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IHD Flashcards

1
Q

Risk factors for IHD

A

Dm, obesity, male, increasing age, hypercholesterolemia, htn, smoking, sedentary life, genetics

dysrhythmias, angina, acute MI, sudden death

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2
Q

Stable angina develops…..

A

Develops in the setting where CA is partiall or sig occluded greater than 70%. Chronic narrowing of CA.

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3
Q

Angina Pectoris releases what?

A

Release of adenosine and bradykinin

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4
Q

Release of adenosine and bradykinin cause…..

A

Cardiac nociceptors->
Afferent neurons->
send pain?
arrises at T1-T5 sympathetic ganglia

slow AV conduction
decrease cardiac contractility

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5
Q

dermatomes for angina/ other diagnosis

A

C8 – T4 dermatome,
C8 = hands
T4 = nipple line

Retrosternal chest pain, pressure, heaviness
Radiates to neck, left shoulder, left arm, or jaw
Occasionally to back or down both arms. chest pain with physical exertion cold weather or emotional tension

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6
Q

Chronic stable CP

A

Chest pain that does NOT change in frequency or severity in 2-month period

doesn’t hurt more or happening more often

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7
Q

Unstable CP

A

Chest pain increasing in frequency and/or severity without increase in cardiac biomarkers

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8
Q

12 lead ECG changes look for

A

ST segment depression
Associated T wave inversion
ST elevation
order biomarkers to correlate

previous MI changes

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9
Q

Exercise stress test assess….

A

Assessing the Relationship of cardiac stressor/ movement to chest pain

assess supply and demand balance

looking for greater degree of ST changes with stress, greater depression = increased CAD

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10
Q

What dx cardiac test has greater sensitivity for assessing CAD?

A

nuclear stress imaging

tracers accumulating = good flow
dark area = no tracer = ischemia

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11
Q

Nuclear stress imaging
measures…..

A

Size of perfusion abnormality = significance of CAD detected
Estimates LV systolic size and function
Differentiates new perfusion abnormality vs. “old” MI

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12
Q

Tracers for nuclear stress imaging used with/without exercise

A

Thallium

Atropine, dobutamine, and pacing- used to help increase hr and cause the stress.

Adenosine, dipyridamole- Help with dilating the areas after we induce stress, only dilate normal CA not going to evoke change in arteries that are atherosclerotic. Poor arteries/ inflamed from atherosclerosis, these wont dilate them anymore

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13
Q

Get Echo when….

A

patho Q wave and new BBB

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14
Q

Echo assesses….

A

Wall motion abnormalities
Valvular function

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15
Q

Function of Coronary angiography

A

Determines location of occlusive disease

Diagnose Prinzmetal (variant/spasm) angina

Assess results of angioplasty/stenting

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16
Q

Coronary angiography does not measure…..

A

Does NOT measure stability of plaque; when it will rupture

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17
Q

Gen treatment for IHD

A

Cessation of smoking
Ideal body weight
Low-fat, low-cholesterol diet; Statins;
Regular aerobic exercise
Treatment of hypertension

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18
Q

When are statins prescribed

A

increased trig
LDL > 160 mg/dl, 50% reduction is what they are looking for

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19
Q

ASA moa

A

inhibits cox 1 = inhibits thromboxane A2= decreased clotting.

Irreversible, plat life span = 7 days

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20
Q

Platlets given to plavix pts is effective….

A

24 hours after the last dose / 5 half lives

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21
Q

Platelet glycoprotein IIb/IIIa receptor antagonists meds and MOA

A

(abciximab, eptifibatide, tirofiban)

Inhibit platelet activation, adhesion, and aggregation

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22
Q

Plavix metabolite increases clearance by….

A

6-8 hrs

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23
Q

Thienopyridines (P2Y12inhibitors)
medications

A

Clopidogrel and Prasugrel

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24
Q

Clopidogrel MOA

A

Inhibits ADP receptor P2Y12 and platelet aggregation

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25
when clopidogrel is DC's platlets....
D/C ~ 80% of platelets recover to normal function , takes time and we are always making plat
26
clopidogrel hypo/hyper responsive percentage
10 - 20% of people hypo/hyper-responsive = less predictable pharmacodynamics
27
Clopidogrel and PPI's
reduce the effectiveness of the drug
28
Pragusul compared to clopidogrel
More predictable pharmacokinetics; more potent than Plavix. Higher risk of bleeding
29
Nitrates effect
Decrease frequency, duration, and severity of CP Increase exercise to produce ST-segment depression Dilate coronary arteries and collaterals Decrease peripheral vascular resistance Decreases preload Potential anti-thrombotic effects; not well researched
30
Nitrates are contraindicated in......
Contraindicated with aortic stenosis and hypertrophic cardiomyopathy AS = need more venous return for forward motion HC = outflow obstructed
31
Nitrates drug interactions
Synergistic with beta-blockers/calcium channel blockers; if given in addition then the effect is more profound.
32
Only drug to prolong life in CAD pts
Beta blockers Decreases risk of death and reinfarction in MI pts
33
Beta blockers effects
Anti-ischemic, anti-hypertensive, anti-dysrhythmic
34
medication that Increased risk of bronchospasm in reactive airway disease
Beta 2 adrenergic blockers (propranolol, nadolol)
35
Beta 1 blockers
Blockade of β1- receptors (atenolol, metoprolol, acebutolol, or bisoprolol)
36
Beta blockers effect
Decrease Heart rate Inrease Diastolic time Reduce Myocardial contractility Decrease Myocardial oxygen demand Helping heart to relax and refill, when increasing diastolic time = increases coronary perfusion time.
37
medication that is Uniquely effective for decreasing frequency/severity of spasm in coronary arteries (prinzmental)
CCB Dilate coronary arteries,
38
CCB decrease ......
Vascular smooth muscle tone Contractility Oxygen consumption Systemic BP
39
Beta blockers compared to CCBs
Not as effective as beta blockers in decreasing incidence of myocardial reinfarction
40
Angiotensin II increases....
Myocardial hypertrophy Interstitial myocardial fibrosis Coronary vasoconstriction Inflammatory responses ace i
41
ACE i treat
Hypertension Heart failure Cardioprotective ; reduce the workload to decrease demand and prevent vent remodeling and stabilize the repercussed heart and prevent the reoccurrence of reperfusion arrhythmias.
42
Medication that helps with coronary plaque stabilization
statins by Decreases, Lipid oxidation, Inflammation, Matrix metalloproteinase, Cell death
43
Statins reduce the mortality noncardiac surgery and vascular surgery by....
Reduces mortality noncardiac surgery (44%) and vascular surgery (59%)
44
Revasularization for what pts....
Failure of medical therapy > 50% L main coronary artery > 70% epicardial coronary artery Impaired EF <40%
45
CABG > PCI when......
L main disease; 2 or 3 vessel CAD, DM and have 2 or 3 Vessels
46
what is Acute Coronary Syndrome
Acute or worsening imbalance of myocardial oxygen supply to demand
47
Events leading to ACS
Atheromatous plaque Coagulation cascade Thrombin generation Arterial occlusion (partial or complete)
48
No st seg elevation and negative biomarkers
unstable angina
49
No st seg elevation with positive biomarkers
NSTEMI
50
St elevation with positive biomarkers
STEMI
51
What forms at the site of the ruptured plaque
plat monolayer and Vulnerable plaques; likely to ruputure.
52
Chemicals that stim plat aggregation
Collagen, ADP, epinephrine, serotonin-> stim plat aggregations TXA2 = vasoconstriction
53
Glycoprotein 2b/3a function
Glycoprotein IIb/IIIa receptors; activated on plat and that enhances the ability to interact with adhesive proteins/ make stickier and make clot bigger -> growth-> stabilize thrombus
54
Troponin increases within....
3 hours after myocardial injury , stay elevated for 7 to 10 days More specific than CK-MB
55
STEMI Dx
evidence of myocardial necrosis with myocardial ischemia; troponin, st changes, patho q wave,
56
reperfusion medical therapy
Tissue plasminogen activator (tPA), streptokinase, reteplase, or tenecteplase- started within 30 min of hospital arrival/ 12 hr or symptom onset. catalyze plasminogen-> plasmin to break down the clot Restores normal antegrade blood flow
57
When are imaging studies ordered
new LBB or abnormal ECG Regional wall motion abnormalities Ad look at valves, if pt has evidence of EKG with an MI. echo is not warranted. Only indictive if the pt needs an echo. Not everyone with an MI will have an echo.
58
Indications for PCI
-Contraindications to thrombolytic therapy -Severe HF and/or pulmonary edema -Symptoms present for 2 - 3 hours -Mature clot
59
Indications for CABG
CABG recommended based on Coronary anatomy failed angioplasty Evidence of infarction-related ventricular septal rupture or mitral regurgitation
60
Drug therapy for ACS
MONA; morphine, oxygen, nitrates, asa P2Y12 inhibitors (clopidogrel, prasugrel, or ticagrelor) Platelet glycoprotein IIb/IIIa inhibitors Unfractionated heparin (esp for PCI/ thrombolytic therapy is planned) β blockers RAAS; ACEi, ARB, prevent vent remodeling.
61
Causes of unstable angina
Rupture or erosion of a coronary plaque Dynamic obstruction due to vasoconstriction (prinzmental/ cold temp) Worsening coronary luminal narrowing (atherosclerosis/ stent restenosis) Inflammation (vasculitis) Myocardial ischemia due to increased oxygen demand
62
Unstable Angina/ NSTEMI
Angina at rest, lasting >10 minutes
63
Chronic angina pectoris
Cp thats more frequent and more easily provoked Crescendo pattern; gaining momentum
64
New-onset angina
severe, prolonged, or disabling cp
65
Treatment for unstable angina/ NSTEMI
Bed rest, oxygen, analgesia, and β-blocker therapy Sublingual or IV nitroglycerin Calcium channel blockers Aspirin, clopidogrel, prasugrel, or ticagrelor and heparin therapy (unfractionated heparin or LMWH)
66
Thrombolytic therapy not indicated in what pts
unstable angina/ NSTEMI because the fibin is not there and pts still have flow
67
Types of PCI
Balloon angioplasty, bare-metal stent, drug eluding stent......Destruction of endothelium of the vessel
68
Reendovasualrization post balloon angioplasty can take.....
2-3 weeks- 2-3 weeks of therapy
69
Reendovasualrization post baremetal stend angioplasty can take.....
12 weeks- 6 weeks of therapy
70
Reendovasualrization post DES angioplasty can take.....
1 year
71
DC clopidogrel or ticagrelor....
5 days to reduce bleeding risk continue asa if possible
72
DC prasugrel ......
7 days
73
Angioplasty without stenting time to wait for elective sx
2-4 weeks
74
Bare metal stent placement time to wait for elective surgery
at least 30 days ; 12 weeks preferable
75
CABG time to wait for elective surgery
at least 6 weeks; 12 weeks preferable
76
DES time to wait for elective surgery
at least 6 months; at least 12 months after acute coronary syndrome
77
what anesthetic to avoid with post-cardiac intervention pts
Anesthetic technique; avoid spinal/ epidural
78
Pre op beta blockers
continue throughtout peri- op
79
treatment for bradycardia with beta blockers
Glycopyrrolate > atropine
80
____ has less potential to cause arrhythmias
glycopyrrolate
81
α2-Agonists MOA
Decrease sympathetic outflow, blood pressure, and heart rate Continue because of rebound effects. Rebound effects; tachycardia/ htn
82
DC ACEi.....
D/C 24 hours before surgery Sympathomimetics to treat hypotension
83
Control hyperglycemia to...
< 180mg/dL
84
Components of RCRI
High risk sx; intraperiotoneal, intrathoracic, subringuinal vasular procedure ischemic heart dz hx of CHF hx of CVA Dm w/ insulin Creat > 2.0
85
RCRI score
0=0.4% 1= 1% 2 = 2.4$ >3 = 5.4% Low risk - <1%= ≤1 RCRI risk factor Elevated risk - >1%= >2 RCRI risk factors
86
Functional capacity assesses....
cardiopulmonary fitness Poor functional capacity = increased peri-operative risk
87
Mets
metabolic equivalent of task Rate of energy consumption at rest 1 MET = 3.5 mL/kg/min want > 4 METs
88
Emergency surgery
life or limb would be threatened if surgery did not proceed within 6 hours or less -Proceed directly to emergency surgery w/o pre-op cardiac assessment -Focus on surveillance and early treatment
89
Urgent surgery
life or limb would be threatened if surgery did not proceed within 6 to 24 hours
90
Time-sensitive surgery
delays exceeding 1 to 6 weeks would adversely affect patient outcomes
91
2, 3, avF artery
RCA areas; RA, RV, SA node, interior LV, AV node
92
1, AVL artery
circumflex area; lateral aspect of the LV
93
V3-V5 artery
LAD area; anterolateral aspect of LV
94
Goals of IHD with anesthesia
Prevent myocardial ischemia Monitor for ischemia Treat ischemia Prevent Persistent tachycardia Systolic HTN SNS stimulation Arterial hypoxemia Hypotension Maintain BP and HR w/in normal awake baseline 20%
95
Causes of decrease oxygen delivery
decrease coronary blood flow tachycardia hypotension hypocapnia Coronary artery spasm decreased oxygen content anemia arterial hypoxemia shift of the oxyghbg dissociation cure to the L
96
Increased oxygen requirements
symathetic nervous sytem stimulation tachycardia htn increase Mypocardial contraciltiy increased afterload increased preload
97
Anesthetic considerations for induction
Succinylcholine, vecuronium, rocuronium, & cisatracurium—avoid histamine release DL ≤15 seconds Laryngotracheal lidocaine, IV lidocaine, esmolol, fentanyl, remifentanil, and dexmedetomidine Volatile anesthetics Nitrous oxide Opioids; Severe LV function Neuraxial anesthesia- avoid if ont DAPT therapy
98
med to give for tachycardia
esmolol
99
Tx for hypotension
Fluid bolus Sympathomimetic drugs (ephedrine, phenylephrine)
100
Pragusul compared to clopidogrel
More predictable pharmacokinetics; more potent than Plavix. Higher risk of bleeding
101
What forms at the site of the ruptured plaque
plat monolayer and Vulnerable plaques; likely to ruputure.
102
New-onset angina
severe, prolonged, or disabling cp

HA (15 decks)

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