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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
Q

Are the effects of aspirin reversible?

What is the dose for aspirin?

A
  • No, COX-1 inhibition will last for the duration of platelet lifespan (7 days)
  • 75-325 mg/day
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26
Q

How do platelet glycoprotein IIb/IIIa receptor antagonists work?

What are examples of these antiplatelet drugs?

A
  • Inhibit platelet activation, adhesion, and aggregation
  • Abciximab, Eptifibatide, Tirofiban
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27
Q

Name a Thienopyridines (P2Y12inhibitors) drug.

A
  • Clopidogrel (Plavix)
  • Prasugrel
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28
Q

Is Clopidogrel reversible?

A

No, Clopidogrel is irreversible.

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29
Q

MOA of Clopidogrel

A

Clopidogrel inhibits the ADP receptor P2Y12 and inhibits platelet aggregation in response to ADP release
from activated platelets.

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30
Q

7 days after cessation of clopidogrel, ____% of platelets will have recovered normal aggregation function.

A
  • 80%
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31
Q

Clopidogrel is a _______ that is metabolized into an active compound in the liver.

A

*prodrug

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32
Q

________ % of patients taking clopidogrel demonstrate resistance or hyperresponsiveness.

A

*10-20%

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33
Q

_________ can affect the enzyme that metabolizes clopidogrel to its active compound and thereby can reduce the effectiveness of clopidogrel.

A
  • PPI
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34
Q

What drug has a similar mechanism action as clopidogrel, more predictable pharmacokinetics, and a higher risk of bleeding?

A
  • Prasugrel
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35
Q

How does Nitrate treat myocardial ischemia?

A
  • 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
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36
Q

Nitrates are contracted indicated with what heart conditions?

A
  • Severe aortic stenosis
  • Hypertrophic cardiomyopathy

Decrease in preload.

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37
Q

Nitrates are synergistic with what drugs?

A
  • β-Blockers and CCB
38
Q

The only drug to prolong life in CAD patients and decrease the risk of death and reinfarction in MI pts.

A

β blockers

39
Q

Effects of β1 antagonist (atenolol, metoprolol, acebutolol, bisoprolol).

A
  • ↓ HR
  • ↑ Diastolic Time, ↑ Coronary Perfusion
  • ↓ Myocardial contractility
  • ↓ Myocardial O2 demand
40
Q

Effects of β2 antagonist (propranolol, nadolol).

A
  • ↑ Bronchospasm

Do not give this drug to asthma patients.

41
Q

__________ are uniquely effective in decreasing the frequency and severity of angina pectoris due to coronary artery spasm (Prinzmetal or variant angina).

A
  • CCB
42
Q

Effects of CCB

A
  • Dilation of coronary artery
  • ↓ Vascular smooth muscle tone
  • ↓ Contractility
  • ↓ O2 Consumption
  • ↓ Systemic BP
43
Q

CCB is not as effective as β-blockers in what aspect?

A
  • β-blockers are more effective in decreasing the incidence of MI.
44
Q

What does ACE inhibitors treat?

A

HTN, HF and is cardioprotective

45
Q

What does ANG II increase?

A

myocardial hypertrophy
interstitial myocardial fibrosis
coronary vasoconstriction
inflammatory responses

46
Q

What drug is used for coronary plaque stabilization?

A

Statins

47
Q

What do statins decrease?

A
  • Lipid oxidation
  • Inflammation
  • Matrix metalloproteinase
  • Cell death
48
Q

Revascularization

A
  • This will be an option for those who have failed medical therapy
49
Q

Revascularization percentages

A
50
Q

CABG vs PCI

A
51
Q

What is ACS?

What is it caused by?

A

Acute or worsening imbalance of myocardial oxygen supply to demand

Atheromatous plaque
Coagulation cascade
Thrombin generation
Arterial occlusion

52
Q

ACS flow chart

A
53
Q

STEMI

A
54
Q

Pathway of Thrombogenesis (will expand on this later)

A

Collagen, ADP, epinephrine, serotonin
Thromboxane A2
Glycoprotein IIb/IIIa receptors
Fibrin deposit

55
Q

Criteria for meeting the dx for MI

A
56
Q

Dx studies for ACS

A

Troponin
Imaging

57
Q

Troponins

A
58
Q

Imaging

A
59
Q

Drug therapy for ACS

A
  • MONA
  • P2Y12inhibitors (clopidogrel, prasugrel, or ticagrelor)
  • Platelet glycoprotein IIb/IIIa inhibitors
  • Unfractionated heparin
  • βblockers
  • RAAS
60
Q

What drugs can be used for Reperfusion Therapy

A

Tissue plasminogen activator (tPA), streptokinase, reteplase, or tenecteplase can restore normal antegrade blood flow.

61
Q

Indications for PCI

A
  • Contraindication to thrombolytic therapy
  • Severe HF and/or pulmonary edema
  • Symptoms present for 2 - 3 hours
    *Mature clot
62
Q

Indication for CABG

A
  • Bad coronary anatomy
  • Failed angioplasty
  • Evidence of infarction-related ventricular septal rupture or mitral regurgitation
63
Q

Causes Unstable Angina/NSTEMI

A
  • Rupture or erosion of a coronary plaque
  • Dynamic obstruction due tovasoconstriction
  • Worsening coronary luminal narrowing
  • Inflammation
  • Myocardial ischemia
64
Q

Presentation of Unstable Angina/NSTEMI

A
  • Angina at rest, lasting >10 minutes
  • Chronic angina pectoris … more frequent and more easily provoked
  • New-onset angina… severe,prolonged, or disabling
65
Q

Treatment of Unstable Angina/NSTEMI

A
  • Bed rest, oxygen, analgesia, andβ-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
Q

What is a PCI?

A
  • Alternative to CABG
  • Balloon angioplasty
  • bare-metal stent
  • drug eluding stent
  • Destruction of endothelium
67
Q

Risk of PCI

A
  • Thrombosis
  • Bleeding
68
Q

What is Dual Antiplatelet Therapy (DAPT)

A

ASA with P2Y12inhibitor

69
Q

What is DAPT used for?

A
  • Balloon angioplasty without stenting
  • Bare-metal stent
  • Drug-eluting stent
70
Q

Time to heal the endothelium layer

A
71
Q

When do you want to d/c DAPT to reduce the risk of

A

5 days - clopidogrel or ticagrelor
7 days – prasugrel
Continue ASA if possible

72
Q

Time for Re-endothelialization
Ballon stent- 2 weeks
Bare metal stent - 6 weeks
Drug-eluding stent 1 year to reendothelialize

A
73
Q

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:

A
74
Q

Surgical Interval Slide

A
75
Q

Pre-operative Assessment for Cardiac Procedures

A
  • Determine the presence of risk factors
  • Evaluate METs
  • Co-existing non-cardiac disease
  • Physical Exam
  • Specialize testing (EKG)
76
Q

Meds to continue before surgery

A
  • β blocker
  • α2-agonist
  • control hyperglycemia (<180 mg/dL)
77
Q

Meds to d/c before surgery

A
  • ACE inhibitor (d/c 24 hours before surgery)
  • Statins
  • DAPT (except aspirin)
78
Q

What is given to a patient experiencing bradycardia in the OR?

A

Glycopyrrolate.

Atropine is not used d/t the increased risk of dysrhythmias.

79
Q

Risk Stratification

A
  • 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
Q

Revised Cardiac Risk Index (RCRI)

A
81
Q

Functional Capacity assesses what?

What does 1 MET equal?

What do you want a patient’s MET to be above?

A

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
Q

What is considered an emergency surgery?

A

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
Q

Urgent Surgery

A
84
Q

Urgent Surgery

A

Urgent – life or limb would be threatened if the surgery did not proceed within 6 to 24 hours.

85
Q

Time Surgery

A

Time-sensitive – delays exceeding 1 to 6 weeks would adversely affect patient outcomes

86
Q

Active Cardiac Conditions

A
  • Unstable coronary syndromes
  • Unstable or severe angina
  • Decompensated HF
  • Severe valvular heart disease
  • Significant dysrhythmias
    *Age
87
Q

Steps to take if surgery is canceled d/t active cardiac conditions.

A
  • Revascularization by cardiac surgery
  • Revascularization by PCI
  • Optimal medical management
88
Q

Anesthetic Goals

A
  • Prevent myocardial ischemia
  • Monitor for ischemia
  • Treat ischemia
  • Maintain BP and HR within the normal awake baseline
89
Q

Anesthetic Preventions

A
  • Persistent tachycardia
  • Systolic HTN
  • SNS stimulation
  • Arterial hypoxemia
  • Hypotension
90
Q

DL should be less than ______ seconds.

A

15 seconds

91
Q

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

A
  • > 70%

Health Assessment (2) (22 decks)

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