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Cardiovascular > IHD part 2 > Flashcards

IHD part 2 Flashcards

1
Q

what is the initial testing acquired for a pt with chest pain?

A

12-lead EKG

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2
Q

indications for 12-lead EKGs

A
  • 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
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3
Q

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?

A

10 minutes

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4
Q

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?

A

serial ECGs to determine ischemic changes
15-30 min intervals during the first 1-2 hrs

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5
Q
  1. Sometimes the earliest presentation of AMI
  2. Rarely seen in clinical practice
    - exist for only 20-30 min after onset of infarct
  3. Must be distinguished from the peaked T waves associated w/ hyperkalemia

what type of EKG finding is this?

A

hyperacute T waves

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6
Q

what are the 3 main EKG findings of ACS?

A
  1. nonspecific or normal EKG - does not exclude ACS
  2. ST segment depression or T wave inversion in 2 or more contiguous leads - sus for NSTEMI or USA
  3. ST segment elevation or new LBBB - sus for STEMI
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7
Q

what is the STEMI evolution

A
  1. ST elevation - mins-hrs
  2. ST elevation, pathological Q wave, inverted T waves, scar formation - 1-2 days
  3. ST flattening, pathological Q waves - 7-10 days
  4. normalization with a persistent Q wave - months
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8
Q

you receive this EKG, you can assume how long have these sx been happening?

A

minutes to hours

ST elevation

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9
Q

you receive this EKG, you can assume how long have these sx been happening?

A

1-2 days

ST elevation, pathological Q wave, inverted T waves, scar formation

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10
Q

you receive this EKG, you can assume how long have these sx been happening?

A

7-10 days
ST flattening
Pathological Q waves

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11
Q

you receive this EKG, you can assume how long have these sx been happening?

A

months

normalization with persistent Q wave

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12
Q

after getting an EKG from a pt with chest pain, what is the next step?

A

obtain cardiac biomarkers/enzymes

  • evaluate myocardial damage - myoglobin, CK-MB, troponins

(this is step 2 for patients without ST-segment elevations)

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13
Q

a contractile protein that normally is not found in serum
only released when myocardial necrosis occurs

A

troponin

Preferred markers for myocardial injury - Highly sensitive and specific for even small amounts of cardiac damage

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14
Q

when can we aspect troponin to be elevated, peaked, and returned to baseline?

A
  • increased - 3-6 hrs
  • peaked - 24-48 h
  • return - 5-14 d
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15
Q

measure troponin levels at ___ and then again at ___

A

presentation
90 mins

then every 6-8 hrs after sx onset x3 until trending down

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16
Q

when can we aspect CK-MB to be elevated, peaked, and returned to baseline?

A
  • increase - 4-8 h after injury
  • peaked - 24 h
  • return - 48-72 h
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17
Q

what are the different types of creatine kinase isoenzymes

A
  1. CK-BB - brain and lungs
  2. CK-MB - heart
  3. CK-MM - msk
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18
Q

CK-MB is positive if it is how much % of total CK?

A

> 5%

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19
Q

false positives for CK-MB

A

exercise
trauma
muscle disease
DM
PE

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20
Q
  • 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?

A

myoglobin

Only real use is in the very early
detection of MI

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21
Q

myoglobin may be detected as early as __ after an AMI

A

2 hours

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22
Q

which cardiac biomarker is not specific - Found in many tissues
(kidney, skeletal muscle, brain, blood cells, lungs, liver)

A

lactate dehydrongenase (LDH)

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23
Q

when does LDH rise, peak, and return back to normal?

A
  • rises - 24-72 h after MI
  • peaks - 3-4 d
  • return - 14 d
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24
Q

pt with chest pain for 90 mins, what cardiac enzyme is best to order?

A

myoglobin

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25
Q

pt with chest pain for 6 hrs, which cardiac enzyme is best to order?

A

troponin

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26
Q

patient with recurrent chest pain 36 hrs aafter having PCI for an MI, which cardiac enzyme is best to order?

A

CKMB > myoglobin

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27
Q

other possible lab findings besides cardiac enzymes

A
  1. leukocytosis
    - several hrs after AMI
    - peaks 2-4 d and returns to normal within 1 week
  2. elevated CRP
    - pts w/o biochemical evidence of myocardial necrosis but with elevated CRP are at increased risk of a subsequent ischemic event
  3. elevated ESR
    - rises above reference range values within 3 d and may stay for weeks
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28
Q

the most commonly used and recommended initial noninvasive procedure for evaluating inducible ischemia in the patient with angina

A

stress test

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29
Q

Stress component can be achieved
two ways:

A

exercise (preferred)
pharm

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30
Q

indications for exercise stress test

A
  • confirm angina dx
  • determine severity of limitation due to angina
  • assess prognosis with known CAD, + pts recovering from MI
  • evaluate response to therapy
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31
Q

limitations of exercise stress test

A
  • More false-positives than true-positives
  • Not a screening tool in asx pts
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32
Q

which stress test is Most useful for pts with low pretest likelihood and normal baseline EKG

A

exercise

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33
Q

which stress test is used for young females with atypical sx

A

exercise

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34
Q

what is HRmax in exercise stress testing?

A

the highest HR someone can achieve without severe problems through exercise stress
value is calculated using pt age

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35
Q

absolute indications for stopping exercise testing

A
  1. drop in SBP >10 from baseline despite increasing workload, when accompanied by other evidence of ischemia/hypoperfusion
  2. moderate-severe angina
  3. increasing nervous system sx (dizzy, ataxia, etc)
  4. poor perfusion (cyanosis, pallor)
  5. technical difficulties in monitoring
  6. subject’s desire to stop
  7. sustained V tach
  8. ST elevations in leads without diagnostic Q-waves
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36
Q

relative indications to stop exercise testing

A
  1. drop in SBP 10 or more from baseline despite increase in workload, in the absence of other evidence of ischemia
  2. ST or QRS changes (excessive ST depression or marked axis shift)
  3. arrhythmias other than sustained VT, including multifocal PVCs, V triplets, SVT heart block, or bradyarrythmias
  4. fatigue, SOB, wheezing, leg cramps, claudication
  5. development of BBB or IVCD that cannot be distinguished from VT
  6. increasing CP
  7. HTN response
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37
Q

absolute CI for exercise testing

A
  1. acute MI within 2 days
  2. high risk unstable angina
  3. uncontrolled arrhythmias causing sx or hemodynamic compromise
  4. severe sx AS
  5. uncontrolled sx HF
  6. acute PE or pulmonary infarction
  7. acute myocarditis or pericarditis
  8. aortic dissection
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38
Q

relative CI to exercise testing

A
  1. left main coronary stenosis
  2. moderate stenotic valvular HD
  3. electrolyte abnormalities
  4. tachy or bradyarrhythmias
  5. hypertrophic CM and other forms of outflow tract obstruction
  6. SBP >220 or DBP >110
  7. Mental or physical impairment leading
    to inability to exercise adequately
  8. High-degree AV block
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39
Q

do NOT perform an EXERCISE stress test IF the EKG is not interpretable due to baseline abnormalities:

A
  • Preexcitation (WPW) syndrome
  • Electronically paced ventricular rhythm
  • > 1 mm of resting ST depression
  • Complete LBBB
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40
Q

indications for Exercise Stress Test with IMAGING Component

A
  1. When resting ECG makes an exercise ECG difficult to interpret
    (eg, LBBB, baseline ST–T changes, low voltage)
  2. For confirmation of the results of the exercise EKG when they are contrary to the clinical impression (eg, a positive test in asx pt)
  3. To localize the region of ischemia
  4. To distinguish ischemic from infarcted myocardium
  5. To assess the completeness of revascularization following bypass
    surgery or coronary angioplasty
  6. As a prognostic indicator in patients with known coronary disease
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41
Q

what can provide relative perfusion data following injection of a radioactive material before a stress test and then after the stress test

A

Exercise Stress Test with Nuclear IMAGING
Resting pictures are compared with post-exercise pictures

Radiotracers and Protocols

  1. Thallium 201
  2. Technetium:
    - Tc-99m Sestamibi (Cardiolite)
    - Tc-99n tetrofosmin
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42
Q

Provides slices of the heart for imaging and is a marked improvement
over planar imaging methods

A

SPECT (single photon emission computed
tomography)

Images from the SPECT enable imaging of wall motion and estimation of EF

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43
Q

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?

A

echo

Looking for regional wall motion
abnormalities or LV dilation in response
to exercise

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44
Q

indications for pharm stress test

A
  • 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

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45
Q

first line for pharm stress agents

A

vasodilators

adenosine, dipyridamole, regadenoson

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46
Q

MOA of vasodilators

A

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

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47
Q

symptoms of vasodiltors

A

SOB
HA
flushing, feeling hot
chest discomfort/pain
dizziness
Nausea
abd discomfort
metallic taste

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48
Q

CI for vasodilators

A
  • 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
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49
Q

2nd-line for pts who can’t exercise and have a contraindication to vasodilator stress

A

Adrenergic Stimulating Agents - dobutamine

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50
Q

what is often used with dobutamine in patients who do not achieve target heart rate

A

Atropine

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51
Q

MOA of Adrenergic Stimulating Agents

A

A synthetic catecholamine that directly stimulates both β1 and β 2 receptors, causing a dose-related ⬆ in HR, BP, and myocardial contractility

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52
Q

sx of Adrenergic Stimulating Agents

A

Tachycardia, increased SBP, PVCs, angina, palpitations, headache, nausea, dyspnea

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53
Q

CI for adrenergic stimulating agents

A
  • 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)
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54
Q

cardiac cath is used to: (3)

A
  • 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)
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55
Q

waht is the definitive diagnostic procedure for evaluating heart function?

A

coronary angiogram/cardiac cath

56
Q

uses for LEFT heart cath with standard coronary angiography

A
  1. Performed to assess the cardiac valves and LV function + presence and severity of CAD
  2. Valvular stenosis and regurgitation can be semi-quantified
  3. The EF and regional wall motion are assessed by contrast left ventriculography
  4. 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
57
Q

uses for right heart cath

A
  1. Allows measurement of RA, RV, PA, and pulmonary capillary wedge pressures
    (PCWP; the latter an indicator of LA pressure), O2 Sat, and CO
  2. Data used to diagnose intracardiac shunts, physiologically significant pericardial disease, and right-sided valve lesions and can distinguish between cardiac and pulmonary disease
  3. Useful in pulmonary HTN to document
    whether the elevated pressures are related to pulmonary disease or to left heart disease
  4. 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
58
Q

how to prep for coronary angiogram

A
  • 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
59
Q

Indications for Coronary Angiogram

A
  • 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
60
Q

risks with coronary angiogram

A
  1. Overall, low mortality risk with procedure
    (0.1%)
  2. Surgical risks include: CVA, coronary artery dissection, retroperitoneal hemorrhage, AKI, femoral pseudoaneurysm
    - Uses IV contrast, so be aware of allergies as
    well as CKD
  3. Performed under moderate sedation
  4. Invasive and costly - not first-line
    unless high pre-test likelihood
  5. Relative CI: severe renal disease,
    anaphylactic allergy to contrast
61
Q

other imaging studies besides an coronary angiogram for IHD

A
  1. CXR
    - Useful for potential pulm causes of chest pain and may show a widened mediastinum in patients with aortic dissection
  2. Chest CT with IV contrast
    - Can help exclude PE and aortic dissection
  3. TTE
    - Can identify a pericardial effusion and tamponade physiology
    - May be useful to detect regional wall motion abnormalities
    - Can identify a proximal aortic dissection
62
Q

factors to consider for CT of coronary arteries

A
  1. Images the heart with contrast medium and multislice technology
  2. Requires both radiation exposure and contrast load
  3. Uses X-ray to produce images of heart and vessels.
  4. HR must be <50
  5. No recovery time needed
  6. If positive –> cardiac cath
63
Q

Overview of Evaluation / Work-up for STABLE ANGINA

A

outpatient work-up

  1. EKG - normal; possible Q-wave, nonspecific ST changes, LVH
  2. CBC; possible trops, CKMB
  3. pretest probability
    - low-intermediate - do noninvasive stress testing
    - high - refer for cath
64
Q

Overview of Evaluation / Work-up for UNSTABLE ANGINA

A

inpatient work-up

  1. EKG - ST depression, T-wave inversions; could be normal
  2. labs - trops (-), +/- CKMB
  3. pretest probability
    - low - no testing needed
    - intermediate - consider stress test with nuclear imaging
    - high - cath
65
Q

Overview of Evaluation / Work-up for NSTEMI

A

inpatient work-up

  1. EKG - ST depression, T-wave inversions; could be normal
  2. labs - trops (+), +/- CKMB
  3. pretest probability
    - low-intermediate- noninvasive stress test
    — normal - consider other causes
    — abnormal - refer for possible cath
    - high - cath
66
Q

Overview of Evaluation / Work-up for STEMI

A

inpatient work-up

  1. EKG- ST elevations in two contagious leads
  2. labs - not needed
  3. diagnostic testing - cath/immediate reperfusion ASAP
67
Q

Unstable Angina / NSTEMI / STEMI Management

A
  1. All should be admitted
  2. All should be placed on telemetry / cardiac monitoring
  3. be placed on strict bedrest
  4. Supplemental oxygen for <95%
  5. Nitrates - first-line therapy for acute coronary syndromes with chest pain
  6. ASA - first-line therapy
68
Q

what should be given regardless of whether fibrinolytic therapy is being considered or pt has been taking ASA

A

ASA
chewable provides more rapid absorption

69
Q

Patients with a definite aspirin allergy
should be treated with ?

A

P2Y12 inhibitor

Clopidogrel (Plavix)
prasugrel (Effient)
ticagrelor (Brilinta)

70
Q

what may be used for pain refractory to NTG and ASA for Unstable Angina / NSTEMI / STEMI Management

A

morphine
Some patients may require sedation with benzo

71
Q

for Unstable Angina / NSTEMI / STEMI Management
BB and ACEI should be started when?

A

first 24 hrs
BB CI: HF, bradycardia, heart block
ARB if ACEI not tolerated

72
Q

Unstable Angina / NSTEMI / STEMI Management

Statins should be started within ?

A

48 hrs
consider adding CCB for persistent ischemia

73
Q

Patients with STEMI who seek medical attention within how many hours of the onset of sx should be treated with immediate re-perfusion therapy?

A

12 hours - Primary PCI or fibrinolytic therapy

74
Q

Primary PCI within what time of first medical contact is the goal and is superior to thrombolysis?

A

90 mins

75
Q

Thrombolysis within ____ of hospital presentation and 6–12 hrs of onset of sx reduces mortality

A

30 mins

76
Q

what are the two reperfusion goals

A

● Door-to-balloon PCI goal of 90 min
● Door-to-needle goal of 30 min

77
Q

MOA of nitrates

A

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
78
Q

SE of nitrates

A

MC reflex tachycardia, but can cause paradoxical bradycardia

79
Q

First-line therapy for pt with acute coronary syndromes presenting with CP?
any exceptions?

A

nitrates
EXCEPT in patients presenting with IWMI

80
Q

dosing routes of nitrates

A

sublingual, oral agents, NTG, ointment, spray, IV

81
Q

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?

A

IV NTG
Continuous BP monitoring is required
with IV NTG

82
Q

SE of IV NTG

A

HA MC– can be SEVERE
Postural hypotension
Tolerance

83
Q

what are the two longer acting nitrates that are used for daily angina control?

A
  1. isosorbide dinitrate
    - half-life: 1 hr
    - duration: 3-6 hrs
  2. isosorbide-5-mononitrate
    - onset: 60 min
    - duration: 8 hrs
84
Q

how does tolerance develop with nitrates?

A
  1. Frequently repeated or continuous exposure to high doses
  2. Prolonged tx with nitrates may not
    only induce a loss of response to nitrates, but also decrease angina threshold in the interval
85
Q

how do you prevent tolerance of nitrates?

A
  1. High doses should be avoided and therapy interrupted for 8–12 h daily
    - Treatment “holiday”
86
Q

what is a major CI with nitrates?

A

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)
87
Q

MOA/purpose of morphine

A
  1. Reduce pain/anxiety
  2. Decreases
    - Sympathetic tone
    - SVR
    - O2 demand

reducing afterload

88
Q

caution with morphine

A

caution in hypotension, hypovolemia, respiratory depression

89
Q

SE of morphine

A

bradycardia, diaphoresis, nausea, constipation, drowsiness, dizziness, confusion

90
Q

MOA of ASA

A

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
91
Q

caution with ASA

A

caution in active PUD, hypersensitivity, bleeding disorders

92
Q

SE of ASA

A

GI (ulcers, dyspepsia, hemorrhage), increased bleeding risk

93
Q
  • Irreversible inhibition of platelet aggregation
  • Used in support of cath / PCI or if unable to take ASA

what is this med?

A

P2Y 12 Inhibitors

  • Clopidogrel (Plavix)
  • Prasugrel* (Effient)
  • Ticagrelor* (Brilinta)

3-12 mo duration depending on scenario

94
Q

what anti-platelet meds cause the delay of elective CABG? For how long and why?

A

postpone CABG

  • 5 days after last clopidogrel or ticagrelor
  • 7 days after last prasugrel

due to risk of bleeding

95
Q
  1. Inhibition of platelet aggregation at final common pathway
  2. In support of PCI intervention as early as possible prior to PCI
    - Not required for most patients

what med is this?

A

Glycoprotein IIb / IIIa Inhibitors

  • Tirofiban (Aggrastat)
  • Eptifibatide (Integrilin)
  • Abciximab(Reopro)
96
Q

Glycoprotein IIb / IIIa Inhibitors may be considered in these high risk patients:

A
  1. Ongoing ischemia despite ASA and P2Y12 inhibitor
  2. Large thrombus found during angiography, esp if have not received prasugrel or ticagrelor
  3. To stabilize pts who need urgent CABG in place of P2Y12 until surgical indications defined
97
Q
  • Adjunct to surgical revascularization and thrombolytic / PCI reperfusion
  • Used in combo with ASA and/or other platelet inhibitors

what are these meds?

A

anticoag

  • indirect thrombin inhibitors - UFH, LMWH
  • direct thrombin inhibitors - bivalirudin
98
Q

which anticoag is only used in the cath lab?

A

bivalirudin

99
Q

T/F: changing from indirect thrombin inhibitor to a direct thrombin inhibitor is safe and recommended

A

F - Changing from one to the other not recommended

100
Q

what is shown to be somewhat more effective than UFH in preventing recurrent ischemic events in the setting of acute coronary syndromes?

A

LMWH - enoxaparin

101
Q

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?

A

bivalirudin - direct thrombin inhibitor

102
Q

BB reduces mortality risk by how much and should be started when after a MI?

A
  1. 14% reduction in mortality risk at 7 days and 23% long
    term mortality reduction in STEMI
  2. Should be started 24-48 hours after MI once patient is stable
103
Q

what do BB do?

A
  1. Reduces:
    - Infarct size and complications
    - Rate of re-infarction
    - Rate of life threatening tachyarrhythmias and thus reduce
    mortality
  2. Prevent cardiac enlargement and remodeling
103
Q

CI for BB

A

acute CHF, heart block, hypotension

104
Q

what med is an Antianginal medication to treat chronic, stable angina?
MOA?

A

Ranexa (ranolazine)

Late sodium channel blocker, decreases intracellular calcium overload

105
Q

pros vs cons (SE) of ranexa

A
  1. Advantages:
    - No effect on HR or BP
    - Safe to use with ED drugs
  2. Cons:
    - May prolong QT so avoid use with other QT prolongation drugs
    - Difficult to get insurance to cover / costly
106
Q

Post MI there is a progressive
increase in ____ activity and ____ activity at the healing infarct site and at other remote sites in the LV

A

ACE
AT type 1

107
Q

Use of what meds to reduce fibrosis and remodeling at the scar site and remote to the infarct?

A

ACEI/ARBs

Can help preserve myocardium in
the setting of an MI.

108
Q

other medications that are helpful for ACS

A
  1. STATINS startin the days immediately following diagnosis of ACS
  2. WARFARIN - intracardiac thrombus or embolic events
  3. ALDOSTERONE ANTAGONISTS - LV dysfunction
  4. 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
109
Q

In the presence of nitrates and without accompanying BB, ____ or_____ are preferred since DHP are more likely to cause reflex tachycardia or hypotension

A

diltiazem
verapamil

Non-DHPs

110
Q

Fibrinolytic Therapy or “Clot busters” are used for _____ treatment only

A

STEMI

111
Q

main complication with fibrinolytic therapy

A

Major bleeding complications occur in 0.5–5% of pts - most serious is intracranial hemorrhage

112
Q

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?)

A

aspirin
anticoagulation
duration of the hospital stay or up to 8 days

113
Q

which anticoag is most preferred after fibrinolytic infusion

A

LMWH (enoxaparin) is preferable to unfractionated heparin

114
Q

Use thrombolysis in the setting of a STEMI if, and only if ?

A

cardiac cath can’t be done within a few hours of the ischemic event

115
Q

Goal is fibrinolytic therapy initiation within ___ of arrival in ED

A

30 min

  1. 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
116
Q

what is done for failure of reperfusion, generally if pain and ST elevation persist > 90 minutes after bolus in

A

Salvage angioplasty

117
Q

All STEMI treated with antithrombotics should be started on prophylactic tx with ___, or antacids and an H2 blocker while hospitalized

A

PPIs

118
Q

Reinfarction (indicated by recurrence of pain and ST-segment elevation) can be treated by readministration of a ____ agent or immediate ___ and ____

A

thrombolytic
angiography and PCI

119
Q

absolute CI to thrombolytic therapy

A
  1. Any prior intracranial hemorrhage
  2. Known structural cerebral vascular lesion (AVM)
  3. Known malignant intracranial neoplasm (primary or metastatic)
  4. Ischemic stroke w/in past 3 mo (except acute ischemic stroke w/in 3 hrs)
  5. Active internal bleeding (except menses)
  6. Suspected aortic dissection
  7. Active bleeding or bleeding diathesis (doesn’t include menses)
  8. Significant closed head or facial trauma within 3 mo
120
Q

relative CI to thrombolytic therapy

A
  1. Known bleeding diathesis
  2. Trauma within the past 2-4 wks
  3. Major surgery within past 3 wks
  4. Prolonged or traumatic CPR
  5. Recent internal bleeding
  6. Noncompressible vascular puncture
  7. Active diabetic retinopathy
  8. Pregnancy
  9. Active PUD
  10. Current use of anticoagulants
  11. BP >180/>110
121
Q

when do PCIs have benefit and don’t have benefit?

A
  • No benefit over taking appropriate meds for those with stable CAD
  • benefit is with unstable disease

More effective than thrombolysis for opening occluded arteries

122
Q

after PCI, pts should receive what?

A

dual antiplatelet therapy (DAPT) = ASA + P2Y12 receptor blocker for 3-12 months

to reduce the risk of MI or death

123
Q
  • 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
A

PCI - balloon angioplasty

124
Q

T/F: balloon angioplasty is MC the only intervention done

A

F - While balloon angioplasty is still done as a part of nearly all PCIs, it is rarely the only procedure performed

125
Q

how is the stent angioplasty done?

A
  • 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
126
Q

what are the two stent types

A
  1. Bare Metal Stents (BMS)
  2. Drug-Eluting Stents (DES)
127
Q

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

A

Bare Metal Stents (BMS)

128
Q

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

A

Drug-Eluting Stents (DES)

129
Q

DES require ____ to prevent stent thrombosis so they aren’t appropriate for all pts

A

a longer period of DAPT

130
Q
  • 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?

A

atherectomy - “roto-rooter”

131
Q

what is needed following atherectomy?

A

DAPT

132
Q

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

A

Coronary Artery Bypass Grafting (CABG)

133
Q

CABG is the preferred method for revascularization in patients with the following conditions:

A
  • 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
134
Q

CABG are usually performed with the heart stopped, necessitating the usage of _______ but more are being done “_____” with the heart still beating

A

cardiopulmonary bypass
off pump

135
Q

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

A

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

Cardiovascular (24 decks)

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