Ischemic Heart Disease Flashcards
What is the typical in a patient history for stable angina?
Symptoms precipitated by stress or exertion. Relieved by rest or nitrates. Long standing >1-2 months
What is the typical in a patient history for unstable angina?
Chest pain at rest or with minimal exertion. New onset angina. Worsening angina (crescendo)
How is ischemic heart disease classified?
class I: asymptomatic. class II: mild limitation of excercise tolerance and sx w/ordinary exertion. class III: moderate limitation of excercise tolerance and sx w/minimal exertion. class IV: severe limitation of activities and sx at rest
What labs should be done for unstable angina?
troponin I, CK-MB, CBC, TSH, update lipids, CMP, DM
What EKG changes are suggestive of ischemia?
New bundle branch block, T wave inversion, depression or flattening, ST depression or elevation, Q waves
When is cardiac catheterization/coronary angiography indicated for chronic stable angina?
Persistent limiting angina despite maximal medical therapy. Stress test suggestive of high risk disease.
History of aortic valve disease. Worsening symptoms
How are short acting nitrates used for immediate relief of anginal sx?
0.4mg sublingual nitroglycerin tablets or spray. Repeat in 3-5 min if needed until pain is gone. Pain lasting > 20 min call EMS
How do nitrates decrease the O2 demand on the heart?
causes vasodilation that decreases arteriolar and venous tone, preload, afterload, and BP.
What are most common side effects of nitroglycerin?
HA, dizziness, hypotension, flushing
What are contraindications to nitrates?
hypotension, aortic stenosis, volume depletion, acute RV infarction, hypertrophic cardiomyopathy, ED meds
Describe the use of long acting nitrates for ischemic heart disease
Used to prevent sx. added to beta blockers or calcium channel blockers. Need a nitrate free interval of 8-10 hours a day to help prevent development of tolerance
What are the three long acting nitrates?
Isosorbide dinitrate (Isordil), Isosorbide mononitrate (Imdur), Transdermal patch (NitroDur)
What is the first line therapy for treatment of angina?
beta blockers: decrease HR, contractility, rate of AV conduction therefore decreasing myocardial O2 consumption
What are contraindications to beta blockers?
Severe bronchospasm, Bradyarrhythmias, Decompensated heart failure, May worsen Prinzmetal’s angina
What is the only approved calcium channel blocker for use with CHF?
Amlodipine (Norvasc). Belongs to class of dihyropyridines which don’t decrease HR or contractility
Name the calcium channel blockers
Dihydropyridines: Amlodipine (Norvasc) and Nifedipine (Adalat, Procardia). Nondihydropyridines: Diltiazem (Cardizem) and Verapamil (decrease HR and contractility)
What are the common side effects of calcium channel blockers?
edema*, HA, constipation, hypotension, dizziness, bradycardia (nondihyropyridines-Cardizem/Verapamil)
What are contraindications to nondihyropyridines (Diltiazem/Verapamil)?
Systolic CHF, AV block or bradycardia
What are the common antiplatelet agents used for ischemic heart disease?
Aspirin 81-325 mg daily or Clopidogrel (Plavix) 75 mg
What diagnostic results characterize vasospastic/Prinzmetal’s/Variant angina?
EKG evidence of ischemia during pain (ST elevation), Normal exercise tolerance, Normal coronary angiogram
What is vasospastic/Prinzmetal’s/variant angina?
chest pain w/o usual precipitating factors that may awaken pt from sleep, be associated with arrhythmias or conduction defects, and presents in a cyclical pattern over months
What are vasospasm triggers?
Exposure to cold, Emotional stress, Vasoconstricting meds, Cocaine, Tobacco, Beta blockers
What disorders are associated with coronary vasospasm?
concomitant coronary artery disease, Migraine headaches, or Raynaud’s phenomenon
How is a coronary vasospasm treated?
Rule out obstructive disease with cardiac catheterization. SL nitro for acute relief. Calcium channel blockers and long acting nitrates for prevention. NO beta blockers
What three medical conditions are classifed as acute coronary syndromes?
NSTEMI, unstable angina, STEMI
What is the EKG criteria for diagnosis of NSTEMI?
New horizontal or down sloping ST depression > .05 mV in 2 contiguous leads and/or T wave inversions
What is the EKG criteria for diagnosis of STEMI?
ST elevation at the J point in 2 contiguous leads of ≥ .1mV. ST elevation ≥ .2mV in men or ≥ .15mV in women in leads V2, V3
What is the medical therapy for unstable angina and NSTEMI?
Oxygen, Nitroglycerin, Morphine, Beta blockers, Antiplatelet therapy, Anticoagulation
What should be added to the antiplatelet therapy for NSTEMI after checking with a cardiologist?
a P2Y12 receptor blocker (platelet inhibitor): Clopidogrel (Plavix), Prasugrel (Effient), Ticagrelor (Brilinta). Often wait until after angiogram because they irreversible inhibit platelets
What is recommended for anticoagulation in unstable angina instead of heparin?
Enoxaparin (Lovenox): 1mg/kg subcutaneous Q 12 h
What should be added to anticoagulation therapy for patient’s with NSTEMI who are high risk and have early invasive surgery in addition to heparin?
GP IIb/IIIa inhibitor: Abciximab (Reo Pro), Eptifibatide (Integrilin), Tirofiban (Aggrastat)
What should be provided to all ischemic heart disease before discharge?
Statins: Atorvastatin (Lipitor) 80 mg daily
What % of risk of all cause mortality for MI are associated with each TIMI score?
0-1: 4.7%. 2: 8.3%. 3: 13.2% 4: 19.9% 5: 26.2% 6-7: at least 40.9%
How is a cocaine associated MI treated?
similar to other ACS patients except give benzodiazepines early and do not use beta blockers
What is a STEMI?
MI due to complete obstruction of the coronary artery
What is medical therapy for STEMI?
same as for NSTEMI plus fibrinolytic therapy or PCI
What is the first line therapy for STEMI?
primary percutaneous coronary intervention (PCI) unless not available within 90-120 minutes otherwise administration of fibrinolytics
What is the mechanism of action of fibrinolytics?
Initiation of local fibrinolysis by binding to fibrin in the thrombus and converts entrapped plasminogen to plasmin
What are contraindications to fibrinolytics?
intracranial hemorrhage, ischemic stroke, cerebral vascular malformation, metastatic intracranial malignancy, aortic dissection, bleeding disorder, closed head injury
Why is there a greater mortality in NSTEMI vs STEMI?
may be related to the fact that over half of patients with NSTEMI have multivessel disease and a greater likelihood of residual ischemia
