Ischemic Heart Disease Flashcards
Major Risk Factors
Primary cause of ischemic heart disease is atherosclerotic occlusion of the coronary arteries
Major risk factors include
Diabetes mellitus (most important and considered a CAD equivalent)
Dmoking (#1 preventable factor)
HTN
High cholesterol / Hyperlipidemia (total cholesterol - HDL ratio > 5.0)
Family history
Age > 65
Minor Risk Factors
Obesity
Lack of estrogens
Homocystinuria
Cocaine use
Amphetamine use
Symptoms
Range from asymptomatic
Particularly in older women and diabetics to substernal tightness and/or pain and dyspnea
Stable Angina
Predictable; presents with consistent amount of exertion
Patient can achieve relief with rest or nitroglycerin
Indicative of a stable, flow-limiting plaque
Unstable Angina
Unpredictable; often presents at period of inactivity
Defined as any new angina or rapidly worsening stable angina
Limited improvement with nitroglycerin, and usually recurs soon afterward
Indicative of a ruptured plaque with subsequent clot-formation in vessel lumen
Physical exam
In asymptomatic patients is usually normal
Can demonstrate mitral regurgitation murmur and/or S4 during episodes
May also include signs of CHF from prior MI including
Elevated JVD
Lower extremity edema
Crackles
and other signs of vascular disease including
Bruits
Ischemic ulcers
Diminished pulses
Evaluation
Cardiac catheterization for definitive diagnosis
locate and assess severity of the lesion(s)
CXR
to rule out aortic dissection
Elevated cardiac biomarkers
troponin, CK, and/or CK-MB may be present
EKG
shows ST elevation or depression depending on severity of ischemia and Q waves
Stress-testing
to evaluate simultaneously with EKG, echo, and radionuclide perfusion studies
for patients without a history of prior coronary artery disease, all antianginal medications (beta-blockers, nitrates, calcium channel blockers) should be held for 48 hours before a stress test
for pharmacological stress tests using adenosine or regadenoson, use of dipyridamole should be held for 48 hours and intake of caffeine held for 12 hours to minimize false negative findings of ischemia
Differential
Myocardial infarction, aortic dissection, GERD, pericarditis, pulmonary embolism, spontaneous pneumothorax, esophageal spasm, and musculoskeletal disorders
Treatment ACS
In acute coronary syndrome use
Morphine
Oxygen
Nitroglycerin
Aspirin
ACEI’s
may also use β-blockers, GPIIb/IIIa antagonists, angioplasty
Treatment Post MI
Drugs that improve post-MI mortality rates include
Aspirin
β-blockers
ACEIs
ARBs
HMG-CoA reductase inhibitors
NOT calcium channel blockers
Prognosis, Prevention and Complications
Must control diabetes considered a CAD equivalent causing MI to often present atypically in these patients
Manage hypertension (<140/90 mmHg)
Manage cholesterol levels (<70 mg/dL)
Encourage smoking cessation and alcohol obstention
MI prevention with
Aspirin or clopidogrel (for ASA sensitivities)
Angina prevention with
β-blockers to lower HR, increase myocardial perfusion time and decrease cardiac work load
Nitrates + calcium channel blockers in severe or recurring cases
High Yield
Patient with chest pain, shortness of breath, left arm pain, jaw pain
next step in management: chewable aspirin, 325 mg (can add ADP antagonists as well)
other drugs to administer after best initial step: β-blockers, oxygen, morphine, and nitrates (none of these decrease mortality except β-blockers in the long term)
best initial test: EKG
most accurate test: cardiac angiogram
next step in management
primary angioplasty - best option
thrombolytics - alternative option if angioplasty is not available or it would take time to deliver
mortality lowering medications for long term management
aspirin
β-blockers
statins
ACE inhibitors/ARB’s (lower mortality if systolic dysfunction)
