Exam 2 Flashcards
1
Q
Impedance or blockage of one or more arteries that supply blood to the heart.
A
Coronary Heart Disease (CHD)
2
Q
Coronary Heart Disease is most commonly caused by __________.
A
Atherosclerosis
3
Q
The hardening of the arteries is due to the buildup of fats/cholesterol.
A
Atherosclerosis
4
Q
A collection of signs and symptoms (chiefly chest pain) brought about by a sudden reduction in blood flow to the muscles of the heart.
A
Acute Coronary Syndrome (ACS)
5
Q
What conditions are considered to be Acute Coronary Syndrome (ACS)?
A
Unstable Angina
ST-Elevated Myocardial Infarction (STEMI)
Non-ST-Elevated Myocardial Infarction (NSTEMI)
6
Q
What causes plaque formation?
A
Factors Contributing to the development of atherosclerosis:
- Cigarette Smoking
- Diabetes Mellitus
- Elevated LDL, Low HDL
- Hypertension
- Obesity
- Family History of Premature Coronary Artery Disease (CAD)
- Physical Inactivity
7
Q
Total inclusion of one or more coronary arteries, leading to death of the myocardium.
A
Myocardial Infarction
8
Q
Events leading to an MI:
A
- Plaque breaks loose, forming a thrombus.
- The thrombus travels and adheres to an area of atherosclerotic plaque.
- Partial or total occlusion of a coronary artery.
- Blockage of a coronary artery
- Decreased profusion (ischemia) of the myocytes surrounding the area of occlusion.
- Death of tissue (infarction).
9
Q
Transmural Myocardial Infarction
A
The zone of the infarction affects the entire thickness of the myocardium.
10
Q
Nontransmural (Subendocardial)
A
The zone of the infarction affects a small portion of the myocardial wall thickness.
11
Q
What are the four components of diagnosing a Myocardial Infarction?
A
- History
- Physical Exam
- Cardiac-Specific Blood Markers
- EKG and Other Imaging
12
Q
What is the most common presenting symptom of a myocardial infarction?
What are other associated symptoms of a myocardial infarction?
A
- Sudden onset of prolonged chest pain.
- Shortness of breath, vomiting, diaphoresis, light-headedness
13
Q
Myocardial Infarction pain is often described as what acronym?
A
OPQRST
Onset - Usually occurs at rest or after exertion.
Provoking & Relieving Factors - Physical activity (or no activity), typically no relieving factors.
Quality - Crushing.
Radiation - Left arm, abdomen, neck.
Severity - High
Timing - ≥ 30 Minutes
14
Q
Symptoms of Myocardial Infarction in elderly, diabetic women
A
- “Silent MI” (without chest pain) or unusual presentations
- Vague abdominal pain/nausea
- Consider a person’s risk for atherosclerosis
15
Q
Patients with a myocardial infarction often have a _______ physical exam.
A
Normal
16
Q
Symptoms of myocardial infarction in a physical exam
A
- Anxiety
- Sweating
- Cool, clammy skin
- Tachycardia or bradycardia
- Elevated blood pressure
- Low blood pressure
17
Q
Symptoms of a large myocardial infarction or if the heart begins to fail in a physical exam:
A
- Lungs with “fluid”
- rales/crackles - late or with large area of necrosis
- Heart with extra sounds (S4), murmur
- Edema in lower extemeties
18
Q
What are the specific cardiac markers in diagnosing an MI?
A
High Sensitivity Cardiac Troponin I and T (hs-cTnT)
Creatine (Phosphate) Kinase - Myocardial Band (C(P)K - MB)
*These proteins are released from dying myocardial cells and can be measured in the blood.
19
Q
Which cardiac-specific marker is more most sensitive/specific and which is less sensitive/specific?
A
More specific/sensitive - hs-cTnT
Less specific/sensitive - C(P)K - MB
*These markers may take up to 4-6 hours to rise (abnormal by 8-12 hours).
20
Q
In order to diagnose a myocardial infarction, an EKG ____ required.
A
Is
21
Q
Is a 6-second rhythm strip helpful in diagnosing an MI?
A
No
22
Q
A 12-lead EKG (allows/doesn’t allow) us to see changes in electrical conduct based on damage to the heart muscle.
A
Allows
23
Q
A 12-lead EKG (allows/doesn’t allow) us to localize the area of an infarction.
A
Allows
*By determining which lead has an arrhythmia.
24
Q
What are the two classifications of an MI on EKG?
A
ST-segment Elevated Myocardial Infarction (STEMI)
Non-ST-segment Elevated Myocardial Infarction (NSTEMI)
25
STEMI or NSTEMI?
* Caused by the classic plaque-thrombi-blockage pathology.
* Associated with transmural infarcts.
* Much more common. Unless specified, we will be referring to this type of MI in the lecture.
STEMI
26
STEMI or NSTEMI?
* Typically associated with nontransmural infarcts.
* Not related to classic plaque-thrombi pathology.
* Secondary to ischemia due to either increased oxygen demand or decreased supply (e.g. coronary artery spasm, hypotension).
NSTEMI
27
Three categories of tissue damage from a STEMI?
* Zone of Ischemia
* Zone of Injury
* Zone of Infarction
28
EKG Findings and Time Course for Myocardial Ischemia
* Inverted T Wave.
* ST-Segment changes begin (elevation).
29
EKG Findings and Time Course for Myocardial Injury
EKG Findings:
* ST-segment changes (Elevation)
Time Course:
* Within first 1-2 hours.
30
EKG Findings and Time Course for Myocardial Infarction (Necrosis):
EKG Findings:
* Pathologic Q-Waves develop
Time Course
* 24-72 Hours
31
How many phases are involved in EKG changes in a STEMI?
Four
32
Time frame and EKG changes of Phase 1 in a STEMI?
* 0-2 Hours
* Ischemia starts immediately and reversible necrosis begins in the subendocardium.
* 20-40 Minutes (on average 30 Minutes)
* Q - Unchanged
* R - Unchanged
* ST - Starts to rise.
* T - Amplitude increases, peaking.
33
Time frame and EKG changes in Phase 2 of STEMI?
* 2-24 Hours
* Infarction occurs, transmural complete by 6 hours.
* Q - Begins to widen, increased depth.
* R - Decreased amplitude.
* ST - Max elevation.
* T - Positive amplitude.
34
Time frame and EKG changes of Phase 3 in a STEMI?
* 24-72 Hours
* Signs of healing begin to show.
* Q - Max size.
* R - Absent.
* ST - Returning to baseline.
* T - May become negative amplitude.
35
Time frame and EKG changes of Phase 4 in a STEMI?
* 2-8 Weeks
* Fibrotic tissue replaces necrosed tissue.
* Q - May return or return to normal.
* R - May return.
* ST - Normal.
* T - May have some inversion indefinitely.
36
Examples of Classic ST Elevations: "Tombstones"
37
Criteria for ST-Segment Elevation
* Sign of severe, extensive, transmural, myocardial ischemia and injury in the evolution of a Q wave MI.
* ST-segment is considered elevated when it is 1 mm (0.1 mC) above the isoelectric baseline, measured 0.04 seconds (1 small square) after the J point of the QRS complex.
* In two contiguous leads [within the same view of the heart].
* ST-segment elevation usually occurs within minutes after the onset of infarction, initially indicating extensive myocardial ischemia and foreshadowing a progression first to myocardial injury within 20 to 40 minutes (average, 30 minutes) and then to significant necrosis in about 2 hours.
* The ST segment is elevated in the leads facing the zone of ischemia and injury and is depressed in the reciprocal leads.
38
Criteria for ST-Segment Depression
* EKG sign of subendocardial ischemia and injury.
* 1 mm (0.1 mV) below the isoelectric baseline, measured 0.04 seconds (1 small square) after the J point of the QRS complex.
* In two contiguous leads [within the same view of the heart].
* Usually appears within minutes after the onset of subendocardial non-Q wave MI and during an anginal attack.
39
Classifications of ST-Segment Depression
* Downsloping
* Horizontal
* Upslopping
Regardless of the slope, a depressed ST segment associated with an ischemic T wave is a reliable manifestation of myocardial ischemia.
40
What are the signs of an ischemic T wave?
* Abnormally tall and peaked or deeply inverted.
41
The junction between the QRS complex and the ST segment.
J Point
42
Significant (Pathologic) Q-Wave Criteria
* The Q wave is the first negative deflection of the QRS complex.
* ≥ 0.04 seconds (1 small box) AND having a depth of at least 1/4 the height of the following R wave.
43
xWhat are reciprocal changes?
* Changes in the EKG show ST-segment depressions in distant leads (or those opposite) from the infarct location.
Note:
Reciprocal changes are not "criteria" for diagnosis of an MI, but do aid in the diagnosis and assessment of severity of an MI.
44
Possible locations of an MI
* Anterior Wall
* Anteroseptal Wall
* Anterolateral Wall
* Lateral Wall
* Inferior Wall
* Posterior Wall
45
Anterior Wall MI Leads and Reciprocal Lead Locations
* V1-V4
* Reciprocal Lead Locations - II, III, aVF
46
Anterior Wall is suppled by ______ artery.
Left Anterior Descending (LAD)
47
There is a high mortality rate with ______ Wall MI because LAD supplies the _____ \_\_\_\_\_\_.
Anterior; Left Ventricle
48
\_\_\_\_\_\_ Wall MI is often associated with "Poor R-wave progression" (not criteria, just a hint).
Anterior
49
Anteroseptal Wall MI leads
* V1-V2; when V1-V4 is involved.
* Pretty much ALL of V1-V4 needs to be involved to be referred to as an Anteroseptal Wall MI rather than an Anterior Wall MI.
50
What is the normal R wave progression?
* R gets larger in amplitude as we move from V1→ V6.
* R wave represents ventricular depolarization. As we move from V1 → V6, we move along the mean vector, therefore R should ↑.
51
Septal Leads
V1-V2
52
Where does the isoelectric baseline begin?
Between the T wave and the P wave.
53
Inferior Wall MI Leads and Reciprocal Change Leads
* II, III, aVF
* Reciprocal Changes - (Left Lateral Leads) - V5, V6
54
\_\_\_\_\_ Wall MI mostly suppled by the Right Coronary Artery (RCA)
Inferior
55
\_\_\_\_\_ Wall MI can be associated with a right ventricular infarction.
Inferior
56
Lateral Wall MI Leads & Reciprocal Changes
* I, AVL, V5, V6
* Reciprocal Changes - II, III, aVF
57
The ______ portion of the heart is supplied by the Left Circumflex Artery (LCA).
Lateral
58
Posterior Wall MI EKG Changes
* ST-Segment Depression AND tall R waves in V1 and V2.
59
\_\_\_\_\_\_\_ Wall MI is suppled by the Distal Right Coronary Artery or Distal Circumflex Artery.
Posterior Wall MI
60
Posterior Wall MI is frequently associated with \_\_\_\_\_\_\_.
Arrhythmia
61
MI that doesn't produce Q waves or ST elevations.
Non-Q Wave or Non-STEMI
62
Associated with non-transmural MI
Non-Q Wave or Non-STEMI
63
On EKG, non-Q Wave or Non-STEMI only shows (2):
* Inverted T wave
* ST depression
64
What is used to diagnose a non-Q Wave or Non-STEMI?
* History
* Cardiac Markers
65
What is a common cause for Non-Q wave or Non-STEMI?
* Increased demand for oxygen and an inability to get blood to that area.
* Vasospasm due to drugs (cocaine).
* Advanced age with congestive heart failure (CHF).
* Arrhythmias
66
Which ST-depression slope has a high association with ischemia?
Down sloping
67
EKG findings of "old" MI
* Look for residual Q waves in specific areas to localize old MIs.
68
Principals (goals) of care in MI patients (3):
1. Stop formation of thrombus.
2. Dissolve thrombus formed.
3. Open any occluded arteries.
69
What is the goal of reperfusion therapy (2):
1. Dissolve formed thrombus
2. Open any occluded arteries
The goal for reperfusion therapy is from the time the patient arrives in the emergency room to the time that they have reperfusion is 90 minutes.
70
What is reperfusion therapy?
Medical treatment to restore blood flow, either through or around, blocked arteries, typically after a heart attack.
71
What are the initial interventions for an MI?
* Morphine
* Oxygen
* Nitroglycerin
* Asprin
The pneumonic is MONA.
72
After the initial intervention for an MI, in the stable phase and in preparation for reperfusion therapy, what is given to the patient?
* **_A_**ntiplatelets
* **_B_**eta-Blockers
* Anti**_c_**oagulants
* **_S_**tatins
ABCs
73
What is the purpose of morphine?
To reduce pain and anxiety.
74
What is the purpose of oxygen?
In order to get as much oxygen to the blood as possible
It is administered via nasal cannula or mask.
75
What is the purpose of aspirin?
A blood thinner that is used to stop future clotting,
Chew and then swallow.
76
What is the purpose of nitroglycerin?
Promotes vasodilation, which increases blood flow to the heart.
77
In what two situations do we need to be careful of administering nitroglycerin to a patient?
1. Inferior Wall MI
2. Recently using Viagra/Cialis
78
During immediate treatment of an MI, what three things need to be monitored?
* Airway
* Breathing
* Circulation
79
What is the purpose of antiplatelets?
* Prevent further clotting by reducing platelet aggregation.
80
What is the purpose of beta-blockers?
* Decreased oxygen demand due to the reductions in the heart rate, blood pressure, and contractility, and the consequent relief of ischemic chest pain.
81
What is the result of using beta-blockers as a treatment for an MI?
Lower incidence of heart failure.
82
What is the purpose of anticoagulants?
Prevents further coagulation.
83
What is the purpose of statins?
Lowers LDL cholesterol and reduces the risk of death.
84
What is the definitive treatment for a MI?
Reperfusion Therapy
85
When do you perform reperfusion therapy?
\< 12 hours after onset of symptoms.
86
What are the three types of reperfusion therapy?
1. Thrombolytic
2. Percutaneous Coronary Intervention (PCI) - AKA Coronary Angioplasty
3. Coronary Artery Bypass Graft (CABG)
87
When should you consider using thrombolysis with t-PA as a treatment for an MI?
\< 3 Hours
88
When should you perform Tissue Plasminogen Activator (tPA)?
\< 3 hours of presentation.
89
What is the purpose of administering Tissue Plasminogen Activator (tPA)?
It is fibrinolytic that facilitates plasminogen to plasmin in order to "bust the clot".
90
What is cardiac catheterization?
Procedure to see how the heart is working. Dye is inserted and a cardiac angiogram is taken to look for an obstruction.
91
What is the purpose of percutaneous transluminal coronary angioplasty (PTCA)?
This is also known as balloon angioplasty. The goal is that the balloon becomes inflated and pushes the plaque to the side and open the artery back up once the balloon is deflated.
92
What is the purpose of percutaneous transluminal coronary angioplasty (PTCA) with stent placement?
The purpose of the stent placement after the angioplasty is to help keep the artery open.
93
What is the purpose of the coronary artery bypass graft?
This machine acts as the lungs during the procedure. Through a vein, it delivers blood to the machine, which oxygenates the blood and returns it back to the aorta to be delivered to the tissues.
94
What is angina?
Chest pain caused by a decreased oxygen supply to the heart.
95
What are the three types of angina?
1. Stable Angina
2. Unstable Angina
3. Prinzmetal Angina
96
What is the typical chest pain associated with MI that presents after stress/exertion?
Stable Angina
97
What relieves stable angina? (2)
Rest
Nitrogylcerin
98
EKG signs of stable angina?
ST Depressions \> 1mm (1 small box) in the specific areas of cardiac muscle tissue, particularly when stressed.
99
What is the chest pain that comes on at rest or lasts \> 30 minutes.
Unstable Angina
100
EKG signs of unstable angina?
ST-Segment Depression \< 1 mm (1 small box)
101
What is the workup for unstable angina?
* Serial EKG (helps rule out STEMI)
* Serial cardiac markers (helps rule out NSTEMI)
102
Chest pain is described as the typical angina pain, which occurs at rest and cyclically.
More common in young people.
Prinzmetal Angina
103
What is the pathology of Prinzmetal Angina?
Vasospasm of coronary arteries. Not related to atherosclerosis.
104
What are the causes of Prinzmetal Angina?
Associated with Raynaud's syndrome and cocaine use.
105
What are the EKG signs of Prinzmetal Angina?
ST Elevations only during periods of spasm.
106
A non-invasive method of assessing the presence and severity of CAD.
Stress Test
107
Stress tests are not performed until an _____ is ruled out.
MI
108
What are the indications for stress testing?
1. DDx of chest pain with normal baseline EKG.
2. Post MI prior to discharge.
1. To see if the patient needs catheterization.
3. Patient is at risk for CAD.
4. Suspicion of silent ischemia.
5. Prior to starting an exercise program in patients greater than 40 years old.
6. Job requirement.
109
Who is at risk for CAD?
1. Type II Diabetes
2. \> 40 years old
3. Peripheral Artery Disease
4. Strong family history
110
Who is at risk for silent ischemia?
* Shortness of Breath (SOB)
* Fatigue
* Dyspnea on Exertion (DOE)
111
Contraindications for stress testing (6)
1. Acute Symptoms
2. Acute Systemic Illness
3. Severe Hypertension
4. Severe Aortic Stenosis
5. Uncontrolled Congestive Heart Failure (CHF)
6. Presence of a significant arrhythmia
112
Used for individuals who cannot exercise.
Pharmacological Stress Test
113
Common drugs used for pharmacological stress tests? (4)
* Adenosine
* Dipyridamole/Persantine
* Dobutamine
* Lexiscan
114
What indicates a positive stress test?
ST-Segment Depressions \> 1mm (1 small box) in a pattern consistent with the areas of localization of an MI.
115
What is the purpose of echocardiography in stress testing?
Looks for wall motion changes in addition to ST depression.
116
What three other cardiac testing modalities?
* Intravascular ultrasound (IVUS)
* Magnetic Resonance Imaging/Angiography (MRI/A)
* Calcium storing via CT
117
What is the mean vector?
The mean direction (average direction) of all electrical activity within the heart can be summarized as follows:
From right to left and from the base toward the apex.4
118
Axis Deviation: Einthoven's Triangle; Where is the location of:
1. aVR
2. aVL
3. aVF
4. Lead I
5. Lead II
6. Lead III
1. Right Arm
2. Left Arm
3. Left Leg
4. Right Arm \> Left Arm
5. Right Arm \> Left Leg
6. Left Arm \> Left Leg
119
What two leads help to determine the axis deviation?
aVF & Lead I
120
What are the four directions of the mean electrical axis?
1. Normal
2. Right Axis Deviation
3. Extreme Right Axis Deviation
4. Left Axis Deviation
121
Lead I and aVF in Normal Axis
Lead I - Up
aVF - Up
122
Lead I and Lead aVF in Right Axis Deviation
Lead I - Dwon
aVF - Up
123
Lead I and Lead aVF in Exteme Right Axis Deviation
Lead I - Down
aVF - Down
124
Lead I and Lead aVF in Left Axis Deviation
Lead I - Up
Lead aVF - Down
125
The normal axis measures from ______ (\_\_\_\_\_) to the ______ (\_\_\_\_\_\_).
Right (Base); Left (Apex)
126
Left Axis Deviation measures from the _____ to the ______ toward the \_\_\_\_\_\_.
Right, Left, Base
127
Right Axis Deviation measures from the _____ (\_\_\_\_) to the _____ towards the _____ ventricle.
Left (Base); Right; Right
128
Extreme Right Deviation measures from the _____ (\_\_\_\_\_) towards the _____ (\_\_\_\_\_).
Left (Apex); Right (Base)
129
Increase in muscle mass of the ventricles.
Hypertrophy
130
Dilaton of the atria.
Enlargement
131
EKG findings of hypertrophy and enlargement are suggestive and must be verified with \_\_\_\_\_\_\_\_\_.
Echocardiogram.
132
EKG Finding - Left Atrial Enlargement
* Biphasic P wave in V1, with a large "terminal portion".
133
What is meant by a "large terminal portion" in Left Atrial Enlargement?
* Deflection \> 1 mm (1 small box)
134
EKG Findings - Right Atrial Enlargement
* Tall, Peaked P waves in lead II, III, aVF
135
What qualifies a tall P wave?
* \> 2.5mm in amplitude
136
What are common causes for Right Atrial Enlargement?
* Tricuspid Stenosis
* Pulmonary Hypertension
* Other lung diseases
137
What are common causes for Left Atrial Enlargement?
* Mitral Stenosis
* Hypertension
* Left Ventricular Hypertrophy
138
What are common causes for LVH?
* Hypertension
* Myocardial Infarction
* Aortic Insufficiency
* Hypertrophic Cardiomyopathy
139
LVH is associated with: (2)
Left Axis Deviation
ST-Segment Depression
\*Not a must.
140
The (3) criteria for LVH are not applicable in: (2)
* \< 35 years old.
* Thin or have a small chest wall.
141
EKG Criteria for LVH:
1. (S in V1 or V2) + (R in V5 or V6) \> 35 mm
2. (R in II) + (S in III) \> 25 mm
3. R in aVL \> 13 mm
142
What are common findings in LVH (not required):
1. ST-Segment Depressions (downsloping) in I, aVL, V5, V6
2. ST-Segment Elevations (upsloping) in V1, V2, V3
3. T-wave inversion in I, aVL, V5, V6
143
EKG Criteria for RVH?
1. Tall R-wave in V1 (R \> S)
2. Deep S wave in V6 (S \> R)
3. Must be accompanied by Right Axis Deviation (RAD)
144
RVH is highly associative with \_\_\_\_\_\_.
Right Atrial Enlargement (RAE)
145
What is commonly seen in RVH, but not considered criteria?
1. T-wave inversions in II, III, aVF
2. ST-Segment depression (downsloping) in II, III, avF
146
Common causes of RVH? (2)
1. Pulmonary Disease
2. Congenital Heart Disease
147
Any obstruction or delay of the normal conduction between the SA node and the Purkinje fibers
Conduction Block
148
EKG Criteria for Left Bundle Branch Block (LBBB):
1. Wide (0.12 second) QRS
2. RSR' in V5 or V6 (AKA "dog ears")
1. It just matters that it is Up-Down-Up.
3. Associated with ST Depression in lead I, aVL, V5, V6
149
What is a common cause of LBBB?
Coronary Artery Disease
150
What is LBBB associated with?
1. ST-Segment Depression and Inverted T-waves left lateral leads.
1. Due to repolarization abnormalities.
151
Additional clues in order to diagnose LBBB in the presence of an MI?
1. Pathological Q-waves in \> 2 Leads.
1. Lead I, aVL, V5, V6
2. Use history, physical exam and cardiac markers.
152
Any new onset of LBBB or RBBB should raise your suspicion for an \_\_\_\_.
Myocardial Infarction (MI)
153
EKG Criteria for Right Bundle Branch Block:
1. Wide QRS (\> 0.12 sec)
2. RSR' in V1 or V2 (aka "Rabbit Ears")
3. May have associated ST depression in V1, V2, ± V3
154
RBBB can be found in _______ EKG. It is not usually associated with \_\_\_\_\_\_\_.
Normal
Coronary Artery Disease
155
