IHD part 2 Flashcards
what is the initial testing acquired for a pt with chest pain?
12-lead EKG
indications for 12-lead EKGs
- Uses: assess for MI, ischemia, cardiac rhythm, conduction abnormalities, & chamber hypertrophy
- Should be obtained in all adults with chest
discomfort who do not have an obvious non-cardiac cause - Routinely ordered in elderly patients, patients with DM (with dyspnea, nausea, malaise), syncopal patients and if an arrhythmia is suspected
12-lead ECG should be performed and evaluated for ischemic changes for anyone with sx of ACS within how many mins of the pts arrival at an emergency facility?
10 minutes
If the initial ECG is not diagnostic but the pt remains symptomatic and there is a high clinical suspicion for ACS, what is the next step?
serial ECGs to determine ischemic changes
15-30 min intervals during the first 1-2 hrs
- Sometimes the earliest presentation of AMI
- Rarely seen in clinical practice
- exist for only 20-30 min after onset of infarct - Must be distinguished from the peaked T waves associated w/ hyperkalemia
what type of EKG finding is this?
hyperacute T waves
what are the 3 main EKG findings of ACS?
- nonspecific or normal EKG - does not exclude ACS
- ST segment depression or T wave inversion in 2 or more contiguous leads - sus for NSTEMI or USA
- ST segment elevation or new LBBB - sus for STEMI
what is the STEMI evolution
- ST elevation - mins-hrs
- ST elevation, pathological Q wave, inverted T waves, scar formation - 1-2 days
- ST flattening, pathological Q waves - 7-10 days
- normalization with a persistent Q wave - months
you receive this EKG, you can assume how long have these sx been happening?
minutes to hours
ST elevation
you receive this EKG, you can assume how long have these sx been happening?
1-2 days
ST elevation, pathological Q wave, inverted T waves, scar formation
you receive this EKG, you can assume how long have these sx been happening?
7-10 days
ST flattening
Pathological Q waves
you receive this EKG, you can assume how long have these sx been happening?
months
normalization with persistent Q wave
after getting an EKG from a pt with chest pain, what is the next step?
obtain cardiac biomarkers/enzymes
- evaluate myocardial damage - myoglobin, CK-MB, troponins
(this is step 2 for patients without ST-segment elevations)
a contractile protein that normally is not found in serum
only released when myocardial necrosis occurs
troponin
Preferred markers for myocardial injury - Highly sensitive and specific for even small amounts of cardiac damage
when can we aspect troponin to be elevated, peaked, and returned to baseline?
- increased - 3-6 hrs
- peaked - 24-48 h
- return - 5-14 d
measure troponin levels at ___ and then again at ___
presentation
90 mins
then every 6-8 hrs after sx onset x3 until trending down
when can we aspect CK-MB to be elevated, peaked, and returned to baseline?
- increase - 4-8 h after injury
- peaked - 24 h
- return - 48-72 h
what are the different types of creatine kinase isoenzymes
- CK-BB - brain and lungs
- CK-MB - heart
- CK-MM - msk
CK-MB is positive if it is how much % of total CK?
> 5%
false positives for CK-MB
exercise
trauma
muscle disease
DM
PE
- Found in cardiac and skeletal muscle
- High sensitivity, poor specificity
- Released more rapidly from infarcted myocardium - The most sensitive early marker for myocardial infarction
what is this cardiac biomarker?
myoglobin
Only real use is in the very early
detection of MI
myoglobin may be detected as early as __ after an AMI
2 hours
which cardiac biomarker is not specific - Found in many tissues
(kidney, skeletal muscle, brain, blood cells, lungs, liver)
lactate dehydrongenase (LDH)
when does LDH rise, peak, and return back to normal?
- rises - 24-72 h after MI
- peaks - 3-4 d
- return - 14 d
pt with chest pain for 90 mins, what cardiac enzyme is best to order?
myoglobin
pt with chest pain for 6 hrs, which cardiac enzyme is best to order?
troponin
patient with recurrent chest pain 36 hrs aafter having PCI for an MI, which cardiac enzyme is best to order?
CKMB > myoglobin
other possible lab findings besides cardiac enzymes
- leukocytosis
- several hrs after AMI
- peaks 2-4 d and returns to normal within 1 week - elevated CRP
- pts w/o biochemical evidence of myocardial necrosis but with elevated CRP are at increased risk of a subsequent ischemic event - elevated ESR
- rises above reference range values within 3 d and may stay for weeks
the most commonly used and recommended initial noninvasive procedure for evaluating inducible ischemia in the patient with angina
stress test
Stress component can be achieved
two ways:
exercise (preferred)
pharm
indications for exercise stress test
- confirm angina dx
- determine severity of limitation due to angina
- assess prognosis with known CAD, + pts recovering from MI
- evaluate response to therapy
limitations of exercise stress test
- More false-positives than true-positives
- Not a screening tool in asx pts
which stress test is Most useful for pts with low pretest likelihood and normal baseline EKG
exercise
which stress test is used for young females with atypical sx
exercise
what is HRmax in exercise stress testing?
the highest HR someone can achieve without severe problems through exercise stress
value is calculated using pt age
absolute indications for stopping exercise testing
- drop in SBP >10 from baseline despite increasing workload, when accompanied by other evidence of ischemia/hypoperfusion
- moderate-severe angina
- increasing nervous system sx (dizzy, ataxia, etc)
- poor perfusion (cyanosis, pallor)
- technical difficulties in monitoring
- subject’s desire to stop
- sustained V tach
- ST elevations in leads without diagnostic Q-waves
relative indications to stop exercise testing
- drop in SBP 10 or more from baseline despite increase in workload, in the absence of other evidence of ischemia
- ST or QRS changes (excessive ST depression or marked axis shift)
- arrhythmias other than sustained VT, including multifocal PVCs, V triplets, SVT heart block, or bradyarrythmias
- fatigue, SOB, wheezing, leg cramps, claudication
- development of BBB or IVCD that cannot be distinguished from VT
- increasing CP
- HTN response
absolute CI for exercise testing
- acute MI within 2 days
- high risk unstable angina
- uncontrolled arrhythmias causing sx or hemodynamic compromise
- severe sx AS
- uncontrolled sx HF
- acute PE or pulmonary infarction
- acute myocarditis or pericarditis
- aortic dissection
relative CI to exercise testing
- left main coronary stenosis
- moderate stenotic valvular HD
- electrolyte abnormalities
- tachy or bradyarrhythmias
- hypertrophic CM and other forms of outflow tract obstruction
- SBP >220 or DBP >110
- Mental or physical impairment leading
to inability to exercise adequately - High-degree AV block
do NOT perform an EXERCISE stress test IF the EKG is not interpretable due to baseline abnormalities:
- Preexcitation (WPW) syndrome
- Electronically paced ventricular rhythm
- > 1 mm of resting ST depression
- Complete LBBB
indications for Exercise Stress Test with IMAGING Component
- When resting ECG makes an exercise ECG difficult to interpret
(eg, LBBB, baseline ST–T changes, low voltage) - For confirmation of the results of the exercise EKG when they are contrary to the clinical impression (eg, a positive test in asx pt)
- To localize the region of ischemia
- To distinguish ischemic from infarcted myocardium
- To assess the completeness of revascularization following bypass
surgery or coronary angioplasty - As a prognostic indicator in patients with known coronary disease
what can provide relative perfusion data following injection of a radioactive material before a stress test and then after the stress test
Exercise Stress Test with Nuclear IMAGING
Resting pictures are compared with post-exercise pictures
Radiotracers and Protocols
- Thallium 201
- Technetium:
- Tc-99m Sestamibi (Cardiolite)
- Tc-99n tetrofosmin
Provides slices of the heart for imaging and is a marked improvement
over planar imaging methods
SPECT (single photon emission computed
tomography)
Images from the SPECT enable imaging of wall motion and estimation of EF
what can be combined with exercise EKG in an attempt to increase the sensitivity and specificity of the stress test, as well as
to determine the extent of myocardium at risk for ischemia?
echo
Looking for regional wall motion
abnormalities or LV dilation in response
to exercise
indications for pharm stress test
- Used when a patient is unable to exercise to a sufficient cardiac workload
- CI to or a clinical reason not to perform an exercise stress test
Sensitivity of a pharm stress EKG is very low, so these tests are always combined with imaging
first line for pharm stress agents
vasodilators
adenosine, dipyridamole, regadenoson
MOA of vasodilators
Cause direct coronary artery vasodilation which is attenuated in diseased coronary arteries which have reduced coronary flow reserve and cannot dilate further in response to adenosine
symptoms of vasodiltors
SOB
HA
flushing, feeling hot
chest discomfort/pain
dizziness
Nausea
abd discomfort
metallic taste
CI for vasodilators
- Bronchospasm
- SSS or >1° AVB (w/o a V demand PM)
- SBP <90
- using dipyridamole/methylxanthines (eg, caffeine, aminophylline)
- Unstable or complicated acute coronary syndrome
— an increased risk for ischemic events is present with all stress modalities
2nd-line for pts who can’t exercise and have a contraindication to vasodilator stress
Adrenergic Stimulating Agents - dobutamine
what is often used with dobutamine in patients who do not achieve target heart rate
Atropine
MOA of Adrenergic Stimulating Agents
A synthetic catecholamine that directly stimulates both β1 and β 2 receptors, causing a dose-related ⬆ in HR, BP, and myocardial contractility
sx of Adrenergic Stimulating Agents
Tachycardia, increased SBP, PVCs, angina, palpitations, headache, nausea, dyspnea
CI for adrenergic stimulating agents
- Sustained arrhythmias
- Recent MI (within 1-3 days) or unstable angina (CI for all stress modalities)
- Hemodynamically LV outflow tract obstruction
- Aortic dissection
- Mod-severe systemic HTN (resting SBP 180-200 mmHg)
cardiac cath is used to: (3)
- Evaluate or confirm the presence of CAD, valve dz, or dz of the aorta
- Evaluate heart muscle function
- Determine the need for further tx (PCI or CABG)
waht is the definitive diagnostic procedure for evaluating heart function?
coronary angiogram/cardiac cath
uses for LEFT heart cath with standard coronary angiography
- Performed to assess the cardiac valves and LV function + presence and severity of CAD
- Valvular stenosis and regurgitation can be semi-quantified
- The EF and regional wall motion are assessed by contrast left ventriculography
- Stenotic valvular disease is well defined by echo with Doppler US, but assessing the consequences of regurgitant valvular dz is more difficult and cardiac cath with hemodynamics is often helpful
uses for right heart cath
- Allows measurement of RA, RV, PA, and pulmonary capillary wedge pressures
(PCWP; the latter an indicator of LA pressure), O2 Sat, and CO - Data used to diagnose intracardiac shunts, physiologically significant pericardial disease, and right-sided valve lesions and can distinguish between cardiac and pulmonary disease
- Useful in pulmonary HTN to document
whether the elevated pressures are related to pulmonary disease or to left heart disease -
Hemodynamic monitoring with a PA
catheter may be very helpful in the assessment and treatment of shock, HF, complicated MI, respiratory failure, and postoperative hemodynamic instability
how to prep for coronary angiogram
- must be NPO for 4-6 hours
- Written consent required
- IV fluids (NS) ran for ~24 hours to “flush out” the contrast
- Hold Metformin for 48 hours to avoid CIN
Indications for Coronary Angiogram
- Life-limiting stable angina despite medical therapy
- High pretest likelihood of CAD
- Concomitant Aortic Valve disease
- asx patients undergoing valve surgery
- Survivors of sudden death, symptomatic, or life-threatening arrhythmias when CAD may be a correctable cause
- Chest pain of uncertain cause or cardiomyopathy of unknown cause
- Emergently for revascularization in patients with STEMI
risks with coronary angiogram
- Overall, low mortality risk with procedure
(0.1%) - Surgical risks include: CVA, coronary artery dissection, retroperitoneal hemorrhage, AKI, femoral pseudoaneurysm
- Uses IV contrast, so be aware of allergies as
well as CKD - Performed under moderate sedation
- Invasive and costly - not first-line
unless high pre-test likelihood - Relative CI: severe renal disease,
anaphylactic allergy to contrast
other imaging studies besides an coronary angiogram for IHD
- CXR
- Useful for potential pulm causes of chest pain and may show a widened mediastinum in patients with aortic dissection - Chest CT with IV contrast
- Can help exclude PE and aortic dissection - TTE
- Can identify a pericardial effusion and tamponade physiology
- May be useful to detect regional wall motion abnormalities
- Can identify a proximal aortic dissection
factors to consider for CT of coronary arteries
- Images the heart with contrast medium and multislice technology
- Requires both radiation exposure and contrast load
- Uses X-ray to produce images of heart and vessels.
- HR must be <50
- No recovery time needed
- If positive –> cardiac cath
Overview of Evaluation / Work-up for STABLE ANGINA
outpatient work-up
- EKG - normal; possible Q-wave, nonspecific ST changes, LVH
- CBC; possible trops, CKMB
- pretest probability
- low-intermediate - do noninvasive stress testing
- high - refer for cath
Overview of Evaluation / Work-up for UNSTABLE ANGINA
inpatient work-up
- EKG - ST depression, T-wave inversions; could be normal
- labs - trops (-), +/- CKMB
- pretest probability
- low - no testing needed
- intermediate - consider stress test with nuclear imaging
- high - cath
Overview of Evaluation / Work-up for NSTEMI
inpatient work-up
- EKG - ST depression, T-wave inversions; could be normal
- labs - trops (+), +/- CKMB
- pretest probability
- low-intermediate- noninvasive stress test
— normal - consider other causes
— abnormal - refer for possible cath
- high - cath
Overview of Evaluation / Work-up for STEMI
inpatient work-up
- EKG- ST elevations in two contagious leads
- labs - not needed
- diagnostic testing - cath/immediate reperfusion ASAP
Unstable Angina / NSTEMI / STEMI Management
- All should be admitted
- All should be placed on telemetry / cardiac monitoring
- be placed on strict bedrest
- Supplemental oxygen for <95%
- Nitrates - first-line therapy for acute coronary syndromes with chest pain
- ASA - first-line therapy
what should be given regardless of whether fibrinolytic therapy is being considered or pt has been taking ASA
ASA
chewable provides more rapid absorption
Patients with a definite aspirin allergy
should be treated with ?
P2Y12 inhibitor
Clopidogrel (Plavix)
prasugrel (Effient)
ticagrelor (Brilinta)
what may be used for pain refractory to NTG and ASA for Unstable Angina / NSTEMI / STEMI Management
morphine
Some patients may require sedation with benzo
for Unstable Angina / NSTEMI / STEMI Management
BB and ACEI should be started when?
first 24 hrs
BB CI: HF, bradycardia, heart block
ARB if ACEI not tolerated
Unstable Angina / NSTEMI / STEMI Management
Statins should be started within ?
48 hrs
consider adding CCB for persistent ischemia
Patients with STEMI who seek medical attention within how many hours of the onset of sx should be treated with immediate re-perfusion therapy?
12 hours - Primary PCI or fibrinolytic therapy
Primary PCI within what time of first medical contact is the goal and is superior to thrombolysis?
90 mins
Thrombolysis within ____ of hospital presentation and 6–12 hrs of onset of sx reduces mortality
30 mins
what are the two reperfusion goals
● Door-to-balloon PCI goal of 90 min
● Door-to-needle goal of 30 min
MOA of nitrates
enters vascular smooth muscle and is converted to nitric oxide, leading to activation of cGMP and vasodilation
- Dilates coronary vessels, increasing blood
flow - Decreases SVR and preload
- caution in hypotension (SBP <100), bradycardia, tachycardia, RV infarction
SE of nitrates
MC reflex tachycardia, but can cause paradoxical bradycardia
First-line therapy for pt with acute coronary syndromes presenting with CP?
any exceptions?
nitrates
EXCEPT in patients presenting with IWMI
dosing routes of nitrates
sublingual, oral agents, NTG, ointment, spray, IV
If chest pain persists or recurs after non-parenteral therapy, start what until angina disappears or MAP drops by 10%?
What in addition is needed?
IV NTG
Continuous BP monitoring is required
with IV NTG
SE of IV NTG
HA MC– can be SEVERE
Postural hypotension
Tolerance
what are the two longer acting nitrates that are used for daily angina control?
- isosorbide dinitrate
- half-life: 1 hr
- duration: 3-6 hrs - isosorbide-5-mononitrate
- onset: 60 min
- duration: 8 hrs
how does tolerance develop with nitrates?
- Frequently repeated or continuous exposure to high doses
- Prolonged tx with nitrates may not
only induce a loss of response to nitrates, but also decrease angina threshold in the interval
how do you prevent tolerance of nitrates?
- High doses should be avoided and therapy interrupted for 8–12 h daily
- Treatment “holiday”
what is a major CI with nitrates?
Nitrates + PDE5 inhibitors
- act synergistically to cause profound increases in cGMP and dramatic
reductions in blood pressure (>25 mm Hg) - extreme caution with PRN nitrates (none can be given < 24 hrs of PDE5 drug)
MOA/purpose of morphine
- Reduce pain/anxiety
- Decreases
- Sympathetic tone
- SVR
- O2 demand
reducing afterload
caution with morphine
caution in hypotension, hypovolemia, respiratory depression
SE of morphine
bradycardia, diaphoresis, nausea, constipation, drowsiness, dizziness, confusion
MOA of ASA
Irreversible inhibition of platelet aggregation, stabilize plaque, and stop thrombus formation, reduce mortality in patients with STEMI
- Give 160–325 mg immediately - chewed - for ACS
- 81 mg/d preferred over higher doses for long-term therapy
caution with ASA
caution in active PUD, hypersensitivity, bleeding disorders
SE of ASA
GI (ulcers, dyspepsia, hemorrhage), increased bleeding risk
- Irreversible inhibition of platelet aggregation
- Used in support of cath / PCI or if unable to take ASA
what is this med?
P2Y 12 Inhibitors
- Clopidogrel (Plavix)
- Prasugrel* (Effient)
- Ticagrelor* (Brilinta)
3-12 mo duration depending on scenario
what anti-platelet meds cause the delay of elective CABG? For how long and why?
postpone CABG
- 5 days after last clopidogrel or ticagrelor
- 7 days after last prasugrel
due to risk of bleeding
- Inhibition of platelet aggregation at final common pathway
- In support of PCI intervention as early as possible prior to PCI
- Not required for most patients
what med is this?
Glycoprotein IIb / IIIa Inhibitors
- Tirofiban (Aggrastat)
- Eptifibatide (Integrilin)
- Abciximab(Reopro)
Glycoprotein IIb / IIIa Inhibitors may be considered in these high risk patients:
- Ongoing ischemia despite ASA and P2Y12 inhibitor
- Large thrombus found during angiography, esp if have not received prasugrel or ticagrelor
- To stabilize pts who need urgent CABG in place of P2Y12 until surgical indications defined
- Adjunct to surgical revascularization and thrombolytic / PCI reperfusion
- Used in combo with ASA and/or other platelet inhibitors
what are these meds?
anticoag
- indirect thrombin inhibitors - UFH, LMWH
- direct thrombin inhibitors - bivalirudin
which anticoag is only used in the cath lab?
bivalirudin
T/F: changing from indirect thrombin inhibitor to a direct thrombin inhibitor is safe and recommended
F - Changing from one to the other not recommended
what is shown to be somewhat more effective than UFH in preventing recurrent ischemic events in the setting of acute coronary syndromes?
LMWH - enoxaparin
what med has shown to be a reasonable alternative to heparin (UFH or enoxaparin) + a glycoprotein IIb/IIIa antagonist
for many with ACS who are undergoing early coronary intervention?
bivalirudin - direct thrombin inhibitor
BB reduces mortality risk by how much and should be started when after a MI?
-
14% reduction in mortality risk at 7 days and 23% long
term mortality reduction in STEMI - Should be started 24-48 hours after MI once patient is stable
what do BB do?
- Reduces:
- Infarct size and complications
- Rate of re-infarction
- Rate of life threatening tachyarrhythmias and thus reduce
mortality - Prevent cardiac enlargement and remodeling
CI for BB
acute CHF, heart block, hypotension
what med is an Antianginal medication to treat chronic, stable angina?
MOA?
Ranexa (ranolazine)
Late sodium channel blocker, decreases intracellular calcium overload
pros vs cons (SE) of ranexa
- Advantages:
- No effect on HR or BP
- Safe to use with ED drugs - Cons:
- May prolong QT so avoid use with other QT prolongation drugs
- Difficult to get insurance to cover / costly
Post MI there is a progressive
increase in ____ activity and ____ activity at the healing infarct site and at other remote sites in the LV
ACE
AT type 1
Use of what meds to reduce fibrosis and remodeling at the scar site and remote to the infarct?
ACEI/ARBs
Can help preserve myocardium in
the setting of an MI.
other medications that are helpful for ACS
- STATINS startin the days immediately following diagnosis of ACS
- WARFARIN - intracardiac thrombus or embolic events
- ALDOSTERONE ANTAGONISTS - LV dysfunction
- CCB
- Not shown to favorably affect outcome in UA
- 3rd-line therapy with continuing sx on nitrates and BBs or those who are not candidates for these drugs
In the presence of nitrates and without accompanying BB, ____ or_____ are preferred since DHP are more likely to cause reflex tachycardia or hypotension
diltiazem
verapamil
Non-DHPs
Fibrinolytic Therapy or “Clot busters” are used for _____ treatment only
STEMI
main complication with fibrinolytic therapy
Major bleeding complications occur in 0.5–5% of pts - most serious is intracranial hemorrhage
After completion of the fibrinolytic infusion, ____ and _____ should be continued until revascularization or for the duration of the hospital
stay (how long is the duration?)
aspirin
anticoagulation
duration of the hospital stay or up to 8 days
which anticoag is most preferred after fibrinolytic infusion
LMWH (enoxaparin) is preferable to unfractionated heparin
Use thrombolysis in the setting of a STEMI if, and only if ?
cardiac cath can’t be done within a few hours of the ischemic event
Goal is fibrinolytic therapy initiation within ___ of arrival in ED
30 min
- Thrombolytic therapy within the first 6-12 h of onset of sx reduces mortality
- greatest benefit occurs if initiated within first 3 h after onset
what is done for failure of reperfusion, generally if pain and ST elevation persist > 90 minutes after bolus in
Salvage angioplasty
All STEMI treated with antithrombotics should be started on prophylactic tx with ___, or antacids and an H2 blocker while hospitalized
PPIs
Reinfarction (indicated by recurrence of pain and ST-segment elevation) can be treated by readministration of a ____ agent or immediate ___ and ____
thrombolytic
angiography and PCI
absolute CI to thrombolytic therapy
- Any prior intracranial hemorrhage
- Known structural cerebral vascular lesion (AVM)
- Known malignant intracranial neoplasm (primary or metastatic)
- Ischemic stroke w/in past 3 mo (except acute ischemic stroke w/in 3 hrs)
- Active internal bleeding (except menses)
- Suspected aortic dissection
- Active bleeding or bleeding diathesis (doesn’t include menses)
- Significant closed head or facial trauma within 3 mo
relative CI to thrombolytic therapy
- Known bleeding diathesis
- Trauma within the past 2-4 wks
- Major surgery within past 3 wks
- Prolonged or traumatic CPR
- Recent internal bleeding
- Noncompressible vascular puncture
- Active diabetic retinopathy
- Pregnancy
- Active PUD
- Current use of anticoagulants
- BP >180/>110
when do PCIs have benefit and don’t have benefit?
- No benefit over taking appropriate meds for those with stable CAD
- benefit is with unstable disease
More effective than thrombolysis for opening occluded arteries
after PCI, pts should receive what?
dual antiplatelet therapy (DAPT) = ASA + P2Y12 receptor blocker for 3-12 months
to reduce the risk of MI or death
- Minimally invasive procedure to
open blocked arteries - Inflation of a balloon within
coronary artery to compress
plaque against walls of artery and open lumen
what is this intervention
PCI - balloon angioplasty
T/F: balloon angioplasty is MC the only intervention done
F - While balloon angioplasty is still done as a part of nearly all PCIs, it is rarely the only procedure performed
how is the stent angioplasty done?
- involves the use of a small, expandable mesh-like tube of thin wire (‘stent’), along with the balloon
- stent is placed around the balloon in a compressed form, and then guided to the site of blockage
- When the balloon is inflated, the stent expands and compresses the plaque
- The balloon is then deflated and removed, leaving behind the stent which acts as a support and helps to keep the artery open
what are the two stent types
- Bare Metal Stents (BMS)
- Drug-Eluting Stents (DES)
which stent:
- Vascular stent without a coating
- Rate of restenosis at one year relatively high (10-20% of pt) d/t development of neointimal hyperplasia
Bare Metal Stents (BMS)
which stent:
- slowly releases a drug to block cell proliferation
- to reduce the relatively high rate of restenosis and subsequent repeat revascularization
- preferred stent used for PCI
Drug-Eluting Stents (DES)
DES require ____ to prevent stent thrombosis so they aren’t appropriate for all pts
a longer period of DAPT
- Use specialized catheters for
mechanical removal of plaque
from the arterial walls - Plaque is either scraped out or
pulverized with the help of tiny
blades - The design and working of these
devices ensures that the arterial
wall remains damage-free
what is this intervention?
atherectomy - “roto-rooter”
what is needed following atherectomy?
DAPT
Procedure in which arteries or veins are harvested from elsewhere in the body and aregrafted to the coronary
arteries to bypass atherosclerotic narrowing and improve blood supply
to the myocardium
Coronary Artery Bypass Grafting (CABG)
CABG is the preferred method for revascularization in patients with the following conditions:
- Left main trunk artery stenosis
- Poor LV function
- 3-vessel CAD or 2-vessel disease that involves proximal LAD
- DM with focal stenosis in +1 vessel
- Concomitant severe valvular disease that necessitates open heart surgery
- Diffuse disease not amenable to treatment with PCI
CABG are usually performed with the heart stopped, necessitating the usage of _______ but more are being done “_____” with the heart still beating
cardiopulmonary bypass
off pump
Non-invasive procedure performed on individuals with angina or HF or cardiomyopathy in order to diminish symptoms of ischemia, improve functional capacity, and quality of life
Enhanced External Counterpulsation
Goal is to reduce cardiac workload and improve blood flow to the heart
been shown to relieve angina and decrease the
degree of ischemia in a cardiac stress test
