IHD part 3 Flashcards
this type of angina is a spasm of the large coronary arteries → decreased coronary blood flow
Prinzmetal / Vasospastic Angina
what causes Prinzmetal / Vasospastic Angina
- spontaneously or induced by exposure to cold, emotional stress, or vasoconstricting meds, such as ergot-derived
- Spasm may occur both in normal and in stenosed coronary arteries
T/F: Myocardial infarction may occur as a result of spasm in the absence of visible obstructive CHD
T
what substance can induce myocardial ischemia and infarction
cocaine
Causes coronary artery vasoconstriction or increases myocardial energy requirements → may contribute to accelerated atherosclerosis and thrombosis
Prinzmetal / Vasospastic Angina Presentation
- Chest pain occurs without usual precipitating factors
- Associated with ST-segment elevation rather than depression
- women under 50
- Characteristically occurs in the early AM, awakening patients from sleep
- Associated with arrhythmias or conduction defects
- No CAD on cardiac catheterization
- May actually be able to induce spasm
- Otherwise, a fairly clinical diagnosis
Patients with chest pain associated with ST-segment elevation should undergo ?
emergent coronary arteriography
- If stenosis is found = aggressive medical therapy or revascularization - this may represent an unstable phase of the dz
- If no significant lesions are seen and spasm is suspected = avoidance of precipitants (smoking and cocaine)
what meds are used for acute spasm symptoms
nitrates
Nitrates and CCB (diltiazem, amlodipine, or nifedipine) recommended for chronic therapy
what meds have exacerbated coronary vasospasm and are typically not used
BB
how to approach acute coronary syndrome
Sx suggestive of ischemia or infarction
- ED Assessment <10 min
- IV, O2, Monitor (VS)
- Consider Fibrinolytics
- Labs: troponins x 3 (baseline and q6 hr x 2), electrolytes, coags, TSH, Lipids, other to r/o
- 12 Lead EKG, CXR
- Targeted H&P - ED general tx
- Morphine
- O2 4L per NC (if <95%)
- NTG (SL)
- ASA 160-325 mg (chewed) - ECG interpretation
- ST elevation or new LBBB = STEMI
- ST depression or T wave inversion = High risk USA / NSTEMI
- Normal or nondiagnostic = Low/Intermediate Risk ACS
Post-MI complications?
- Ischemic
- Mechanical
- Arrhythmic
- Embolic
- Inflammatory
Pt post-MI is now having Angina, reinfarction, infarct extension
what complication are they having?
ischemic
Pt post-MI is now having HF, cardiogenic shock, mitral valve dysfunction, aneurysms, cardiac rupture, cardiac tamponade
what complication are they having?
mechanical
Pt post-MI is now having Atrial or ventricular arrhythmias, sinus or atrioventricular node dysfunction
what complication are they having?
Arrhythmic
Pt post-MI is now having CNS (Stroke) or peripheral embolization
what complication are they having?
Embolic
PT post-MI is now having pericarditis
what complication are they having?
inflammatory
A type of pericarditis that occurs post MI or CABG
Believed to be caused by an immune system mediated inflammatory response following damage to heart tissue or the pericardium
dressler’s syndrome
May occurs between 1 to 12 weeks post-MI
sx - CP and fever
presentation of right ventricular infarction
- Present in 1/3 of pts with inferior wall infarction
- clinically significant in <50% of these - Presents as hypotension with relatively preserved LV function
what complication should be considered whenever pts with inferior infarction present with hypotension, elevated venous pressure, and clear lungs?
right ventricular infarction
is different than LV failure from anterior MI
Hypotension in RV infarction is often made worse by what two meds, which are routinely used in ACS cases
nitrates
morphine
tx for RV infarction
IV normal saline (bolus then continuous infusion) or inotropic agents if necessary
presentation of Ventricular Free-Wall Rupture
- MC in the anterior or lateral wall of LV
- Associated with elderly, poor collateral circulation, ischemic preconditioning, and first MI
- occurs 1-4 days post-MI, MC w/n 24 hrs
- May present as a pericardial effusion post-MI or pulseless electrical activity (PEA)
- Rare post-MI complication occurring a few days following initial cardiac event
- Associated with transmural MI involving the septum
what is this complication
Post-MI Ventricular septal defect (VSD)
Mortality rate is high without surgical intervention
presentation of MV Regurg From Ruptured Papillary Muscle
- Rare complication
- 2-7 days post-MI
- sudden onset decompensated HF
- Mortality high without surgical intervention
a few changes done when recovering from a cardiac event:
- Dietary changes
- Implementation of an exercise regimen
- Addition of appropriate medications
- Increased frequency/number of follow up care visits
Patients must understand that these things can help to lower the risk of having another heart attack, reduce risk of death from heart disease, and often increase their ability to exercise and be active.
Most patients can be discharged when post-MI, depending on need for surgical intervention or development of complications?
3-5 days
Detailed discharge instructions post-MI should include:
- Education on medications, diet, exercise, and smoking cessation counseling
- Referral to a cardiac rehab/secondary prevention program (when appropriate), and scheduling of timely f/u appointment
- given specific instruction on activities (heavy lifting, climbing stairs, yard work, and household activities) that are permissible and those that should be avoided
— resumption of driving, return to work, and sexual activity
f/u for post-MI
- made with Cardiology and PCP
- Low-risk medically treated or revascularized patients should return in 4-6 wks
- Higher risk within 1-2 weeks
- Detailed education should include change in physical activity, new pattern of angina, compliance, modification of risk factors, development of comorbid conditions
Dietary Changes for Post-MI pts
No one diet is perfect
- Generally:
- Limit the intake of saturated and trans fatty acids, free sugars, and salt
- Increase the intake of fruits, vegetables, legumes, nuts, and whole grains - Examples:
- Ornish Diet / Lifestyle
- Mediterranean Diet
- DASH Diet
- Low-fat / low-cholesterol Diet
exercise for post-MI patients
- Most can exercise safely after but intensity and duration of exercise varies
- should be able to increase intensity and duration of exercise with time - use large muscle groups and include aerobic exercise
- at least 150 mins of moderate intensity exercise per week or 75 mins of high intensity exercise per week
- Example exercise prescription
— Frequency 3-5x/wk
— 5- to 10-min warm-up phase
— Conditioning phase of at least 20 minutes
— 5- to 10-minute cool-down phase
Psychosocial Issues with Post-MI
Debility / Decreased exercise tolerance
Activity / Recreation
Depression
Sexual activity
Work / Driving
what are the “cardiac blues”
- Many experience a strong emotional reaction at the time of or soon after an acute cardiac event
- 3x MC in patients after MI > the general population
- Depression after an MI leads to emotional distress and suffering but also associated with increased risk of having another MI or dying over the ensuing months and years
characteristics in depressed persons could account for a poorer prognosis after a heart attack:
- Medication non-compliance
- Continuing to smoke
- Less physical activity
- Increased stress hormone levels
- Increased blood glucose and lipid levels
- Increased tendency of blood to clot
- Increased inflammatory cytokine levels
what factors contribute to decreased libido / less satisfaction regarding sexual activity in post-MI pts?
drug side effects (BB)
depression
fear of triggering another heart attack or dying
Sexual activity is reasonable how long after uncomplicated MI if the pt is w/o cardiac sx during mild-moderate physical activity?
how long for complicated MI?
≥ 1 week
2 to 3 weeks is recommended, as long as asx
For post-MI men with ED, medications can help. One important exception…
nitrostat
this program can improve cardiac function and reduce mortality / development of complications
cardiac rehab
3 aspects of cardiac rehab:
1. Exercise
2. Education to help reduce risk factors
3. Counseling to help patients deal with stress, anxiety, and depression
