**Ischemic Heart Disease Flashcards
Stable angina c/f
- Coronary artery NOT completely blocked
- Chest pain worse on exertion
- Lasts <10mins
Coronary Artery disease includes (3)
- Stable angina
- Acute coronary syndromes
-Unstable angina
-Non - ST elevated Myocardial infarction- ST elevated Myocardial infarction
- Variants of angina
Mc r/f of CAD
HTN
Most sever/worst r/f of CAD
DM
Most important reversible r/f of CAD
LDL cholesterol
Most imp r/f to eliminate to see immediate benefit in CAD
Smoking (↓50% risk in 1yr, ↓90% in 2yrs)
Menstruating women virtually never have myocardial infarctions. Why?
Protective effect of menstruation and
Estrogen
Tako Tsubo cardiomyopathy
Post overwhelming emotional stress
Ballooning of apical LV, Lv dyskinesis
*Coronary angio normal
ST elevated
Pt with left sided chest pain,
ECG shows elevated ST seg. Next step Cardiac markers? Diagnosis?
ST segment elevated -
Diagnosis: STEMI
Pt with left sided chest pain,
ECG normal/no ST elevation. Next step Cardiac markers? Diagnosis?
Cardiac troponin
Positive - NSTEMI
Negative - Unstable angina
Thrombolytic therapy is beneficial in?
STEMI - complete blockade
Harmful in Unstable angina and NSTEMI
Exercise tolerance test/Stress test (ETT)
Done for stable angina
Chest pain h/o on exertion
ECG normal
Cannot pin point etiology
Pt should be able to run on threadmill
Chest pain h/o on exertion
Cannot pin point etiology
ECG BASELINE ABNORMALITIES,
what tests are indicated?
Baseline abn ECG d/t LBBB, LVH
While exercising below inv can be done
1. Nuclear isotope uptake: thallium or sestamibi
Myocardial perfusion scan
↓Uptake - artery block
2. ECHO - ↓wall motion (low blood supply)
When results are abn, do
●CT - Coronary angio
●Best - invasive coronary angiogram
<50% insignificant
>70% block - STENT in the same procedure
Chest pain h/o on exertion
Cannot pin point etiology
ECG normal
But pt cannot execise, what can induce exercise like symptoms?
Dipyridamole/Adenosine with nuclear scan
Dobutamine with ECHO
Criteria for Stent and CABG in CAD
Stent:
2 vessels are blocked
CABG/Bypass Sx:
2 vessels blocked with DM
3 vessels blocked
Left main artery blocked (50% stenosis)
Holter monitor
Ambulatory, continuous ECG monitor
RHYTHM EVALUATION - AF, flutter, ectopy such as premature beats, ventricular tachycardia.
Cannot detect ischemia/ST seg
STEMI Mx
●MONA therapy - initial
1. ASPIRIN (30mg loading dose)
2. Morphine - chest pain
3. NTG if chest pain not reduced with morphine (nitroglycerine)
4. O2 if sat <90%
●SEND IMMEDIATELY TO CATHETER LAB - with in 90mins
Percutaneous coronary intervention (PCI) performing ..
CT-CA stent/CABG
●In absence of catheter lab, THROMBOLYTICS (tPA tissue plasminogen activator) - within 6hrs
Streptokinase not used in aus
(Clopidogrel, prasugrel, or ticagrelor if aspirin C/I)
STEMI symptoms onset <12 hrs and >12hrs mx
<12 hrs - Aspirin, PCI»_space; thrombolytics
> 12 hrs - same mx, urgency wont change outcome
NSTEMI Mx
No ST seg elevation, ST DEPRESSION seen in few cases
Troponin positive
First - Aspirin …
Troponin
Next - Heparin (URGENT) to avoid clotting (does not break clots)
No ST elevation - thrombolysis not req
Angiogram with in 48hrs - >70% block - stent
Mcc of death after PCI for CAD
Ventricular fibrillation
Complications of CAD
- Postinfarction angina after PCI - do bypass Sx
- Pump dysfunction
●Contractile dysfunction - LV, RV, Both ventricles, true aneurysm
●Mechanical- mitral regurgitation, pseudoaneurysm
●Electromechanical dissociation - Dressler syndrome: MI f/b Pericarditis like pain
Mx- Aspirin, NSAIDs
Prinzmetal angina
Caused d/t spasm of coronary artery
Happens at rest
ST elevation only during episodes - difficult to diagnose
ETT, CT-CA will be normal
●Diagnosis:
Ergonovine - causes coronary artery spasm - ST elevation
●Rx:
NTG/CCB
ECG in NSTEMI
- ST depression -
downsloping/horizontal in 2 contiguous leads significant (upsloping not significant) - T wave flattening or inversion
