Ischemic Heart Disease (2) Flashcards
1
Q
Why is PCI preferred over thrombolytic therapy for severe heart failure?
A
Because they will probably end up needing assistive devices anyways (balloon pump, impella, etc)
2
Q
Indications for Percutaneous Coronary Intervention for a STEMI:
A
- If there is contraindications to thrombolytic therapy
- Severe HF and/or pulmonary edema
- Symptoms present for 2-3 hours
- Mature clot
3
Q
The combination of what 2 things provide the maximum chance of achieving normal antegrade coronary blood flow and decreases the need for a subsequent revascularization procedure?
A
Intracoronary stents and antiplatelet drugs
4
Q
What is the ideal timeframe to perform an angioplasty for a STEMI?
A
Within 90 minutes of arrival and within 12 hours of symptom onset
5
Q
What situations would need a CABG for a STEMI?
A
- Coronary anatomy that inhibits PCI
- Failed angioplasty
- Evidence of infarction-related ventricular septal rupture or mitral regurg
6
Q
Causes of unstable angina/NSTEMI:
A
- Reduction of myocardial oxygen supply
Rupture or erosion of a coronary plaque - Dynamic obstruction due to vasoconstriction
- Worsening coronary luminal narrowing
- Inflammation
- Myocardial ischemia
7
Q
Presentation for unstable angina/NSTEMI:
A
- Angina at rest - lasting >10 minutes
- Chronic angina pectoris - more frequent and more easily provoked
- New-onset angina - severe, prolonged or disabling
8
Q
Why is chronic angina pectoris more easily occuring than unstable angina?
A
Because of the narrowing of the vessel so there’s less blood flow
9
Q
What is the acute phase of treatment for unstable angina/NSTEMI directed at?
A
Decreasing myocardial oxygen demand and stabilizing culprit lesion
10
Q
What is the longer term phase of treatment for unstable angina/NSTEMI directed at?
A
Prevention of disease progression and future plaque erosion and rupture
11
Q
Treatment for unstable angina/NSTEMI:
A
- Bedrest, oxygen, analgesia, and B-blocker therapy
- Sublingual or IV nitroglycerin
- Calcium channel blockers
- Aspirin, clopidogrel, prasugrel or ticagrelor and heparin therapy
12
Q
_____ _____ is not indicated in UA/NSTEMI and has been shown to increase mortality.
A
Thrombolytic therapy
13
Q
Risks for PCI:
A
- Thrombogenesis from vessel injury
- Bleeding/rupture
- Can increase ischemia (completely occluding artery for a short period of time)
14
Q
What are the 3 types of PCI?
A
- Balloon angioplasty
- Bare-metal stent
- Drug eluding stent
15
Q
Reendothelialize after balloon angioplasty-
A
2-3 weeks
16
Q
Reendothelialize after bare-metal stent placement-
A
12 weeks
17
Q
Reendothelialize after drug-eluting stent:
A
A full 1 year or longer
18
Q
____ ____ discontinutation is the most significant independent predictor of stent thrombosis
A
P2Y12 inhibitor
19
Q
Most common combination of meds for dual antiplatelet therapy:
A
Aspirin with P2Y12 inhibitor
20
Q
How soon do you D/C DAPT before surgery to reduce bleeding risk?
A
- Clopidogrel or ticagrelor - 5 days
- Prasugrel - 7 days
- Continue ASA if possible
21
Q
Timing of the operation after PCI
A
22
Q
What are important parts of the pre-op assessment for ischemic heart disease?
A
- Determine presence of risk factors
- Evaluate METs
- Co-existing non-cardiac disease
- Physical exam
- Specialized testing
23
Q
Ischemic heart disease medications:
A
- Beta blockers
- Alpha 2 agonists (decrease sympathetic outflow, BP and HR)
- ACE Inhibitors
- Statins
- DAPT
- Control hyperglycemia
24
Q
Revised Cardiac Risk Index:
A
25
Components of RCRI:
26
Functional Capacity:
27
It is suggested that more than __ days should elapse after a recent MI before noncardiac surgery is undertaken
60
28
Active cardiac conditions that may increase the risk of perioperative adverse cardiac events:
- Unstable coronary syndromes
- Unstable or severe angina
- Decompensated heart failure
- Severe valvular heart disease
- Significant dysrhythmias
- Age
29
What are risk factors for ischemic heart disease? (1st 2 are most important)
*Male Gender*
*Increasing Age*
Hypercholesterolemia
HTN
Smoker
DM
Obesity
Sedentary lifestyle
Genetics
30
____% of surgical patients have ischemic heart disease
30%
31
What are the first manifestations of ischemic heart disease?
* Angina pectoris
* Acute MI
* Sudden death (dysrhythmias)
32
Stable angina develops in partial occlusion or >____% narrowing of coronary artery
70%
33
How is stable angina characterized?
Chest pain relieved by rest
34
What vital sign changes are associated with decreased coronary blood flow? What about if you are under GA?
* ↓BP and ↑ HR
* EKG changes when under anesthesia
35
What causes Angina Pectoris?
Imbalance between coronary blood flow and myocardial O2 consumption
36
________ is the most common cause of impaired coronary blood flow resulting in angina
Atherosclerosis
37
What mediators are released with angina and what do they do?
-Stimulate cardiac nociceptors→ afferent neurons coverage T1-T5 sympathetic ganglia→ produce thalamic and cortical stimulation causing chest pain
*Release of Adenosine and bradykinin
-Slow AV conduction and decrease cardiac contractility (attempting to balance O2 supply and demand)
38
What are common signs and symptoms of angina pectoris
- Retrosternal chest pain, pressure, heaviness
-Radiates to neck, left shoulder, left arm, or jaw
- SOB, Dyspnea
39
Which group of people have atypical presentation of angina pectoris?
- Diabetics
- Females
Me ;)
40
What are some things discussed in class that can cause chest pain?
- Physical exertion
- Emotional tension
- Cold weather
41
Describe chronic stable angina:
Chest pain that does NOT change in frequency or severity in 2-month period
42
What causes chronic stable angina?
Distal occlusions
43
What are characteristics of unstable angina?
Angina at rest (>10min)
Unstable angina is chest pain increasing in frequency and/or severity without increase in cardiac biomarkers
44
What are some chest pain differential diagnoses?
(I'm sorry I simply could not type this one)
45
What diagnostic tests can be done when someone presents with chest pain?
- 12 lead EKG
- Exercise stress test
- Nuclear stress imaging
- Echo
- Coronary Angiography
46
What EKG changes correlate with likelihood of significant coronary artery disease?
Greater ST depression = more significant CAD
47
Which test has the greatest sensitivity for detecting ischemic heart disease?
Nuclear stress imaging
48
What does the nuclear stress imagining assess?
- Coronary perfusion
- Size of perfusion abnormality
- Estimates LV systolic size/fxn
- Differentiates new from"Old" MI
49
What tracers are used for nuclear stress imaging?
- Thallium
- Atropine, Dobutamine, Pacing
- Adenosine, Dipyridamole
50
What diagnostic study is used to diagnose Prinzmetal angina?
Coronary angiography
51
What does an area of ischemia look like in an echo?
Wall motion abnormalities
52
Which diagnostic for chest pain can determine the location of occlusive disease?
Coronary angiography
(does not measure stability of plaque)
53
Non-pharmacologic treatment for angina?
- Stop smoking
- Lose weight
- Low fat/low CHO diet
- Regular exercise
- HTN treatment
54
Primary drug therapy for angina pectoris:
- ASA
-Platelet glycoprotein IIb/IIa receptor antagonists
- P2Y12 inhibitors
- Prasugrel (short term in cathlab)
- Nitrates
- Beta blockers
- CCB
- ACE inhibitors
- Statins
55
All patients with suspected AMI should receive ______.
Aspirin
if allergic should get P2Y12 inhibitor
56
MOA of aspirin and dose:
- Irreversibly inhibits COX-1 (thromboxane A2)
- 75 – 325 mg/day
57
MOA of glycoprotein IIb/IIa receptor antagonists:
- IV, more effective than ASA (short half lives)
- Inhibit platelet activation, adhesion, and aggregation
58
What is a typical platelet lifespan?
7-14 days
59
MOA of Clopidogrel (Plavix):
- Inhibits ADP receptor P2Y12 and platelet aggregation
- Irreversible, platelet life span
-D/C ~ 80% of platelets recover to normal function
- Prodrug: variability from person to person
60
What class of drug is Prasugrel? When is it used?
P2Y12 inhibitor (Thienopyridines)
-More predictable pharmacokinetics than plavix
- Higher risk of bleeding (given short term in cath lab)
61
What are characteristics of Nitrates?
-Decrease frequency, duration, and severity of chest pain
-Increase exercise to produce ST-segment depression
- Dilate coronary arteries and collaterals
- Decrease peripheral vascular resistance
- Decreases preload
- Potential anti-thrombotic effects
62
What are drug interactions with Nitrates?
- Synergistic with beta blocker and CCBs
63
What diseases are nitrates contraindicated?
-Aortic stenosis
- Hypertrophic cardiomyopathy
64
What class of drug is the only drug to prolong life in CAD patients?
Beta blockers
65
Do you stop beta blockers preop?
No, want to continue them or stop and give something similar (esmolol)
66
Which drugs are B1 selective beta blockers?
-Atenolol
-Metoprolol
- Acebutolol
- Bisoprolol
67
Beta 2 adrenergic blockers:
-Propranolol
- Nadolol
68
What are the benefits of beta 1 blockade for angina?
- Lower HR
- Increase diastolic time
- Decrease myocardial contractility
- Decrease myocardial O2 demand
69
Which patients do you want to avoid beta 2 blockers in?
Reactive airway → increase risk of bronchospasm
70
What type of angina are CCBs appropriate for?
- Prinzmetal/ Variant Angina
- Uniquely effective for decreasing frequency/severity of spasm
71
What is the MOA of CCBs?
- Dilated coronary arteries
-Decreases vascular tone
- Decreases contractility
- Decreases O2 consumption
- Decreases Systemic BP
72
What do ACE inhibitors treat?
- Hypertension
- Heart failure
- Cardioprotective
73
ACE inhibitors block conversion of angiotensin I to angiotensin II. What does angiotensin II do?
- Increases myocardia hypertrophy
- Increases interstitial myocardial fibrosis
- Increases coronary vasoconstriction
- Increases inflammatory responses
74
What is the purpose of statins?
- Coronary plaque stabilization
- Decreases lipid oxidation
- Decreases inflammation
- Decreases matrix metalloproteinase
- Decreases cell death
75
What drug reduces mortality in noncardiac surgery and vascular sugery?
Statins
76
When is revascularization (PCI) indicated?
- Meds fail
- >50% L main coronary artery
- >70% epicardial coronary artery
- Impaired EF <40%
77
When is CABG preferred treatment over PCI?
- 50% LAD occulsion
- Coronary artery stenosis 70% occluded
- 3 vessel coronary artery disease
- DM pt who have 2-3 vessel CAD
78
What is acute coronary syndrome?
Acute or worsening imbalance of myocardial oxygen supply to demand → leads to chest pain
79
What are causes of acute coronary syndrome?
- Atheromatous plaque
- Coagulation cascade
- Thrombin generation
- Arterial occlusion
80
What are the 3 categories of acute coronary syndrome based on 12-lead ECG and cardiac biomarkers?
- STEMI
- Non STEMI
- Unstable angina (cardiac makers - )
81
What causes an MI?
- Coronary blood flow decreases abruptly
- Acute thrombus formation
82
What is the process of thrombus formation?
-Collagen, ADP, epinephrine, serotonin
- Thromboxane A2
- Glycoprotein IIb/IIIa receptors
- Fibrin deposit
83
When is the term myocardial infarction used?
When there is evidence of myocardial necrosis
84
What diagnostic data is indicative of myocardial infarction:
- Rise/fall of cardiac biomarkers (trop) AND evidence of myocardial ischemia indicated by at lease one of the following:
-Symptoms of ischemia
-ECG changes (new ST, T changes LBBB)
- Pathologic Q waves
- Imaging evidence of new loss of viable myocardium or new regional wall motion
- ID of intracoronary thrombus by angiography
85
When does troponin increase?
Increase within 3 hours after myocardial injury
86
What cardiac lab test is more specific for cardiac damage than CK-MB?
Troponin
87
When would fentanyl be given over morphine for patient having an MI?
Fentanyl over morphine to avoid hypotension
88
Drug therapy for Acute coronary syndrome:
-MONA
- P2Y12 inhibitors
- Platelet glycoprotein IIb/IIIa inhibitors
- Unfractionated heparin
- β blockers
89
What meds are used for thrombolytic therapy?
- tPA
- Streptokinase
- Reteplase
- Tenecteplase
90
What is the time frame to give tPA?
- Earlier the better
- 30-60min of hospital arrival, within 12 hours of symptom onset
91
What is the goal of thrombolytic therapy?
Restore normal anterograde blood flow in occluded coronary artery
92
What is the urgency of surgery if life or limb would be threatened if surgery did not proceed within 6 hours or less?
Emergency
93
What is the urgency of surgery is life or limb would be threatened if surgery did not proceed within 6 to 24 hours?
Urgent
94
What is the urgency of surgery if delays exceeding 1 to 6 weeks would adversely affect patient outcomes?
Time-sensitive
95
Pre-op Cardiac Risk Assessment Algorithm
96
ACC/AHA algorithm recommends that a patient with a functional capacity of ____ METs should proceed directly to surgery
4 or more
97
Preoperative _____ ______ is most suitable for patients with stress test results suggesting significant myocardium at risk
coronary angiography
98
What are the goals for anesthesia in patients with ischemic heart disease?
- Prevent myocardial ischemia
- Monitor for ischemia
- Treat ischemia
99
What are anesthetic considerations for prevention of ischemic heart disease?
- Persistent tachycardia
- Systolic HTN
- SNS stimulation
- Arterial hypoxemia
- Hypotension
**Maintain BP and HR within normal awake baseline
100
What things are a result of decreased oxygen delivery?
- Decreased coronary blood flow
- Tachycardia
- Hypotension
- Hypocapnia
- Coronary artery vasospasm
- Decreased oxygen content
- Anemia
- Arterial hypoxemia
- Shift of the oxyhemoglobin dissociation curve to the left
101
In patients with Ischemic HD, hyperventilation must be avoided because _____ may cause coronary artery vasoconstriction
Hypocapnia
102
What things increase oxygen requirements in patients with ischemic HD?
- SNS stimulation
- Tachycardia
- Hypertension
- Increased myocardial contractility
- Increased afterload
- Increased preload
103
Why might opioids be preferred at the principal anesthetic?
Patients with severely impaired LV function may not tolerate anesthesia induced myocardial depression
104
What meds would you give if HTN exists longer than 15 seconds while intubating and why?
Laryngotracheal lidocaine, IV lidocaine, esmolol, fentanyl, remifentanil and precedex
- they can all blunt the increased HR caused by intubation
105
Anesthetic considerations for ischemic heart disease:
- Succinylcholine, vec, roc, cis
- DL 15 seconds or less
- Volatile anesthetics
- Nitrous oxide
- Opioids
- Neuraxial anesthesia (epidural may be better to prevent hypotension)
106
Why would volatile anesthetics be beneficial in patients with ischemic hd?
they decrease myocardial oxygen requirements and may precondition the myocardium to tolerate ischemic events
107
Why could volatile anesthetics be detrimental in patients with ischemic hd?
they lead to a decrease in blood pressure and an associated reduction in coronary perfusion
108
What are the risks of using epidural or spinal anesthesia in patients with ischemic hd?
They decrease blood pressure - prompt treatment of hypotension that exceeds 20% of the preblock blood pressure is necessary
109
What is the drug of choice for tachycardia in patients with ischemic hd?
Esmolol
110
What is the drug of choice for bradycardia in patients with ischemic hd?
Glycopyrrolate (over atropine)
111
Treatment for hypotension in patients with ischemic hd:
- Fluid bolus
- Sympathomimetic drugs: ephedrine preferred over epi because it won't make you tachycardic
112
Monitoring for Ischemic HD:
113
Vessel occlusion:
