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Clin Med Exam 1(Lauren) > Ischemia > Flashcards

Ischemia Flashcards

1
Q

What is ischemic heart disease (IHD)?

A

Inadequate supply of blood/oxygen to a portion of the myocardium

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2
Q

What is CAD?

A

Coronary arteries are fucked up (atherosclerosis)

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3
Q

What is CHD?

A

Things caused by CAD:
Angina pectoris

MI

Death etc

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4
Q

What is CVD?

A

All of your arteries are fucked up (atherosclerosis)

vs CAD where just your coronary arteries are bad

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5
Q

Is it common for patients to drop dead from CHD when they didn’t even know they had it?

A

Yes in 15% of CHD patients, Sudden Cardaic Death is the first event they have

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6
Q

Nitric oxide is produced by _______

A

Endothelial cells

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7
Q

If your endothelial cells get damaged, and they can’t produce nitric oxide, what can happen?

A

Atherosclerosis

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8
Q

In addition to vasodilation, what other 2 things does nitric oxide do?

A
  • inhibits plaque formation

- has anti-inflammatory properties

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9
Q

True or False:

HDL plays an atheroprotective role, due to it’s anti-inflammatory and antioxidant properties?

A

True

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10
Q

What is the first step of athersclerosis?

A

Endothelial dysfunction

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11
Q

What populations have atypical ischemic heart disease symptoms?

A

Women

Elderly

Diabetic

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12
Q

Atherosclerotic plaques usually form in sites of:

A

Increased blood turbulence

Branching

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13
Q

The main coronary arteries are located in the _________

A

Epicardium

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14
Q

What is another term for angina pectoris?

A

Stable angina

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15
Q

Transient~ ischemia may result in _________

A

Angina pectoris aka stable angina

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16
Q

Prolonged~ ischemia may result in _________

A

MI

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17
Q

Is stable angina considered part of Acute Coronary Syndrome?

A

No

ACS is unstable angina and MI (both STEMI and NSTEMI)

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18
Q

How long does stable angina pain last?

A

2-10 minutes

Typically a crescendo-decrescendo

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19
Q

What makes stable angina pain go away?

A

Rest

Nitro

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20
Q

When someone has stable angina pain, how will they describe the pain?

A

Heaviness

Pressure

Squeezing/tightness

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21
Q

Will people with stable angina pain demonstrate Levine’s sign?

A

Yes

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22
Q

Can stable angina pain radiate beyond the sub sternal region?

A

Yes.

Shoulders, arms, neck, jaw, teeth, epigastrum, mid back

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23
Q

What are some atypical presentations of angina, and which one is very common in women?

A

Shortness of breath- common in women

Nausea

Fatigue

Faintness

(All of these more common in elderly, diabetic and women)

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24
Q

If your female patient says she feels “breathless,” should you be concerned for angina?

A

Yes, dyspnea is a common presentation in women

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25
Q

Are sharp stabs of chest pain, or a prolonged dull ache likely to be ischemic in nature?

A

No, but you cant rule out based on this

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26
Q

What is stable angina?

A

Exertional related chest/arm discomfort that resolves with rest or nitro and usually doesnt last more than 5-10 minutes***

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27
Q

Will you see ECG changes in a patient with stable angina?

A

You might see some ST and T wave changes during their episodes, but they’ll go away when the patient’s pain goes away

(Basically, they ARE having ischemia, but its not lasting long enough to cause damage that would last on an EKG)

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28
Q

Why do we do exercise stress testing?

A

We are attempting to reproduce cardiac ischemia through defined exertion

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29
Q

What is the Bruce protocol?

A

On the treadmill, you increase speed and incline every 3 MINUTES*** until their heart rate is at 85% of the max HR for their age

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30
Q

What things are we looking for when we get the patient on the treadmill?>

A

ECG Changes

Decreased heart perfusion seen on nuclear imaging

Drop in systolic BP more than 10mm

Any other symptoms 🤷🏻‍♂️

(this was in red)

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31
Q

In what situations would we skip the treadmill and go right to pharmacologic stres testinf?

A
  • pt unable to exercise (old, legs don’t work, breathing problems, neurological deficits)
  • can’t get to target HR through exercise becasue they’re on beta blockers
  • high likelihood of false-positive since they have poor exercise tolerance
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32
Q

What will we see on a stress echocardiogram in a patient with ischemia?

A

Wall motion abnormality with stress/exercise

**in red

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33
Q

What are you looking for on nuclear medicine imaging before and after the patient’s heart is stressed?

A

Perfusion defect (when you compare resting to stressed)

***in red

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34
Q

What is the Gold Standard for diagnosing CAD?

A

Coronary angiography **

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35
Q

Will coronary angiography show the presence of vulnerable plaques?

A

No

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36
Q

Is coronary angiography without risk?

A

No, there’s definitely risks…..

Bleeding, arrhythmias, vessel injury, emboli and renal failure (from the contrast dye)

37
Q

Is the current treatment for ischemic heart disease based on prevention?

A

No 🤑 it 🤑 is 🤑 based 🤑 on 🤑 treating 🤑 symptoms 🤑 so 🤑 that 🤑 BIG 🤑 PHARMA🤑 gets 🤑 richer🤑

38
Q

Do we see a lot of CAD in cultures that primarily eat plant based diets? 🐇

A

No almost zero

39
Q

How do we treat stable angina?

A

Risk factor modification- statins, stop smoking, lose weight etc

Meds- nitrates, beta blockers, CCB, statins, antiplatelets

Revascularization

40
Q

What 3 classes of meds DECREASE oxygen demand?

A

Nitrates- preload reduction

Beta blockers-afterload reduction

Calcium channel blockers- afterload reduction for patients who don’t respond to nitrates and beta blockers

41
Q

What is the first line medication for chronic angina?

A

Beta blockers

42
Q

What 2 meds INCREASE oxygen supply?

A

Nitrates-dilate coronary arteries

Calcium channel blockers- coronary vasodilators

(YES both of these also Decreased oxygen demand)

43
Q

What is the typical dose of nitroglycerin?

A

0.3-0.6 mg sublingual/buccal spray

Take at onset of pain and every 5 minutes for up to 3 doses

If still no relief, call 911

44
Q

What are the antiplatelet medications we can give for stable angina?

A

Aspirin (75-325mg) - basically every patient

Plavix- if they cant take aspirin

Combination of the 2

45
Q

Patients who have had an MI are at a _____x higher risk of death from CHD than those who don’t have CVD

A

20x more likely to die from CHD

This was in red

46
Q

What role do statins have in treating stable angina?

A

They STABILIZE PLAQUES***

-slow progression and even reverse coronary atherosclerosis

47
Q

Do we care what the pateints’ baseline LDL is when we put them on high dose statins for angina

A

No

48
Q

When would we do CABG instead of PCI for revasculartizaon ?

A

Left main coronary stenosis

Triple vessel disease

49
Q

Which vessels do we use for CABG?

A

Saphenous vein

Internal mammary arteries

50
Q

What 3 things fall under the umbrella of Acute Coronary Syndromes?

A

Unstable Angina

NSTEMI

STEMI

51
Q

“Sudden breathlessness” and a sense of impending doom……

Should you be worried?

A

Lol yeah your patient probably has unstable angina, STEMI, or NSTEMI

52
Q

What are the 5 diagnoses that should be on your differential for chest pain that you need to rule out?

THIS SLIDE HAD A STAR ON IT

A

Aortic dissection

PE

Pneumothorax

Perforated viscous (?)

Cocaine abuse 🦄

53
Q

What is unstable angina?

A

Ischemic pain AND at least one of the following:

  • occurs at rest, usually lasts more than 10 min
  • new onset and severe
  • occurs with a crescendo pattern
54
Q

What is prinzmetals angina?

A

Ischemic symptoms caused by vasospam!

This will be chest pain at rest

55
Q

What ECG findings will you see with prinzmetals angina/

A

Transient ST elevations

56
Q

Who usually gets prinzmetals angina?

A

Younger people with few risk factors

57
Q

How do you diagnose Prinzmetals angina?

A

Coronary angiography

Stress testing unhelpful

58
Q

How do you treat Prinzmetals Angina?

A

Nitrates

Calcium channel blockers

59
Q

Should we give beta blockers to our patient with prinzmetals angina?

A

NO

Might make it worse

60
Q

What are the 4 ways you can end up with unstable angina or NSTEMI?

A
  1. Plaque rupture with a nonocclusive thrombus (not completely~ occluded) MOST COMMON
  2. Obstruction due to vasospasm (prinzmetals)
  3. Progressive mechanical obstruction- following Percutaneous coronary intervention
  4. Increased oxygen demand/decreased supply like from tachycardia or anemia
61
Q

What is the most common cause of unstable angina and NSTEMI?

A

Plaque rupture with a nonocclusive thrombus ***

62
Q

If we think someone is having unstable angina or an NSTEMI, should we do stress testing?

A

No, its not safe if they are actually having an event. BUT if their enzymes are normal and there is no evidence of infarction and we don’t know what’s going on you can do it

63
Q

Will your cardiac enzymes be elevated in unstable angina?

A

NO NO NO NO NO NO NO!!!

64
Q

Will your cardiac enzymes be elevated in NSTEMI>?

A

YES YES YES

There has been an actual MI!!!!

65
Q

What kind of ECG changes are you likely to see with unstable angina or NSTEMI?

A

ST depression

T wave inversion

66
Q

How do you treat unstable angina/NSTEMI?

A

Bedrest with cardaic monitoraing and oxygen

MONA

Beta blockers

Antiplatelets (plavix)

Heparin

Statins

Revascularization if needed

67
Q

What is MONA?

A

Morphine, oxygen, nitro, aspirin/antiplatelet

Not done in this order

68
Q

What are the TIMI variables for calculating the risk of progression of unstable angina or NSTEMI?

A

65 or older

3+ risk factors for CHD

Prior coronary stenosis of 50%+

ST segment deviation on admission ECG

2+ anginal episodes in 24hrs

Increased cardaic enzymes

Aspirin use in last 7 days

(Basically the more of these you have, the more likely you are to die or have a serious ischemic event in the next 2 weeks)

69
Q

What time of day is STEMI more likely?

A

Within a few hours of waking up in the morning

70
Q

What 3 things are known to precede STEMIs in 50% of cases?

A

Vigorous exercise

Extreme emotional stress

Illness

71
Q

What 2 things can cause a STEMI?

A

Rupture of a vulnerable plaque that causes 100% occlusion of a coronary artery (MUCH more common)

Slowly developing stenosis of an artery (rare, because collateral vessels usually develop as stenosis increases)

72
Q

what is it:
ST elevation

No cardiac enzymes

A

unstable angina

73
Q

What is it:
ST elevation

Increased cardaic enzymes

A

STEMI

74
Q

What is it:
No ST elevations

Increased cardaic enzymes

A

NSTEMI

75
Q

What is it:
no ST elevation

No cardaic enzymes

A

Unstable angina

76
Q

When is the onset of increased cardaic enzymes? (Both CK and troponin)

A

3-12 hours

77
Q

When do cardiac enzymes peak? (Both CK and troponin)

A

18-24 hours

78
Q

How long do CK enzymes stay elecvated ?

A

36-48 hours

79
Q

How long do troponins stay elevated ?

A

Up to 10 days

80
Q

What should you do if patient has STEMI?

A

MONA

IV access

Beta blockers (CCB too if nitro and B-blockers not relieving pain)

Antiplatelet (plavix)

Heparin

Anti-arrhythmics

ACE-inhibitors

Statins

REVASCULARIZATION

81
Q

In what order do we do MONA?

A

O N M A

82
Q

What are the ABSOLUTE contraindications to thrombolytic/fibrinolytic therapy?

A

Hx of intracranial hemorrhage

Stroke in past year

Poorly controlled HTN (180/110+)

Suspected aortic dissection

Active internal bleeding lol

83
Q

What are the 2 ways we can achieve revascularization?

A

Percutaneous coronary intervention

Thrombolytic drugs

(In experienced hands, PCI is more effective)

84
Q

Do we give thrombolytics for unstable angina or NSTEMI?

A

No

85
Q

Both UA/NSTEMI and STEMI will get PCI or CABG, but what is the difference?

A

STEMI will get it as soon as possible

NSTEMI/UA will get it later

86
Q

What is “Dressler’s Syndrome”?

A

Pericarditis after MI, CABG, or heart trauma

87
Q

What are the complications after an MI?

A

Recurrent ischemia

Depression!***

Pump failure-leading cause of death

Arrhythmias

Pericarditis/Dresslers syndrome

Mural thrombus

Cardiac rupture/LV aneurysm

88
Q

How do we manage a patient after an MI?

A

Risk stratification-consider stress test

Treat risk factors- diet, smoking, BP

Medications- Bblockers, aspirin, and ACE or ARB if LV is messed up

Clin Med Exam 1(Lauren) (8 decks)

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