Ischemic HD

Question 1

Myocardial ischemia

Answer 1

clinical symptoms & elevated blood troponin

High-sensitivity troponin detectable 3 h after symptom onset.

Question 2

STEMI

Answer 2

Symptoms + elevated troponins + ECG features:

ST segment elevation defined as J point > 2mm

Question 3

NSTEMI

Answer 3

Symptoms + elevated troponins + ECG features:

no changes or ST depression or T wave inversion or transient changes

Question 4

Angina: new onset

Answer 4

Quantify exertion needed for symptom onset

Question 5

Angina: at rest

Answer 5

Increased risk

Question 6

Indications for preop revascularisation

Answer 6

Left main disease (significant?)

Question 7

Surgery post-CABG

Answer 7

minimum 1 month (sternal healing)

optimally >3 mos

Question 8

Surgery post-stent

Answer 8

Elective sx: > 6 mos

Urgent surgery: minimally 6 weeks of DAPT

Question 9

POISE-2 findings:

Answer 9

Beta-blockers: continue long-term therapy, periop initiation not endorsed (risk of 30d all cause mortality, stroke hypotension)
ASA: Excluded patients for retinal, intracranial & spine sx. Increased bleeding risk for ASA >100 mg / d with no benefit for 30 d MACE or death

Question 10

ASA

Answer 10

Hold 7 days if primary or 2o prevention (< 100 mg?)
Continue with carotid endarterectomy
Continue with prior PCI > 12 mos

Question 11

Statins

Answer 11

continue, improves risk of 30d all cause mortality ACM 
Atorvastatin loading (40 mg) within 18h of surgery in naive pts may be useful (up to 7 days)

Question 12

ACE-I

Answer 12

Risk of hypotension

Must resume within 14d of surgery to prevent increases in ACM

Question 13

ARB

Answer 13

Risk of hypotension

Must resume within 48h of surgery to decrease adverse events 30d post op

Question 14

Indications for diagnostic angiography

Answer 14

Non-invasive testing shows: 
Anterior wall motion abnormalities
Multiple reversible defects
transient ischemic dilatation
Ischemia @ low HR