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CV > Ischemic Dx Part 2 > Flashcards

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!

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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

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3
Q

What exists on EKG for ONLY 20-30 min after infarct onset?

A

Hyperacute T waves

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4
Q

What must we rule out with ACS EKG Hyperacute T wave finding?

A

Hyperkalemia

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5
Q

Three T Wave patterns clue

A
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6
Q

Different EKGS and what to sus out

A
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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

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8
Q

Which enzymes are evaluated to check for myocardial damage?

A

Myoglobin
CK-MB
Troponin I, T

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9
Q

Where is myoglobin found?

A

Cardiac and skeletal muscle

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10
Q

Myglobin has high or low sensitivity and specificity

A

HIGH sensitivity
LOW specificity

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11
Q

_______ is released MORE rapidly than troponin and CK-MB from MI

A

Myoglobin

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12
Q

Myoglobin can be detected as early as _________ after an AMI

A

1-4 hours

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13
Q

Which cardiac enzyme is NOT commonly seen? Why?

A

Myoglobin
Patients usually do not show up early enough to catch this enzyme

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14
Q

What is the most sensitive EARLY marker for myocardial infarction

A

Myoglobin

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15
Q

Is troponin normally found in serum?

A

NO!

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16
Q

Troponin is released when?

A

ONLY when myocardial necrosis occurs!

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17
Q

What are the preferred markers for Myocardial Injury?

A

Troponin! It is HIGHLY sensitive AND specific for even the smallest cardiac damage

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18
Q

When does Troponin increase?

A

Within 3-12 hours and peaks at 24-48 hours

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19
Q

When does Troponin return to baseline?

A

5-14 days

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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!)

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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!

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22
Q

CK-MB is less or more sensitive and specific than Troponin?

A

LESS

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23
Q

CK-MB will increase when?

A

3-12 hours after injury, peaks at 24 and remains elevated for 36-48 hours

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24
Q

There can be a false positive of CK-MB with what?

A

Exercise
Trauma
Muscle Disease
DM
PE

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25
Q

What is CK-MB?

A

Creatinine Kinase Myocardial Band

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26
Q

Where is Lactate Dehydrogenase (LDH)?

A

Kidney, Lungs, Muscle, Brain, Blood

Because of this, it is not the best indicator for myocardial injury

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27
Q

Which enzyme to test with CP for 2 hours?

A

Myoglobin

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28
Q

Which enzyme to test with CP for 6 hours?

A

Troponin

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29
Q

Which enzyme to test with reccurent CP 36 hours after Percutaneous Coronary Intervention (PCI) for an MI?

A

CK-MB

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30
Q

If a patient has no evidence with markers that they have myocardial necrosis BUT they have High CRP, what does that mean?

A

They have INCREASED risk for subsequent ischemic event

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31
Q

What things may be increased after AMI?

A

WBC
ESR

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32
Q

Which test is MC for inducible ischemia

A

Stress Test

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33
Q

What two ways can we stress test?

A

Exercise or Pharmacologic

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34
Q

Who would be a good candidate for stress test?

A

Someone who can walk >5 minutes on flat ground OR can walk up 2 flights of stairs without stopping

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35
Q

What is monitored during stress test?

A

EKG, BP, HR

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36
Q

What is a Positive Stress Test?

A

ST depression of 1mm

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37
Q

T/F: There are more FALSE POSITIVES than true positives with stress testing

A

TRUE!

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38
Q

How to calculate HR max?

A

220-age

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39
Q

When should we absolutely STOP exercise test?

A

Sustained ventricular high HR
ST elevation >=1mm WITHOUT diagnostic Q waves

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40
Q

If someone has baseline abnormalities on EKG that are not interpretable, could we do a stress test?

A

Nope

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41
Q

When should we add imaging to a stress test?

A

If exercise EKG is hard to interpret
If doing Pharm stress test is used

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42
Q

What types of imaging could we use with stress test?

A

Nuclear- Using Thallium 201, Technetium
Singe Photon Emission Computed Tomography (SPECT)
ECHO - check for LV dilation or wall motion abnormalities

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43
Q

What are some examples of pts that could NOT do exercise stress test?

A

Left Bundle Branch Block
V paced rhythm
Beta Blocker or CCB tx
Large abdominal aortic aneurysm

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44
Q

Pharmacologic Stress test is ALWAYS paired with ________ because pharmacologic sensitivity is low

A

Imaging

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45
Q

List the Pharmacologic Stress Agent options

A

Vasodilators are preferred:
Adenosine
Dipyridamole
Regadenoson

Adrenergic Stimulating Agents are 2nd line:
Dobutamine +/- Atropine

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46
Q

CI for Vasodilator

A

Bronchospasm

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47
Q

Adrenergic SE

A

High HR
Increased SBP
Angina

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48
Q

Vasodilator SE

A

SOB
HA
Flushing
CP
Dizzy

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49
Q

Cardiac Catheterization info

A

Invasive and costly
Uses IV contrast (hold Metformin for 48 hours before)
NPO 4-6 hours before

50
Q

When is the ONLY instance cardiac catheterization is first line?

A

HIGH pre-test likelihood

51
Q

What can LEFT Heart cath angio tell us?

A

Valves and LV function
Assess Ejection Fraction and regional wall motion

52
Q

What can RIGHT heart cath tell us?

A

Measures pressures
Assesses shunts
Helpful for Pulm HTN
Monitors hemodynamics

53
Q

In order to do CT of Coronary Arteries, HR must be below what?

A

<50

54
Q

If CT of Coronary Artery is positive, what should we do next?

A

Cardiac Cath

55
Q

Levine Sign

A

Pt clenches fist over chest in pain

56
Q

How to manage Stable Angina

A

Antiplatelet
Beta Blocker (#1= Metoprolol)
Statin if appropriate
Nitrate for CP sx

57
Q

Everyone with CAD needs what type of statin?

A

HIGH intensity!

58
Q

Ranexa and Amlodipine both have anti-______ properties

A

anti-anginal

59
Q

What are some antiplatelet med options?

A

ASA
Clopidogrel
Prasugrel
Ticagrelor

60
Q

How to manage ACS- Unstable Angina, STEMI, NSTEMI

A

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
Q

If someone has an inferior STEMI, what medication could cause severe HoTN?

A

Nitrates

62
Q

What is specific to STEMI patients in terms of time of treatment?

A

They need IMMEDIATE reperfusion to avoid long term cardiac damage

63
Q

If someone with a STEMI comes in within 12 hours of sx onset, what tx should we do?

A

IMMEDIATE reperfusion with primary PCI within 90 minutes

If you do not have PCI access, must thrombolysis within 30 min

64
Q

Part 1: General chart of how to tx patient you sus ischemia or infarction

A
65
Q

Part 2: General chart of how to tx patient you sus ischemia or infarction

A
66
Q

What is the first line tx for ischemic heart disease

A

ASA

67
Q

MOA of ASA

A

IRREVERSIBLE inhibition of platelet aggregation

68
Q

If ACS, how much ASA do we give?

A

162-325 mg chewed

69
Q

If ACS but have ASA allg, what do we give?

A

P2Y12 Inhibitor- Clopidogrel, Prasugrel, Ticagrelor

70
Q

ASA should be used with caution for what disorders?

A

Active Peptic Ulcer Disease or bleeding disorders

71
Q

What are the three P2Y12 Inhibitors?

A

Clopidogrel
Prasugrel
Ticagrelor

72
Q

MOA of P2Y12 Inhibitors

A

Irreversible Inhibition of platelet aggregation

73
Q

Load ______ prior to heart cath

A

P2Y12, usually Clopidogrel

(Because it lowers risk of ischemic event)

74
Q

If someone is getting a CABG, how long should they be off P2Y12 before the procedure?

A

Clopidogrel or Ticagrelor-5 days before procedure
Prasugrel- 7 days before procedure

75
Q

What are the 3 Glycoprotein 2b/3a Inhibitors?

A

Tirofiban
Eptifibatide
Abciximab

76
Q

MOA of Glycoprotein 2b/3a Inhibitors

A

Inhibits platelet aggregation

77
Q

If someone has ongoing ischemia despite ASA and P2Y12 inhibitor, what med might we try?

A

Glycoprotein 2b/3a Inhibitors

78
Q

If someone needs urgent CABG but cannot use their P2Y12 inhibitors, what med can we give them?

A

Glycoprotein 2b/3a Inhibitors

79
Q

What are the Anticoag meds?

A

INDIRECT Thrombin Inhibitors:
Unfractioned Heparin
Low Molecular Weight Heparin:
-Enoxaparin
-Fondaparinux
-Dalteparin

DIRECT Thrombin Inhibitors:
Bivalirudin (only used in cath lab)

80
Q

T/F: Changing from one Anti-coag to another is recommended

A

FALSE

81
Q

T/F: LMWH is more effective than UFH in preventing recurrent ischemic events in ACS

A

True

82
Q

Nitrate MOA

A

Nitrate that enters vascular smooth muscle and is converted to Nitric Oxide= activates cGMP and vasodilation

83
Q

Nitrate needs to be used in caution with what issues?

A

HoTN SBP<100
Low HR
High HR
RV infarcation

84
Q

SE of Nitrates

A

HA, reflex high HR

85
Q

Nitrate has DDI with what?

A

PDE5 Inhibitors

86
Q

What is the only type of MI in which Nitrate is NOT the first line option for ACS CP?

A

Inferior Wall MI

87
Q

MC long acting nitrate which can also be used as a daily med for chronic stable angina

A

Isosorbide Mononitrate

88
Q

Morphine will lower what?

A

Sympathetic tone
Systemic Vascular Resistance
O2 demand

89
Q

Morphine should be used with CAUTION with what dx?

A

HoTN, Hypovolemia, Respiratory Depression

90
Q

What are Beta Blocker CI?

A

Acute CHF
Heart Block
HoTN

91
Q

How do Beta Blockers help with MI?

A

REDUCES the following:
-Infarct size and complications
-Rate of re-infarcation
-Rate of life threatening tachyarrhythmias

Prevents Cardiac remodeling

92
Q

Ranolazine MOA

A

Late Na-Channel Blocker which decreases intracellular Ca overload

93
Q

What are the advantages of Ranolazine?

A

NO effect on HR or BP
Safe to use with ED meds

94
Q

Ranolazine may prolong ______

A

QT

95
Q

Ranolazine is used for what?

A

Chronic stable angina
(usually used if can’t tolerate nitrate bc this med is very expensive)

96
Q

Why are ACEIs helpful post-MI?

A

The body will increase ACE activity post-MI which will lead to remodeling and fibrosis

Using ACEI will reduce the fibrosis and remodeling

97
Q

Sometimes patients can take _____ if LV dysfunction

A

Aldosterone Antagonist

98
Q

When do we use Fibrinolytic Therapy?

A

ONLY IF STEMI!

99
Q

What are the 2 Fibrinolytics?

A

Altepase
Tenecteplase

100
Q

After completing fibrinolytic infusion with STEMI since PCI was not available, what should be started?

A

ASA and Anticoag (LMWH preferred)

Use until revascularization or for entire hospital stay

(max of 8 days)

101
Q

If its going to take longer than 90 minutes to get to a cath lab, what should we do?

A

Administer Fibrinolytics then transfer

102
Q

If MI tx is failing to reperfuse body, what would we do?

A

Salvage angioplasty
Generally do if pain and ST elevation persist over 90 minutes after bolus

103
Q

ALL patients with STEMI that was treated with fibrinolytics, should be started on a prophylactic treatment with what?

A

PPIs “-prazole”

104
Q

What are the CIs to Thrombolytic therapy

A

ANY prior ICH
Cerebral Vasc lesion
IC neoplasm
Ischemic stroke in last 3 mo
Sus aortic dissection

105
Q

How does a Percutaneous Coronary Intervention (PCI) work?

A

Minimally invasive procedure that widens the blocked vessel

It is ONLY helpful to UNstable disease

106
Q

What are the two types of PCI?

A

Balloon Angioplasty
Stent Angioplasty

107
Q

What are the PCI Stent types?

A

Bare Metal Stents (BMS)
Drug-Eluting Stents (DES)

108
Q

Describe the details of Bare Metal Stents

A

Is a stent withOUT a coating
Restenosis rate is high

109
Q

Describe the details of Drug-Eluting Stents

A

**Preferred stent for PCI
Slowly releases a drug that blocks cell proliferation

110
Q

Drug-Eluting Stents are not available to all patients because ?

A

They require a longer period of Dual Anitplatelet Therapy

111
Q

After someone has a PCI, what are the education points we must give them for recovery?

A

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
Q

What are the 2 meds for DAPT after a PCI?

A

ASA + P2Y12 Inhibitor

Helps reduce risk of MI or death

113
Q

What is an atherectomy?

A

Catheter that removes the plaque from vessel walls

114
Q

What medication therapy is needed after an atherectomy?

A

DAPT

115
Q

What is Coronary Artery Bypass Grafting (CABG)

A

Vessels are harvested from elsewhere in the body and grafted to the coronary arteries

It helps improve blood supply to myocardium

116
Q

What are the types of Coronary Artery Bypass Surgery

A
117
Q

When is CABG the preferred method for revascularization

A

-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
Q

Explain how the CABG procedure happens

A

Heart is stopped which means we use cardiopulmonary bypass
OR
Can be done “off pump” while heart is still beating

119
Q

What is Enhanced External Counterpulsation?

A

NON-invasive procedure where cuffs are placed around LE that inflate and deflate with cardiac cycle rhythm

120
Q

What is the point of using Enhanced External Counterpulsation?

A

Reduce cardiac workload
Diminishes symptoms of ischemia, improves functional capacity and quality of life

121
Q

How often is Enhanced External Counterpulsation done for?

A

Done 1-2 times daily for 1+ months

121
Q

How long can results last for Enhanced External Counterpulsation?

A

5 years

CV (6 decks)

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