Ischemia Heart Disease 2/20 Flashcards
Test 2
IHD =
Ischemic heart disease
____% of Sx pts are at increased risk for IHD
30%
What are the 2 most important risk factors for developing IHD or atherosclerosis involvinf the coronaries?
Male gender
Increasing age
What are the first manifestations of IHD?
Angina pectoris
Acute MI
sudden death
What are things that can result in sudden death?
CAD
overdose
cardiomyopathy
Stable angina is also known as _________
Angina Pectoris
Stable angina is relieved by _______
rest
Stable angina is an imbalance between what?
Decreased coronary blood flow & increased myocardial O2 demand
Stable angina is ______ occlusion/narrowing w ____% being affected
partial
> 70%
What mediators are released with stable angina?
adenosine & bradykinin
stable angina affects the _______ sympathetic ganglia
T1 - T5
What type of CV changes are expected in stable angina? Why?
Increased risk for bradyarrhymthias
Decreased HR and contractility
Decreased flow thru coronaries –> decreased flow AV nodes –> decreased contractility and HR
_________ is the most common cause of impaired coronary blood flow resulting in angina pectoris
atherosclerosis
What are populations that you may see weird presentation with CP in?
DM
female gender
Where does retrosternal CP often radiate to?
dermatomes from C8 to T4
Which can then radiate to:
neck
left shoulder/arm
jaw
back
down both arms
T/F: Cold weather can induce angina
T
Differentiate between Chronic stable, unstable, and new onset angina
Chronic: No change in severity/frequency
> 2 months
Unstable: Increasing severity/frequency
-no change in cardiac biomarkers
New onset: Severe, prolonged, disabling
What can cause chronic stable angina?
distal occlusion
If CP is increasing in frequency/severity w increase in cardiac biomarkers WITHOUT EKG changes then…
NSTEMI
T/F: ECHO is useful in patients with confirmed AMI Dx
F
Only needed when Dx is uncertain with abnormal EKG
Your T wave is _____ from previous MI. What happens to it during a reccurent MI? What is this called?
inverted
If having another MI, T wave may go back to upright position
Pseudinormalization of T wave
Exercise ECG is ______ sensitive/specific than nuclear/chemical cardiology techniques
less (75%)
What is the most thorough/greater sensitivity test for coronary perfusion or IHD? What does it assess?
Nuclear (Chemical) stress imaging
Exercise or cardiac stress is produced by administration of: atropine, dobutamine, pacing, adenosine, dipyridamole –> radionunuclide tracer scanning is performed to asses myocardial perfusion.
Helps to also figure old vs new MI problems
-estimates LV size/function
What is the gold standard for assessing the coronaries?
Coronary angiography
Describe Prinzmetal-Variant angina. What trigges this?
A sudden, temporary spasm or narrowing of a small part of a coronary artery causing CP & an episode of ST elevation
triggers: cold
cocaine
What are AMI often a result from?
plaque rupture from a coronary artery that was less than 50% stenosed
Losing 10% of body wt decreases risk of ACS/IHD by ______%
50%
Statins are used when LDL cholesterol levels are ______. What are the reduction goals?
> 160 mg/dL
goals: >50% reduction or <70 mg/dL
All suspected or definite AMI patient should receive _____
ASA
If you have an allergy to ASA, what should you take? MOA? Describe them
P2Y12 inhibitors: clopidogrel
prasugrel
ticagrelor
MOA: inhibit ADP receptor and platelet aggregation
-irreversible
-pro drug
With drug therapy, what is more effective than ASA? What is the MOA?
Glycoprotein IIb/IIIa receptor antagonist: abciximab
eptifibatide
tirofiban
MOA: inhibit, platelet activation, adhesion and aggregation
What drugs reduce the effectiveness of clopidogrel (P2Y12 inhibitors)?
PPI
What is special about the response you can have to clopidogrel?
You can have a hypo or hyper response –> need platelet function panel to evaluate this –> will tell you how to treat if bleeding occurs
When is Effient used? Why?
This is an anti-platelet used with ACS/IHD with a higher risk of bleeding
Very predictable
Usually used in short term in Cath Lab, where patient can be monitored closely
How does organic nitrates effect the CVS?
Decreases angina
Increases amount of exercise required to produce ST depression
-reduces L vent afterload
-reduces myocardial O2 demand
-reduces Venus return/preload
nitrates ________ antithrombotic effects
increases
What is the only type of medication that increases life span if you have CAD?
BB
Propanolol and nadolol are _________ agonist
Beta-2
What does literature support about beta blockers during periop?
Continue them or give them something else during Sx
What are the differences between esmolol, metoprolol, & labetolol?
esmolol: controls HR – less effect on contractility
Metoprolol: More effect on contractility – less on HR
Labetolol: affects both HR & contractility equally
What is the 2nd line therapy when pt doesnt response to BB in IHD?
CCB
_______ reduces motality in any surgery!!!!!
Statins
During revascularizaton, when would you want to do CABG over PCI? What are other CABG indications?
failure of medical therapy
-50% L main coronary art occluded
-70% epicardial coronary art occluded
-EF <40%
-3 vessel coronary art disease
-DM w 2 or 3 vessel coronary art disease
Indications: coronary anatomy
-failed PCI
-infarct-related septal rupture
-mitral regurg
-multiple stents present
What chemical mediators could be the causes of Thrombogenesis in a STEMI?
Collagen
ADP
epinephrine
serotonin
Thromboxane A2
Glycoprotein IIb/IIIa receptors
Fibrin deposits
We give ______ to decrease vasospasms in STEMI
CCB
How do you Dx a STEMI?
Cardiac biomarkers and 1 of the following:
-ST/T changes
-New onset L BBB
-New pathologic Q waves
-New loss of viable myocardium
-wall motion abnormality
-thrombus identification by angiography/autopsy
Changes in angina may happen _____ before an AMI
30 days
Whats the difference between troponin and CK-MB?
CK-MB is not cardiac specific – just indicated muscle injury
troponin is cardiac specific
You’ll see an increase in cardiac markers within _______ after my cardio injury. They stay elevated for _______
3 hours
7 - 10 days
With MONA, what other things can we use to replace the M? What benefits do they carry?
M = morphine
Can use fentanyl or toradol
Both dont have major effects on BP which can further worsen ischemia by increasing demand of heart like morphine.
Toradol also has anti platelet affects (still give ASA tho)
What is the goal of MONA?
reduce catecholamine release because that increase myocardial O2 demand (which is bad)
What drugs do we use for thombolytic therapy?
tPa
Streptokinase
reteplase
tenecteplase
When should thrombolytic therapy be initiated?
within 30-60 mins of arrival to hospital
within 12 hours of symptom onset
What are indications to PCI/stents?
thrombolytic therapy contraindication
-severe HF
-pulmonary edema
-Symptoms for 2 -3 hrs –> mature clot
When should PCI be initiated?
within 90 mins of arrival to hospital
within 12 hours of symptom onset
T/F: Anemia increases metabolic demand of the heart
T
This worsens/causes myocardial ischemia
Thrombolytics are for _______ only
STEMI
What are the risks with PCI/stents?
Thrombosis – can temp worsen ischemia
Bleeding – from vessel rupture
What is DAPT? What is the relevance of this?
Dual Antiplatelet Therapy
ASA w P2Y12 inhibitor like clopidogrel after any cardiac Sx, PCI/stent
___________ discontinuation is the most significant independent predictor of stent thrombosis
P2Y12 inhibitor
What are the d/c time frames for P2Y12 inhibitors?
Clopidogrel/ticagrelor: 5-7 days
Prasugrel: 7-10 days
Ticlopidine: 10 days
When can we do an operation after PCI for angioplasty w/o stunting?
2 - 4 weeks
When can we do an operation after PCI for Bare-metal stent placement?
At least 30 days
12 weeks preferred
When can we do an operation after PCI for coronary artery bypass grafting?
At least 6 weeks
12 weeks preferred
When can we do an operation after PCI for drug eluding stent placement?
At least 6 months
At least 12 months after ACS
What does a carotid bruit indicate?
cerebrovascular disease
What medications should we continue with ACS?
BB
A2 agonists
Statins
What medication should I give with BB to combat drop on HR? What is the dose for this?
Glycopyrrolate
0.8 mg
You give ________ with Neostigmine. What are the doses? Peds?
Glycopyrrolate: 0.8 mg
Neostigmine: 5 mg
Peds: 1:1 ratio
We give ______ for refractory hypotension
vasopressin
D/c of BB during postop can cause _________
rebound HTN & tachycardia
Based on the Revised Cardiac Risk Index (RCRI), what components increase risk for major cardiac events after surgery? How do you score this?
- High risk surgery
- ischemic heart disease
- Hx of congestive heart failure
- Hx of cerebral vascular disease
- DM requiring insulin
- creatinine greater than 2
Each is worth 1 point
Risk or major cardiac event
0 = 0.4%
1 = 1.0%
2 = 2.4%
3 or more = 5.4%
Components of RCRI: High-risk Sx
Abdominal aortic aneurysm
-Peripheral vascular operation
-Thoracotomy
-major abdominal operation
Components of RCRI: ischemic heart disease
Hx of MI
-Hx of positive finding on exercise testing
-current complaints of angina pectoris
-use of nitrate therapy
-presence of Q waves
Components of RCRI: congestive heart failure
Hx of CHF
-Hx of pulmonary edema
-Hx of paroxysmal nocturnal dyspnea
-physical examination showing rales or S3
-chest radiograph showing pulmonary vascular redistribution
Components of RCRI: cerebral vascular disease
Hx of stroke
-Hx of transient ischemic attack
What does functional capacity do?
-Assesses cardiopulmonary fitness
-estimates patient’s risk for a major postop morbidity or mortality
-assesses preoperative risk
With functional capacity, what is considered a good METs score?
> 4 METs
How do we normally test functional capacity?
METs score of 5:
Climbing 1 flight of stairs
What are the times for urgency of surgeries?
Emergent: 30 minutes - 6 hours
Urgent: 6 to 24 hours
Time sensitive: 1 to 6 weeks
What is the Preop Cardiac risk assessment algorithm?
Sx
Step 2. Active cardiac conditions:
ACS
decompensated HF
significant arrhythmia
severe valvular disease
–> Postpone until eval/Tx
Step 3. Estimate risk using RCRI –> less than 2 –> Sx
Step 4. Assessed functional capacity –> greater than 4 –> Sx
Step 5. Assess whether testing will impact care.
Step 6. Proceed to Sx or consider alternative strategies.
When is the ideal time frame for Sx post MI?
> 60 days
What is our main anesthesia considerations with ACS/IHD?
Keep them as normal as possible!!!!!
Increasing O2 requirements has these effects:
SNS stimulation –>
Tachycardia
-hypertension
-increase myocardial contractility
-increase afterload/preload
Decreasing O2 delivery has these effects:
Decreased coronary blood flow
-tachycardia
-hypotension
-hypocapnia
-coronary artery spasm
-decreased oxygen content
-anemia
-arterial hypoxemia
-shift of oxyhemoglobin dissociation curve to the left
What causes the oxyhemoglobin dissociation to shift to the left?
Decreased oxygen delivery
What causes the oxyhemoglobin dissociation to shift to the right?
Increased oxygen delivery
T/F: Esmolol helps decrease the risk of sympathetic surge during intubation which increases myocardial demand
T
Why are volatile anesthetics beneficial in IHD?
decrease myocardial O2 demand
but could be detrimental if they decrease blood pressure
In ACS, we want to give ________ for hypotension.
Ephedrine - good for low BP & normal HR
-Phenylephrine
Why is glycopyrrolate preferred over atropine in ACS in bradycardia?
Has much less chronotropic effect & central effect than atropine
What are the most common leads for heart monitoring in pts with CAD? What does it look at?
Lead II –> R coronary view
V5 –> L coronary view
