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Cardiology > IHD > Flashcards

IHD Flashcards

1
Q

Acute coronary syndrome consists of

A

-unstable angina, STEMI, STEMI, LBBB

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2
Q

Pathophysiology of stable angina

A

They have a stable plaque occluding. There are collaterals that are capable of supplying blood to the myocardium in stable resting stages.

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3
Q

Blood supply to the myocardium.

A

RCA divides into right marginal artery and posterior interventicular artery. LCA divides into left circumflex artery and left anterior descending artery (anterior interventicular artery)

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4
Q

Acute coronary syndrome pathophysiology

A

Due to the lack of collaterals and the sudden narrowing of the coronary artery due to the rupture of an immature plaque which has a thin capsule, exposes the highly thrombogenic lipid core. Inflammation at the shoulder of the plaque also cause a clot formation. There is a vascular spasm due to imbalance between vasoconstriction and vasodilators

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5
Q

Diagnosing 3 main categories for acute coronary syndrome

A

Pain, ECG changes, cardiac biomarkers.

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6
Q

Pain in acute coronary syndrome.

A

Acute chest pain, tightening type lasting more than 20 min retrosternal radiating to the jaw, shoulder left arm

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7
Q

ECG changes in acute coronary syndrome STEMI

A
  • ST elevations of 2 Or more contiguous leads there should be a >= 1.0mm in limb leads or V4-6
  • V2-3 > 2.5mm in <40y , >= 2.0mm in men >40y, >=1.5mm in women
  • V7-9 >0.5mm
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8
Q

ECG changes in nstemi and unstable angina

A
  • New ST depressions
  • T inversions.
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9
Q

DDs for acute coronary syndrome.

A
  • Aortic dissection
  • acute pericarditis
  • pulmonary embolism
  • pneumothorax
  • esophageal pain
  • PUD
  • acute pancreatitis
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10
Q

Mx of ACS

A
  1. Admit
  2. Acute side bed
  3. Check A, B, C and correct as necessary. Oxygen if SpO2 < 90%
  4. Connect to cardiac monitor
  5. Blood – FBC, SE, BU, S.Cr, Lipid profile, cardiac biomarkers, blood sugar
     Troponin I – (highly specific and highly sensitive - may remain
    elevated for upto 2 weeks)
  6. Commence drug therapy
     Aspirin 300 mg
     Clopidogrel 300 mg
     Atorvastatin 40-80 mg
     IV morphine – 2.5 -5 mg as single dose/GTN – sublingual
    IV metochlopromide 10 mg
  7. Take 12 lead ECG & CXR if suspecting HF
     ECG – ST elevation – STEMI
     Non ST elevation but ST depression and T inversion – unstable angina or
    NSTEMI
     If the initial ECG is not diagnostic serial ECGs should be performed
  8. Unstable angina and NSTEMI will be treated with Heparin
    STEMI and LBBB wil be treated with streptokinase.
    The best Mx would be PCI
  9. Reperfusion
     Percutaneous coronary intervention – limited
     Thrombolytics- EgSK – 1.5 MU in 100 mL N/S over 1 hour(or fibrin specific
    fibrinolytics)
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11
Q

ACS pain interms of ChLORIDE

A

 Ch- Character –tightening type of pain
 L – Location – Retrosternal
 O – Onset – sudden onset
 R – radiation – jaw, shoulder tip, left arm
 I – Intensity – severe
 D – duration - > 20-30 min
 E – aggravating factors

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12
Q

ECG changes associated with STEMI

A

1.Hyperacute (10-20 min) -Tall peaking T waves and progressive ST
elevation
2.Acute (min to hrs)- ST elevation
3.Early (hours to days)- ST elevation disappear and Q waves appear
4.Intermediate (days to weeks)- Q waves and T inversions

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13
Q

Dosage of the thrombolytics

A

1.5 MU in 100 mL N/S over 1 hour(or fibrin specific fibrinolytics)

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14
Q

Indications of thrombolytics in ACS

A

 Within 12 hours of onset of pain
 STEMI
 New onset LBBB
 True posterior MI

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15
Q

Contraindications for thrombolysis (Absolute contraindications)

A

 Past history of haemorrhagic stroke
 PHx of ischaemic stroke within last 6 months
 Intracranial tumour
 Aortic dissection
 Active internal bleeding within last 2 weeks

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16
Q

Assessing the response to thrombolysis

A

 Relief of pain
 Restoration of haemodynamic stability
 Reduction of ST elevation by 50% in 60-90 min following administration

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17
Q

Time window for PCI as the first step

A

less than 120 minutes

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18
Q

PCI wire entry sites

A

Radial Artery
Femoral Artery

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19
Q

Q waves on the ECG means

A
  • Indicates and old infarction
  • Permanent on ECG
  • Transmural infarction
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20
Q

Transmural infarction

A

whole thickness is involved

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21
Q

How to Dx a true posterior MI from anterior leads

A

If there is an ST depression in V1.

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22
Q

Most common reperfusion arrhythmia

A

Accelerated idioventricular arrhythmia

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23
Q

the cardiac biomarker that can be done within 1-2 hours

A

highly sensitive troponin I

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24
Q

Drug therapy in ACS stat Mx

A

 Aspirin 300 mg
 Clopidogrel 300 mg
 Atorvastatin 40-80 mg
 IV morphine – 2.5 -5 mg as single dose/GTN – sublingual
IV metochlopromide 10 mg

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25
Q

ECG changes with NSTEMI and unstable angina

A

Non ST elevation but ST depression and T inversion

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26
Q

Heparin is given for

A
  • Unstable angina
  • NSTEMI
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27
Q

Streptokinase is given for

A
  • STEMI
  • LBBB
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28
Q

ECG changes with STEMI within 10-20 min

A
  • Tall peaking T waves
  • progressive ST elevation
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29
Q

ECG changes with STEMI within mins to hours

A

ST elevation

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30
Q

ECG changes with STEMI within hours to days

A

ST elevation disappears and Q waves appear

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31
Q

ECG changes with STEMI within days to weeks

A
  • Q waves
  • T inversions
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32
Q

Inferior MI occurs due to a block in

A

Posterior interventricular artery

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33
Q

Why are heart blocks more common with inferior MI

A

conducting system is also supplied by RCA

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34
Q

Dressler Syndrome

A

Immune- mediated pericarditis

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35
Q

Ventricular ectopics after giving SK indicates

A

successful reperfusion

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36
Q

Assessing the response to thrombolysis

A

 Relief of pain
 Restoration of haemodynamic stability
 Reduction of ST elevation by 50% in 60-90 min following administration

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37
Q

Beta Blockers are contraindicated in

A
  • in patients with HR<60
  • SBP<100
  • conduction defects
38
Q

strategies to limit infarct size

A

 Β blockers
 ACEI
 Statin
 Aspirin ( later maintenance dose)
 Clopidogrel ( later maintenance dose)
 (( other Gp2b/3a receptor inhibitors- abciximab, eptifibatide and tirofiban

39
Q

Abciximab, eptifibatide, tirofiban mechanism

A

inhibit final common pathway for platelet adhesion and aggregation

40
Q

Troponin I +ve - NSTEMI Mx

A

Enoxaparin 1mg/kg bdfor 72 hours

41
Q

Troponin I –ve – Unstable angina Mx

A

Enoxaparin 1 mg/kgbd for 48-72 hours

42
Q

Early complications for ACS

A
  • Arrhythmia
  • Heart Block
  • HF and cardiogenic shock
  • Post infarction angina
  • Acute pericarditis
  • Acute MR
43
Q

Heart block is mostly seen in

A

Inferior MI

44
Q

Mx of heart block due to ACS

A

Use atropine, consider
temporary cardiac pacing

45
Q

Mx of cardiogenic shock in ACS

A

inotropes

46
Q

Post infarction angina Mx

A

increase antianginal drugs,
consider coronary angiography

47
Q

Rx of Acute pericarditis in ACS

A

No Rx needed

48
Q

Acute MR Mx

A

Surgical referral

49
Q

Intermediate and late complications of ACS

A
  • VSD
  • Dressler’s syndrome
50
Q

principles of Mx prior to discharge

A
  • Counsel regarding lifestyle modification
  • Mx of stress
  • Arrange for ECHO and coronary angiography
  • Discharge with medications
51
Q

Discharge medications

A

 Clopidogrel
 Aspirin
 Atorvastatin
 B Blockers
 ACEI
 Nitrates

52
Q

Mechanism of Clopidogrel

A

inhibit P2Y 12receptors in platelets there by block ADP dependent activation of glycoprotein 2b/3a complex

53
Q

Mechanism of aspirin

A

inhibit COX 1- reduce thromboxane A2 from platelet

54
Q

Lifestyle modification post discharge

A
  • Aerobic exercises ( 30 min brisk walking per day at least 5 days a week)
  • Stop smoking, alcohol
  • Reduce salt, fatty food, carbs
55
Q

Pathophysiology of stable angina

A

most have stable plaque occluding 70-80%, calcified mature plaques which has thick capsule

56
Q

P/C of stable angina

A

chest pain on exertion. Relieved by rest or GTN

57
Q

Grading – Canadian Cardiovascular Society

A

o Grade 1 – ordinary [physical activity does not cause angina, angina at strenuous or
prolonged exercise
o Grade 2 – slight limitation of ordinary activity
o Grade 3 - marked limitation of ordinary activity
o Grade 4 – angina at any level of exertion

58
Q

Ix done for stable angina to assess the severity

A

Exercise ECG

59
Q

why is a normal ECG not done in stable angina

A

it can be normal in 50% of patients

60
Q

Other Ix done for stable angina

A
  • coronary angiography
  • Angioplasty
  • CABG
61
Q

Mx of stable angina

A

o Lifestyle modification
o Medications – Aspirin( clopidogrel if aspirin is not tolerated) ,statin
Antianginal drugs

62
Q

mechanism of nitrates

A
  • Relaxation of vascular smooth muscle causing venodilation
  • arteriolar dilation
  • coronary artery dilation
63
Q

Examples of nitrates

A
  • GTN (sublingual)
  • ISMN(iso sorbide mono
    nitrate) ,ISDN (oral)
64
Q

ADRS of nitrates

A
  • Headache
  • Flushing
  • tolerance
  • Postural hypotension
65
Q

Beta blockers mechanism

A
  • Reduction of heart rate
  • myocardial contractility
66
Q

Examples of Beta blockers

A
  • Atenolol
  • Bisoprolol
67
Q

ADRS of beta blockers

A
  • Conduction abnormalities
  • Bronchoconstriction
  • Worsening of PVD
  • Impotence
  • Depression
  • Nightmares
  • impaired glucose tolerance
  • Bradycardia
68
Q

Calcium channel blockers mechanism

A
  • Vasodilation
  • Conduction block
  • Reduced myocardial
    contractility
69
Q

Two types of CCBs

A
  • Dihydropyridine-**( not
    preferred in IHD) **
    Nifedipine
  • Non dihydropyridine-
    Verapamil
    Diltiazem
70
Q

ADRS of dihydropyridine

A
  • Oedema
  • head ache
  • flushing
  • worsening heart failure
  • Tachycardia
  • gum hyperplasia
71
Q

ADRS of non dihydropyridine

A
  • Oedema
  • Bradycardia
  • heart block
  • constipation
72
Q

Beta blockers are not given together with

A

non- dihydropyridines - worsen bradycardia

73
Q

why is dihydropyridines not recommended in IHD

A

tachycardia worsens IHD

74
Q

K channel blocker

A

Nicorandil

75
Q

SA node funny current channel blocker

A

Ivabradine

76
Q

Inhibiting delayed Na channel

A

Ranolozine

77
Q

Enoxaparin is given as (route of administration)

A

Subcutaneous

78
Q

Cardiac troponin takes …… days to return to baseline

A

4-14 days sometimes

79
Q

If a patient gets another chest pain episode 5 days after he got a STEMI. How to check if the second chest pain episode is also an MI?

A

Ask for a quantitative Troponin T. levels which should be reducing would suddenly increase.

80
Q

Coronary artery vasospasm is

A

Prinzemetal angina

81
Q

Prinzemetal angina is seen among

A
  • common in females
  • common among smokers
82
Q

Inferior MI can present with….

A
  • Epigastric pain
  • AV block
83
Q

If the BP reduce a little 30min after starting Streptokinase infusion. Next step?

A

Reduce the infusion rate and elevate the limbs

84
Q

If the BP drops significantly 30 min after starting streptokinase infusion. Next step?

A

Stop SK and give IV NS bolus ( could be an allergy)

85
Q

New risk factors for MI

A
  • Hyperhomocystinemia
  • Increased CRP
  • Increased Fibrinogen
86
Q

ECG leads V1- V4 look at the

A

anterior surface of the heart (septum)

87
Q

aVL, V5, V6 look at the

A

lateral surface of the heart

88
Q

II, III, aVF look at the

A

inferior surface of the heart

89
Q

V7, V8, V9 look at the

A

back leads, Good to check for posterior MI

90
Q

Can you have a STEMI in all leads in an ECG

A

Theoretically possible. but not possible to get acute blocks in all coronary arteries

91
Q
A

Cardiology (7 decks)

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