Ischemic Dx Part 2 Flashcards
1
Q
If someone has ACS symptoms, what should be done within 10 minutes of arrival at ED?
A
EKG!
2
Q
If patient remains symptomatic despite nondiagnostic EKG, what should we sus? What should we do?
A
ACS
Do Serial EKGs 15-30 min intervals for first couple hours
3
Q
What exists on EKG for ONLY 20-30 min after infarct onset?
A
Hyperacute T waves
4
Q
What must we rule out with ACS EKG Hyperacute T wave finding?
A
Hyperkalemia
5
Q
Three T Wave patterns clue
A
6
Q
Different EKGS and what to sus out
A
7
Q
Describe how STEMI evolves
A
ST Elevation -> Q-wave, inverted T wave->ST Flattens, Q wave is not pathological-> Everything normalizes, pathological Q wave is present though
8
Q
Which enzymes are evaluated to check for myocardial damage?
A
Myoglobin
CK-MB
Troponin I, T
9
Q
Where is myoglobin found?
A
Cardiac and skeletal muscle
10
Q
Myglobin has high or low sensitivity and specificity
A
HIGH sensitivity
LOW specificity
11
Q
_______ is released MORE rapidly than troponin and CK-MB from MI
A
Myoglobin
12
Q
Myoglobin can be detected as early as _________ after an AMI
A
1-4 hours
13
Q
Which cardiac enzyme is NOT commonly seen? Why?
A
Myoglobin
Patients usually do not show up early enough to catch this enzyme
14
Q
What is the most sensitive EARLY marker for myocardial infarction
A
Myoglobin
15
Q
Is troponin normally found in serum?
A
NO!
16
Q
Troponin is released when?
A
ONLY when myocardial necrosis occurs!
17
Q
What are the preferred markers for Myocardial Injury?
A
Troponin! It is HIGHLY sensitive AND specific for even the smallest cardiac damage
18
Q
When does Troponin increase?
A
Within 3-12 hours and peaks at 24-48 hours
19
Q
When does Troponin return to baseline?
A
5-14 days
20
Q
How often to measure troponin levels
A
Presentation
90 min
Q6-8hrs after sx onset
(YOU CANNOT DX MI WITH JUST ONE READING, must determine the trend!)
21
Q
Does troponin always mean there is an MI occuring?
A
NO! it just shows there is myocardial injury which can be caused by many things!
22
Q
CK-MB is less or more sensitive and specific than Troponin?
A
LESS
23
Q
CK-MB will increase when?
A
3-12 hours after injury, peaks at 24 and remains elevated for 36-48 hours
24
Q
There can be a false positive of CK-MB with what?
A
Exercise
Trauma
Muscle Disease
DM
PE
25
What is CK-MB?
Creatinine Kinase Myocardial Band
26
Where is Lactate Dehydrogenase (LDH)?
Kidney, Lungs, Muscle, Brain, Blood
Because of this, it is not the best indicator for myocardial injury
27
Which enzyme to test with CP for 2 hours?
Myoglobin
28
Which enzyme to test with CP for 6 hours?
Troponin
29
Which enzyme to test with reccurent CP 36 hours after Percutaneous Coronary Intervention (PCI) for an MI?
CK-MB
30
If a patient has no evidence with markers that they have myocardial necrosis BUT they have High CRP, what does that mean?
They have INCREASED risk for subsequent ischemic event
31
What things may be increased after AMI?
WBC
ESR
32
Which test is MC for inducible ischemia
Stress Test
33
What two ways can we stress test?
Exercise or Pharmacologic
34
Who would be a good candidate for stress test?
Someone who can walk >5 minutes on flat ground OR can walk up 2 flights of stairs without stopping
35
What is monitored during stress test?
EKG, BP, HR
36
What is a Positive Stress Test?
ST depression of 1mm
37
T/F: There are more FALSE POSITIVES than true positives with stress testing
TRUE!
38
How to calculate HR max?
220-age
39
When should we absolutely STOP exercise test?
Sustained ventricular high HR
ST elevation >=1mm WITHOUT diagnostic Q waves
40
If someone has baseline abnormalities on EKG that are not interpretable, could we do a stress test?
Nope
41
When should we add imaging to a stress test?
If exercise EKG is hard to interpret
If doing Pharm stress test is used
42
What types of imaging could we use with stress test?
Nuclear- Using Thallium 201, Technetium
Singe Photon Emission Computed Tomography (SPECT)
ECHO - check for LV dilation or wall motion abnormalities
43
What are some examples of pts that could NOT do exercise stress test?
Left Bundle Branch Block
V paced rhythm
Beta Blocker or CCB tx
Large abdominal aortic aneurysm
44
Pharmacologic Stress test is ALWAYS paired with ________ because pharmacologic sensitivity is low
Imaging
45
List the Pharmacologic Stress Agent options
Vasodilators are preferred:
Adenosine
Dipyridamole
Regadenoson
Adrenergic Stimulating Agents are 2nd line:
Dobutamine +/- Atropine
46
CI for Vasodilator
Bronchospasm
47
Adrenergic SE
High HR
Increased SBP
Angina
48
Vasodilator SE
SOB
HA
Flushing
CP
Dizzy
49
Cardiac Catheterization info
Invasive and costly
Uses IV contrast (hold Metformin for 48 hours before)
NPO 4-6 hours before
50
When is the ONLY instance cardiac catheterization is first line?
HIGH pre-test likelihood
51
What can LEFT Heart cath angio tell us?
Valves and LV function
Assess Ejection Fraction and regional wall motion
52
What can RIGHT heart cath tell us?
Measures pressures
Assesses shunts
Helpful for Pulm HTN
Monitors hemodynamics
53
In order to do CT of Coronary Arteries, HR must be below what?
<50
54
If CT of Coronary Artery is positive, what should we do next?
Cardiac Cath
55
Levine Sign
Pt clenches fist over chest in pain
56
How to manage Stable Angina
Antiplatelet
Beta Blocker (#1= Metoprolol)
Statin if appropriate
Nitrate for CP sx
57
Everyone with CAD needs what type of statin?
HIGH intensity!
58
Ranexa and Amlodipine both have anti-______ properties
anti-anginal
59
What are some antiplatelet med options?
ASA
Clopidogrel
Prasugrel
Ticagrelor
60
How to manage ACS- Unstable Angina, STEMI, NSTEMI
Admitted with telemetry
Supplemental O2 if <95%
#1 Tx= ASA
#1 for CP= Nitrates
If refractory pain, try morphine
Beta Blocker within 24 hours
ACEI/ARBs within 24 hours
61
If someone has an inferior STEMI, what medication could cause severe HoTN?
Nitrates
62
What is specific to STEMI patients in terms of time of treatment?
They need IMMEDIATE reperfusion to avoid long term cardiac damage
63
If someone with a STEMI comes in within 12 hours of sx onset, what tx should we do?
IMMEDIATE reperfusion with primary PCI within 90 minutes
If you do not have PCI access, must thrombolysis within 30 min
64
Part 1: General chart of how to tx patient you sus ischemia or infarction
65
Part 2: General chart of how to tx patient you sus ischemia or infarction
66
What is the first line tx for ischemic heart disease
ASA
67
MOA of ASA
IRREVERSIBLE inhibition of platelet aggregation
68
If ACS, how much ASA do we give?
162-325 mg chewed
69
If ACS but have ASA allg, what do we give?
P2Y12 Inhibitor- Clopidogrel, Prasugrel, Ticagrelor
70
ASA should be used with caution for what disorders?
Active Peptic Ulcer Disease or bleeding disorders
71
What are the three P2Y12 Inhibitors?
Clopidogrel
Prasugrel
Ticagrelor
72
MOA of P2Y12 Inhibitors
Irreversible Inhibition of platelet aggregation
73
Load ______ prior to heart cath
P2Y12, usually Clopidogrel
(Because it lowers risk of ischemic event)
74
If someone is getting a CABG, how long should they be off P2Y12 before the procedure?
Clopidogrel or Ticagrelor-5 days before procedure
Prasugrel- 7 days before procedure
75
What are the 3 Glycoprotein 2b/3a Inhibitors?
Tirofiban
Eptifibatide
Abciximab
76
MOA of Glycoprotein 2b/3a Inhibitors
Inhibits platelet aggregation
77
If someone has ongoing ischemia despite ASA and P2Y12 inhibitor, what med might we try?
Glycoprotein 2b/3a Inhibitors
78
If someone needs urgent CABG but cannot use their P2Y12 inhibitors, what med can we give them?
Glycoprotein 2b/3a Inhibitors
79
What are the Anticoag meds?
INDIRECT Thrombin Inhibitors:
Unfractioned Heparin
Low Molecular Weight Heparin:
-Enoxaparin
-Fondaparinux
-Dalteparin
DIRECT Thrombin Inhibitors:
Bivalirudin (only used in cath lab)
80
T/F: Changing from one Anti-coag to another is recommended
FALSE
81
T/F: LMWH is more effective than UFH in preventing recurrent ischemic events in ACS
True
82
Nitrate MOA
Nitrate that enters vascular smooth muscle and is converted to Nitric Oxide= activates cGMP and vasodilation
83
Nitrate needs to be used in caution with what issues?
HoTN SBP<100
Low HR
High HR
RV infarcation
84
SE of Nitrates
HA, reflex high HR
85
Nitrate has DDI with what?
PDE5 Inhibitors
86
What is the only type of MI in which Nitrate is NOT the first line option for ACS CP?
Inferior Wall MI
87
MC long acting nitrate which can also be used as a daily med for chronic stable angina
Isosorbide Mononitrate
88
Morphine will lower what?
Sympathetic tone
Systemic Vascular Resistance
O2 demand
89
Morphine should be used with CAUTION with what dx?
HoTN, Hypovolemia, Respiratory Depression
90
What are Beta Blocker CI?
Acute CHF
Heart Block
HoTN
91
How do Beta Blockers help with MI?
REDUCES the following:
-Infarct size and complications
-Rate of re-infarcation
-Rate of life threatening tachyarrhythmias
Prevents Cardiac remodeling
92
Ranolazine MOA
Late Na-Channel Blocker which decreases intracellular Ca overload
93
What are the advantages of Ranolazine?
NO effect on HR or BP
Safe to use with ED meds
94
Ranolazine may prolong ______
QT
95
Ranolazine is used for what?
Chronic stable angina
(usually used if can't tolerate nitrate bc this med is very expensive)
96
Why are ACEIs helpful post-MI?
The body will increase ACE activity post-MI which will lead to remodeling and fibrosis
Using ACEI will reduce the fibrosis and remodeling
97
Sometimes patients can take _____ if LV dysfunction
Aldosterone Antagonist
98
When do we use Fibrinolytic Therapy?
ONLY IF STEMI!
99
What are the 2 Fibrinolytics?
Altepase
Tenecteplase
100
After completing fibrinolytic infusion with STEMI since PCI was not available, what should be started?
ASA and Anticoag (LMWH preferred)
Use until revascularization or for entire hospital stay
(max of 8 days)
101
If its going to take longer than 90 minutes to get to a cath lab, what should we do?
Administer Fibrinolytics then transfer
102
If MI tx is failing to reperfuse body, what would we do?
Salvage angioplasty
Generally do if pain and ST elevation persist over 90 minutes after bolus
103
ALL patients with STEMI that was treated with fibrinolytics, should be started on a prophylactic treatment with what?
PPIs "-prazole"
104
What are the CIs to Thrombolytic therapy
ANY prior ICH
Cerebral Vasc lesion
IC neoplasm
Ischemic stroke in last 3 mo
Sus aortic dissection
105
How does a Percutaneous Coronary Intervention (PCI) work?
Minimally invasive procedure that widens the blocked vessel
It is ONLY helpful to UNstable disease
106
What are the two types of PCI?
Balloon Angioplasty
Stent Angioplasty
107
What are the PCI Stent types?
Bare Metal Stents (BMS)
Drug-Eluting Stents (DES)
108
Describe the details of Bare Metal Stents
Is a stent withOUT a coating
Restenosis rate is high
109
Describe the details of Drug-Eluting Stents
**Preferred stent for PCI
Slowly releases a drug that blocks cell proliferation
110
Drug-Eluting Stents are not available to all patients because ?
They require a longer period of Dual Anitplatelet Therapy
111
After someone has a PCI, what are the education points we must give them for recovery?
No soaking in baths, pools, etc for the first 1-2 days
No heavy lifting or sex for 2-5 days
If excessive bleeding- hold and call 911
MUST TAKE MEDS- DAPT for 6-12 mo
112
What are the 2 meds for DAPT after a PCI?
ASA + P2Y12 Inhibitor
Helps reduce risk of MI or death
113
What is an atherectomy?
Catheter that removes the plaque from vessel walls
114
What medication therapy is needed after an atherectomy?
DAPT
115
What is Coronary Artery Bypass Grafting (CABG)
Vessels are harvested from elsewhere in the body and grafted to the coronary arteries
It helps improve blood supply to myocardium
116
What are the types of Coronary Artery Bypass Surgery
117
When is CABG the preferred method for revascularization
-L main trunk stenosis
-Poor LV function
-DM with stenosis in >1 vessel
-Valve dx that requires open heart surgery
-3-vessel CAD or 2-vessel CAD that involves proximal LAD
118
Explain how the CABG procedure happens
Heart is stopped which means we use cardiopulmonary bypass
OR
Can be done "off pump" while heart is still beating
119
What is Enhanced External Counterpulsation?
NON-invasive procedure where cuffs are placed around LE that inflate and deflate with cardiac cycle rhythm
120
What is the point of using Enhanced External Counterpulsation?
Reduce cardiac workload
Diminishes symptoms of ischemia, improves functional capacity and quality of life
121
How often is Enhanced External Counterpulsation done for?
Done 1-2 times daily for 1+ months
121
How long can results last for Enhanced External Counterpulsation?
5 years
