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Health Assessment (2) > **in progress** Ischemic Heart Disease (Exam IV) > Flashcards

**in progress** Ischemic Heart Disease (Exam IV) Flashcards

1
Q

Risk Factors for Ischemic Heart Disease (IHD)

A
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2
Q

What percentage of patients will have a risk factor for ischemic heart disease?

A

30%

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3
Q

What are the manifestations of IHD?

A
  • Angina Pectoris
  • Acute MI
  • Sudden Death
  • Dysrhythmias
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4
Q

What is Angina Pectoris

A

Chest pain d/t imbalance between coronary blood flow and myocardial oxygen consumption.

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5
Q

Stable angina typically develops in the setting of partial occlusion or significant (>______%) chronic narrowing of a segment of the coronary artery.

A
  • > 70%
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6
Q

Angina pectoris reflects the intracardiac release of what two substances during ischemia?

A
  • Adenosine
  • Bradykinin
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7
Q

What are the CV effects of adenosine and bradykinin release?

A
  • Stimulate Cardiac nociceptors whose afferent neurons converge with the T1 to T5 sympathetic ganglia resulting in chest pain.
  • Slow AV conduction
  • Decrease Contractility
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8
Q

How would a patient describe angina pectoris?

A
  • Retrosternal chest discomfort
  • Elephant sitting on their chest
  • Chest discomfort radiates to left shoulder/jaw
  • SOB and dyspnea
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9
Q

Angina Pectoris affect which dermatomes?

A
  • C8 to T4
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10
Q

What factors can induce angina pectoralis?

A
  • Physical exertion
  • Emotional tension
  • Cold weather
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11
Q

Differentiate Chronic vs Unstable Angina

A

Chronic stable: Chest pain that does NOT change in frequency or severity in a 2-month period

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

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12
Q

During myocardial ischemia, the standard 12-lead ECG demonstrates ST-segment _______ that coincides with the anginal chest pain. This may be accompanied by transient symmetric _________ inversion.

A

During myocardial ischemia, the standard 12-lead ECG demonstrates ST-segment depression that coincides with the anginal chest pain. This may be accompanied by transient symmetric T-wave inversion.

indicative of subendocardial tissue damage

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13
Q

What does the Exercise Stress Test evaluate on the EKG?

A
  • Degree of ST-segment depression

The greater the degree of ST-segment depression, the greater the likelihood of significant coronary artery disease.

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14
Q

What does nuclear stress imaging assess?

A
  • Assesses coronary perfusion (greater sensitivity than other tests)
  • Tracer activity in perfused vs ischemic areas
  • 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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15
Q

What drugs can be administered to produce a rapid HR to create cardiac stress?

A
  • Atropine
  • Dobutamine
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16
Q

What is the chemical tracer used to analyze cardiac blood flow?

A
  • Thallium
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17
Q

These drugs dilate normal coronary arteries but evoke no change in the diameter of atherosclerotic coronary arteries.

A
  • Adenosine
  • Dipyridamole
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18
Q

What does an ECHO assess?

A
  • Wall motion abnormalities
  • Valvular functions
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19
Q

Purpose of coronary angiography.

A
  • Determines the location of occlusive disease
  • Diagnose Prinzmetal (variant/spasm) angina
  • Assess results of angioplasty/stenting
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20
Q

Coronary angiography does NOT measure what?

A
  • Stability of the plaque.
  • Does not tell you when the plaque will rupture.
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21
Q

Treatment for angina pectoralis?

A
  • Cessation of smoking
  • Ideal body weight
  • Low-fat, low-cholesterol diet (Statins)
  • Regular aerobic exercise
  • Treatment of hypertension
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22
Q

Patients are placed on statins when LDL levels are above ________ mg/dL.

A

160 mg/dL

Providers would like a 50% reduction in LDL during statin therapy.

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23
Q

Drug therapy for angina pectoralis

A
  • Antiplatelet drugs
  • Nitrates
  • β-blockers
  • Ranolazine
  • CCB
  • ACE inhibitors
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24
Q

Aspirin inhibits the enzyme _________. This results in the inhibition of ________, which plays an important role in platelet aggregation.

A

Aspirin inhibits the enzyme COX-1. This results in the inhibition of thromboxane A2, which plays an important role in platelet aggregation.

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25
Are the effects of aspirin reversible? What is the dose for aspirin?
* No, COX-1 inhibition will last for the duration of platelet lifespan (7 days) * 75-325 mg/day
26
How do platelet glycoprotein IIb/IIIa receptor antagonists work? What are examples of these antiplatelet drugs?
* Inhibit platelet activation, adhesion, and aggregation * Abciximab, Eptifibatide, Tirofiban
27
Name a Thienopyridines (P2Y12 inhibitors) drug.
* Clopidogrel (Plavix) * Prasugrel
28
Is Clopidogrel reversible?
No, Clopidogrel is irreversible.
29
MOA of Clopidogrel
Clopidogrel inhibits the ADP receptor P2Y12 and inhibits platelet aggregation in response to ADP release from activated platelets.
30
7 days after cessation of clopidogrel, ____% of platelets will have recovered normal aggregation function.
* 80%
31
Clopidogrel is a _______ that is metabolized into an active compound in the liver.
*prodrug
32
________ % of patients taking clopidogrel demonstrate resistance or hyperresponsiveness.
*10-20%
33
_________ can affect the enzyme that metabolizes clopidogrel to its active compound and thereby can reduce the effectiveness of clopidogrel.
* PPI
34
What drug has a similar mechanism action as clopidogrel, more predictable pharmacokinetics, and a higher risk of bleeding?
* Prasugrel
35
How does Nitrate treat myocardial ischemia?
* Decrease the frequency, duration, and severity of angina pectoris. * Increase the amount of exercise required to produce ST-segment depression. * Dilate Coronary Arteries and Collaterals * Decrease peripheral vascular resistance * Decrease Preload * Anti-thrombotic effects
36
Nitrates are contracted indicated with what heart conditions?
* Severe aortic stenosis * Hypertrophic cardiomyopathy *Decrease in preload.*
37
Nitrates are synergistic with what drugs?
* β-Blockers and CCB
38
The only drug to prolong life in CAD patients and decrease the risk of death and reinfarction in MI pts.
β blockers
39
Effects of β1 antagonist (atenolol, metoprolol, acebutolol, bisoprolol).
* ↓ HR * ↑ Diastolic Time, ↑ Coronary Perfusion * ↓ Myocardial contractility * ↓ Myocardial O2 demand
40
Effects of β2 antagonist (propranolol, nadolol).
* ↑ Bronchospasm *Do not give this drug to asthma patients.*
41
__________ are uniquely effective in decreasing the frequency and severity of angina pectoris due to coronary artery spasm (Prinzmetal or variant angina).
* CCB
42
Effects of CCB
* Dilation of coronary artery * ↓ Vascular smooth muscle tone * ↓ Contractility * ↓ O2 Consumption * ↓ Systemic BP
43
CCB is not as effective as β-blockers in what aspect?
* β-blockers are more effective in decreasing the incidence of MI.
44
What does ACE inhibitors treat?
HTN, HF and is cardioprotective
45
What does ANG II increase?
myocardial hypertrophy interstitial myocardial fibrosis coronary vasoconstriction inflammatory responses
46
What drug is used for coronary plaque stabilization?
Statins
47
What do statins decrease?
* Lipid oxidation * Inflammation * Matrix metalloproteinase * Cell death
48
Revascularization
* This will be an option for those who have failed medical therapy
49
Revascularization percentages
50
CABG vs PCI
51
What is ACS? What is it caused by?
Acute or worsening imbalance of myocardial oxygen supply to demand Atheromatous plaque Coagulation cascade Thrombin generation Arterial occlusion
52
ACS flow chart
53
STEMI
54
Pathway of Thrombogenesis (will expand on this later)
Collagen, ADP, epinephrine, serotonin Thromboxane A2 Glycoprotein IIb/IIIa receptors Fibrin deposit
55
Criteria for meeting the dx for MI
56
Dx studies for ACS
Troponin Imaging
57
Troponins
58
Imaging
59
Drug therapy for ACS
* MONA * P2Y12 inhibitors (clopidogrel, prasugrel, or ticagrelor) * Platelet glycoprotein IIb/IIIa inhibitors * Unfractionated heparin * β blockers * RAAS
60
What drugs can be used for Reperfusion Therapy
Tissue plasminogen activator (tPA), streptokinase, reteplase, or tenecteplase can restore normal antegrade blood flow.
61
Indications for PCI
* Contraindication to thrombolytic therapy * Severe HF and/or pulmonary edema * Symptoms present for 2 - 3 hours *Mature clot
62
Indication for CABG
* Bad coronary anatomy * Failed angioplasty * Evidence of infarction-related ventricular septal rupture or mitral regurgitation
63
Causes Unstable Angina/NSTEMI
* Rupture or erosion of a coronary plaque * Dynamic obstruction due to vasoconstriction  * Worsening coronary luminal narrowing * Inflammation * Myocardial ischemia
64
Presentation of Unstable Angina/NSTEMI
* Angina at rest, lasting >10 minutes * Chronic angina pectoris … more frequent and more easily provoked * New-onset angina… severe, prolonged, or disabling
65
Treatment of 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 * Thrombolytic therapy NOT indicated
66
What is a PCI?
* Alternative to CABG * Balloon angioplasty * bare-metal stent * drug eluding stent * Destruction of endothelium
67
Risk of PCI
* Thrombosis * Bleeding
68
What is Dual Antiplatelet Therapy (DAPT)
ASA with P2Y12 inhibitor
69
What is DAPT used for?
* Balloon angioplasty without stenting * Bare-metal stent * Drug-eluting stent
70
Time to heal the endothelium layer
71
When do you want to d/c DAPT to reduce the risk of
5 days - clopidogrel or ticagrelor 7 days – prasugrel Continue ASA if possible
72
Time for Re-endothelialization Ballon stent- 2 weeks Bare metal stent - 6 weeks Drug-eluding stent 1 year to reendothelialize
73
Time to wait for Elective Surgery for the following procedures: Angioplasty w/o stent: Bare-metal stent placement: Coronary artery bypass grafting: Drug-eluting stent placement:
74
Surgical Interval Slide
75
Pre-operative Assessment for Cardiac Procedures
* Determine the presence of risk factors * Evaluate METs * Co-existing non-cardiac disease * Physical Exam * Specialize testing (EKG)
76
Meds to continue before surgery
* β blocker * α2-agonist * control hyperglycemia (<180 mg/dL)
77
Meds to d/c before surgery
* ACE inhibitor (d/c 24 hours before surgery) * Statins * DAPT (except aspirin)
78
What is given to a patient experiencing bradycardia in the OR?
Glycopyrrolate. Atropine is not used d/t the increased risk of dysrhythmias.
79
Risk Stratification
* Stable condition undergoing elective major noncardiac surgery * Increased probability of peri-op cardiac complications * Presence of clinical risk factors and the risk of the surgery
80
Revised Cardiac Risk Index (RCRI)
81
Functional Capacity assesses what? What does 1 MET equal? What do you want a patient's MET to be above?
Assessment of cardiopulmonary fitness Poor functional capacity = increased peri-operative risk Measured in METs (metabolic equivalent of task) Rate of energy consumption at rest 1 MET = 3.5 mL/kg/min > 4 METs
82
What is considered an emergency surgery?
Emergency – life or limb would be threatened if the 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
83
Urgent Surgery
84
Urgent Surgery
Urgent – life or limb would be threatened if the surgery did not proceed within 6 to 24 hours.
85
Time Surgery
Time-sensitive – delays exceeding 1 to 6 weeks would adversely affect patient outcomes
86
Active Cardiac Conditions
* Unstable coronary syndromes * Unstable or severe angina * Decompensated HF * Severe valvular heart disease * Significant dysrhythmias *Age
87
Steps to take if surgery is canceled d/t active cardiac conditions.
* Revascularization by cardiac surgery * Revascularization by PCI * Optimal medical management
88
Anesthetic Goals
* Prevent myocardial ischemia * Monitor for ischemia * Treat ischemia * Maintain BP and HR within the normal awake baseline
89
Anesthetic Preventions
* Persistent tachycardia * Systolic HTN * SNS stimulation * Arterial hypoxemia * Hypotension
90
DL should be less than ______ seconds.
15 seconds
91
Stable angina typically develops in the setting of partial occlusion or significant (>______%) chronic narrowing of a segment of the coronary artery.
* >70%

Health Assessment (2) (22 decks)

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