in the US and what fraction of people does it affect?

A

CHD.

1/3 of all deaths in individuals over 35

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4
Q

What is the definition of atherosclerosis?

A

Pathological process causing disease of the coronary, cerebral, and peripheral arteries as well as the aorta

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5
Q

What does nitric oxide do and what cells secrete it?

A

Produced by endothelial cells.

Inhibits plaque formation and has anti-inflammatory properties

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6
Q

What is metabolic syndrome?

A

When you have 3 or more of the following:

  • Abdominal obesity
  • HDL <40 (M) or <50 (F)
  • T> 150
  • FBG > 110
  • HTN
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7
Q

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

A

CHD

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8
Q

Atypical symptoms of CHD are more common in what populations?

A

Women, elderly, and diabetics

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9
Q

Does angina pectoris result from transient or prolonged ischemia?

A

Transient

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10
Q

What is stable angina (Angina Pectoris)?

A
  • Chest discomfort thought to be related to ischemia.

- Exertional or stress relegated chest or arm discomfort that resolves with rest and/or nitro

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11
Q

How long does stable angina typically last?

A

5-10 minutes

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12
Q

What is the character of stable angina?

A
  • Not pain, but heaviness, pressure, and tightness
  • Levines sign
  • radiation to shoulder, jaw, epigastric, mid back
  • 2-10 minutes and crescendo decrescendo
  • Tachycardia, hypertensive, abnormal heart sounds
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13
Q

What is Levine’s sign?

A

A clenched fist over the heart

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14
Q

What are the atypical presentations of stable angina?

A

Dyspnea (very common in women), nausea, fatigue, and faintness

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15
Q

What is Bruce protocol?

A

Used for exercise stress tests, speed and incline are increased every 3 minutes until patients HR is at 85% of the max HR predicted for their age.

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16
Q

What kind of tests would you order for stable angina?

A

EKG, CXR, cardiac enzymes, and stress test (either exercise or nuclear)
-Possibly coronary angiography (cath)

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17
Q

What are the contraindications of an exercise stress test?

A

Acute MI within 48 hrs, unstable angina, uncontrolled arrhythmia, uncontrolled HF, symptomatic aortic stenosis, uncontrolled HTN, severe PAH, aortic dissection, and acute illness.

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18
Q

What is the gold standard for diagnosing CAD?

A

Coronary angiography (Cath)

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19
Q

What are the indications for coronary angiography?

A
  • Known or suspected CAD
  • atypical chest pain
  • before valve surgery
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20
Q

What is the management of stable angina?

A
  • Risk factor modifications such as heathy diet, smoking cessation, weight reduction, HTN treatment, etc
  • Medications that decrease oxygen demand, meds that increase oxygen supply, statins, and antiplatelet meds
  • Revascularization
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21
Q

CAD is virtually absent in what cultures?

A

Cultures that eat a plant based diet

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22
Q

What are the medications that decrease oxygen demand?

A

Nitrates, beta blockers, and CCBs

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23
Q

What medication is first line for acute angina?

A

Short acting nitrates

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24
Q

What medication is first line for chronic angina?

A

Beta blockers

25
Q

How do Beta blockers affect the heart?

A

Decrease HR, BP, and contractility. Afterload reduction

26
Q

What is the only antianginal medication proven to prevent re-infarction and improve survival post MI?

A

Beta blockers

27
Q

What medication is indicated for patients who dont respond to nitrates and beta blockers?

A

CCBs

28
Q

How do CCBs affect the heart?

A

Decrease BP and contractility. Afterload reduction

29
Q

How do nitrates affect preload?

A

They reduce preload

30
Q

What medications can increase oxygen supply? How?

A

Nitrates and CCBs

They both act as coronary vasodilators

31
Q

What is the dosing of nitrates?

A

0.3-0.6mg sublingually or buccal spray. Give at onset of pain and every 5 minutes after for up to 3 doses. If no improvement, 911 or IV nitro

32
Q

What are the 3 options for antiplatelet medications?

A

Aspirin, clopidogrel, or a combo of the 2

33
Q

What are the benefits of using statins?

A
  • They stabilize plaques
  • reduce clinical events
  • slow progression or coronary atherosclerosis
  • induce regression of coronary atherosclerosis
34
Q

What are the two types of revascularization?

A

Percutaneous Coronary Intervention (PCI) or Coronary artery bypass grafting (CABG)

35
Q

When is a CABG typically performed?

A

Left main coronary stenosis or triple vessel disease

36
Q

When is PCI used?

A

When there is a history of angina despite medical treatment and there is evidence of ischemia on stress testing

37
Q

What are the 4 pathophysiologic processes that lead to ACS? Which is most common?

A

1) Plaque rupture or erosion with a superimposed occlusive thrombus (MOST COMMON)
2) Dynamic obstruction
3) progressive mechanical obstruction
4) Unstable angina secondary to increased myocardial oxygen demand and/or decreased supply

38
Q

What is an example of dynamic obstruction?

A

Coronary artery spasm (Prinzmetals angina)

39
Q

What is an example of progressive mechanical obstruction?

A

Progressive atherosclerosis or restenosis following percutaneous coronary intervention (PCI)

40
Q

What is the presentation of Prinzmetals angina?

A
  • ischemic symptoms secondary to Vasospasm

- Chest pain occurring at rest with transient ST segment elevation

41
Q

What is the treatment of Prinzmetals angina?

A

Nitrates and CCBs

42
Q

What is the typical presentation of ACS?

A

Ischemic pain, SOB, weakness, nausea, anxiety, sense of doom

43
Q

What is the presentation of unstable angina?

A
  • Ischemic discomfort with at least one more of the following:
  • Occurs at rest and lasts longer than 10 minutes
  • Severe and new onset (in prior 4-6 weeks)
  • occurs in crescendo pattern (more severe, more prolonged, more frequent)
44
Q

Should you stress test when there is suspected unstable angina or NSTEMI?

A

This is reserved for situations where there is no evidence of infarction, but diagnosis is unclear

45
Q

Are cardiac enzymes elevated with unstable angina? Are there any EKG changes?

A

Troponin and CK are NOT elevated.

EKG is usually normal, but there might be ST depression or T wave inversion

46
Q

Are cardiac enzymes elevated with NSTEMI? Are there any EKG changes?

A

Troponin and/or CK ARE elevated.

-There may be ST depression or T wave inversion, but no ST elevation on EKG

47
Q

What medications should be given when patient has NSTEMI or unstable angina?

A
  • Nitro x3 at 5 min intervals
  • Beta blockers (Metoprolol or atenolol w/in 24 hrs)
  • CCBs if symptoms not relieves with nitro and beta blockers
  • High intensity statin (atorvastatin 80mg daily)
  • antiplatelet therapy in all NSTEMI if not contraindicated
  • Anticoagulation
48
Q

What are the 7 components of a TIMI score?

A
  • age >65
  • > 3 risk factors for CHD
  • prior coronary stenosis of >50%
  • ST segment deviation on admission EKG
  • > 2 angina episodes in the last 24 hrs
  • increased cardiac enzymes
  • aspirin use in the last 7 days
49
Q

What does a TIMI score tell you?

A

Who is likely to progress to a STEMI

50
Q

What are the identifiable precipitating factors for STEMI that occur in 50% of the cases?

A
  • Vigorous exercise
  • extreme emotional stress
  • medical or surgical illness
51
Q

What is the cause of a STEMI?

A

Most common is rupture of a vulnerable plaque that results in complete occlusion of a coronary artery

52
Q

What medications should be given when you have a patient with a STEMI?

A
  • ASA 325 chewed
  • Nitro
  • Beta blockers if not contraindications (metoprolol)
  • High intensity statin therapy
53
Q

What labs should be ordered for management of STEMI?

A

Cardiac enzymes, electrolytes, CBC, Coags

54
Q

When should Fibrinolysis be performed with a STEMI?

A
  • if PCI is not available within 120 minutes of first medical contact
  • symptoms < 12 hours
  • No contraindications
55
Q

What are the absolute contraindications of Fibrinolytic therapy?

A
  • Hx of intracranial hemorrhage
  • hx of stroke in last year
  • Poorly controlled HTN
  • Suspected aortic dissection
  • active internal bleeding
56
Q

What revascularization strategy is preferred with a STEMI?

A

PCI

57
Q

What are the complications that often occur post MI?

A

-recurrent ischemia, pump failure, ventricular arrhythmia, pericarditis, mural thrombus, cardiac rupture, and depression

58
Q

What is Dressler’s syndrome?

A

Chest pain due to pericardial inflammation following MI, CABG, or traumatic injury to the heart.

59
Q

What is a mural thrombus?

A

Thrombi that attached to the vessel wall

Clinical Medicine 2 (22 decks)

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