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Gen Med Unit 7: Cardio > Ischemic Heart Disease 2 > Flashcards

Ischemic Heart Disease 2 Flashcards

1
Q

Define CT angiography

A
  1. Image heart and coronary vessels using contrast medium
  2. High sensitivity excluding significant CAD
  3. Not frequently used due to radiation exposure and contrast load
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2
Q

Define electron beam ct (EBCT)

A
  1. Used to quantify coronary artery calcification

A. Highly correlates w/atherosclotic plaque

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3
Q

When is EBCT used?

A
  1. High sensitivity but low specificity for CAD
    A. Used in moderate CAD risk pts
    B. Pts w/moderate risk have 10–20% chance of having MI w/in the next 10 yrs
    C. Coronary calcium scan may help doctors decide who within this group needs treatment
    D. Selects pts who need more aggressive management of lipids
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4
Q

What are the benefits of cardiac MRI

A

Provides high resolution images of heart and great vessels without radiation exposure or contrast media exposure

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5
Q

What is cardiac MRI used for?

A
  1. Used to assess pericardial disease, neoplastic disease of heart, myocardial thickness, chamber size and many congenital heart defects
  2. Not usually used to assess coronary arteries
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6
Q

What is the definitive procedure for CAD?

A

Coronary angiography

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7
Q

What are the indications for coronary angiography?

A
  1. Unstable angina or MI
  2. Non-invasive testing suggests high risk for CAD
  3. In concomitant aortic valve disease and angina
    A. Used to determine if angina due to CAD
  4. Assess pts pre-operatively for valve surgery
  5. Assess vessels after CABG
  6. Survivors of life threatening arrhythmias
  7. Chest pain of uncertain etiology
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8
Q

What is hemodynamically significant narrowing of a vessel?

A

Narrowing > 50%

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9
Q

What percentage of lumen narrowing is asst. with ischemia producing lesions?

A

> 70%

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10
Q

What is the invasive diagnostic method of choice for ostial left main lesions and coronary dissections?

A

Intravascular ultrasound

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11
Q

How does intravascular ultrasound work?

A

Intravascular ultrasound (IVUS) can be positioned within artery and images below endothelial surface can be obtained

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12
Q

what is the drug of choice for acute ischemia?

A

SL Nitrolycerin (0.4 mg)

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13
Q

How is SL ntg dosed?

A
  1. Acts in 1-2 mins
  2. May be repeated q 3-5 min x 3 doses
  3. Pain not responsive to 3 tabs or lasting > 20 min may represent evolving MI
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14
Q

What is the moa for nitrates?

A

↓ Arteriolar and venous tone
↓ Preload & after-load
↓ Oxygen demand of heart

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15
Q

How is ischemic heart disease prevented?

A 
1. Treat or avoid aggravating factors
A. HTN
B. LV failure
-Causes: Cardiac ischemia, HTN, Aging, Obesity, Aortic stenosis
C. Tachycardia
D. Strenuous activity
E. Cold temperatures
F. Emotional states
2. All of above can precipitate angina
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16
Q

What nitrates are available for ischemic heart disease prevention?

A
  1. Isosorbide dinitrate (Isordil, Dilatrate-SR)
  2. Isosorbide mononitrate ER (Imdur)
  3. Nitroglycerin ointment (Nito-Bid)
  4. Nitroglycerin transdermal patch (Nitro-Dur)
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17
Q

What is the main limitation to nitrates?

A
  1. Main limitation is tolerance

A. To avoid tolerance, recommend 10-12 hr drug free period

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18
Q

What are the se for nitrates?

A

Headache, nausea, lightheadedness, hypotension

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19
Q

What is 1st line therapy in pts with chronic stable angina & post MI?

A

Beta -1 Blockers

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20
Q

What are the effects of beta blockers?

A
  1. ↓ Myocardial oxygen demand
    A. Slows HR, (-) inotropic effect, ↓ workload, coronary art. vasodilation
  2. Only anti-anginal agents that have been demonstrated to prolong life in pts with CAD post-MI
    A. ↓ Risk of sudden death post MI
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21
Q

What are the SE of beta 1 blockers?

A

Impotence, fatigue, bradycardia, insulin resistance

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22
Q

What are the contraindications of beta 1 blockers?

A

Severe bronchospastic disease, bradyarrhythmias, decompensated heart failure [fluid overload, pulm edema, ↓ CO (EF <40%)]

23
Q

What is the goal LDL for pts w/ heart disease?

A

< or equal to 70mg/dL

24
Q

How is goal LDL achieved?

A

Statin

25
Q

When are CCB used in MI pts?

A
  1. Poor evidence that CCB have favorable effect on pt outcomes
  2. CCB should never be considered 1st line agents in post-MI pt
  3. Can be considered 3rd line agent in pt who cannot tolerate nitrates or beta blockers
26
Q

What is the moa of ccb?

A

↓ Myocardial oxygen demand by ↓ after-load

27
Q

What is the newest first line agent in chronic angina?

A

Ranolazine (Ranexa)

28
Q

What is the moa of Ranolazine (Ranexa)?

A
  1. ↓ Intracellular calcium –>prevents calcium overload –> improves diastolic function
  2. No effect on HR & BP, ↓HbA1c, ↓ risk of arrhythmias
29
Q

What are the se of Ranolazine (Ranexa)?

A

Prolongs QT interval, bradycardia, dizziness, headache, hypotension, edema, constipation, nausea, dyspepsia, ↑Cr

30
Q

How is Ranolazine (Ranexa) prescribed?

A
  1. Used alone or in combination with traditional Tx for chronic angina (BB, Nitrates, CCB)
  2. Appears to be more effective in men
  3. Safe to use with ED drugs
31
Q

Why is asa used in preventing cardiac events?

A

Evidence suggests reduction in ischemic vascular events

32
Q

What is asa moa?

A

Inhibits thromboxane A2 → inhibits platelet aggregation

33
Q

why is clopidogrel used in preventing cardiac events?

A

Reduces vascular events

Use if pt intolerant to asa

34
Q

What is clopidogrel’s moa?

A

Irreversibly inhibits binding of ADP to its receptor on plts inhibits activation of GPIIb/IIIa receptors which are required for plt binding to fibrinogen

35
Q

How is the risk of cardiac events reduced?

A 
Aggressive risk factor modification
A. Treat lipids 
B. Treat HTN
C. Stop smoking
D. Aerobic exercise
E.Weight control
36
Q

When is coronary revascularization indicated?

A
  1. Patients with breakthrough sx’s despite medical therapy
  2. Patients with left main coronary artery stenosis > 50% (with or without sx’s)
  3. Patients with 3 vessel disease and LV dysfunction
    A. EF < 50% or previous transmural (full thickness) MI
  4. Successfully medicated patients with recurrent unstable angina & ischemia on stress test
  5. Post-MI pts with angina or severe ischemia on noninvasive testing
37
Q

When is coronary artery bypass grafting used?

A

Commonly used with disease of left main coronary artery

38
Q

What is the procedure for CABG?

A
  1. Grafts using one or both internal mammary arteries to the LAD artery provide best long term results
  2. Saphenous vein also used
39
Q

What risk factors increase the morbidity and mortality of CABG?

A
  1. Age > 70 yrs
  2. Pts undergoing repeat procedures
  3. Pts with DM or CKD
  4. Pts with poor general health
40
Q

Post CABG, when is graft failure likely?

A
  1. Early graft failure is common in vessels with poor distal flow
  2. Late graft failure is common in smokers and those with untreated hyperlipidemia
    A. Treatment goal for hyperlipidemia
    -LDL 70-100 mg/dl
    -HDL > 45 mg/dl
41
Q

What are the early graft patency rates?

A

85-90%

42
Q

What is the goal of PCI percutaneous coronary intervention with stenting (angioplasty)?

A
  1. Can open stenotic coronary arteries
43
Q

How does PCI w/ angioplasty prevent recurrent blockage and peri-procedural MI?

A
  1. Drug-eluting stents -polymer coating over mesh that emits a drug over time to help keep the blockage from recurring
    A. Preferred over bare metal stents (BMS)
  2. During procedure, plt glycoprotein IIb/IIIa inhibitors (abciximab/Reopro) reduces rate of peri-procedural MI
44
Q

What is a peri-procedural MI?

A
  1. After PCI, all pts should have troponin and CK-MB checked

A. A new rise > 3 x the upper limit of normal constitutes peri-procedural MI

45
Q

How is acute thrombosis after stent placement prevented?

A
  1. aggressive antithrombotic therapy
46
Q

What are the antithrombotic treatment options after PCI?

A 
1. ASA 81-325 mg po qd 
A. Lifetime
2. Clopidogrel (Plavix) 75 mg po qd
A. 6 months – 1 year
B. Pantoprazole A. (Protonix) only safe PPI
3. Prasugrel (Effient) 10 mg po qd 
A. More effective at prevention of stent thrombosis, but ↑ hemorrhagic risk by 30 %
4. Ticegralor (Brilinta) 90 mg po bid
47
Q

What is the major limitation of a PCI procedure?

A
  1. Re-stenosis can occur within first 6 months
    A. < 10% in drug eluting stents
    B. 15-30% bare metal stents
48
Q

What factors are asst. with re-stenosis after a PCI?

A
  1. Diabetics
  2. Small lumen diameter
  3. Longer & more complex lesions
  4. Lesions in coronary ostia or LAD
49
Q

What do PCI mortality rates depend on?

A
  1. Number of diseased vessels
  2. Severity of obstruction
  3. Status of LV function
  4. Presence of complex arrhythmias
50
Q

When is a bare metal stent preferred over a drug eluting stent?

A
  1. DES cannot be implanted for technical reasons
  2. Compliance w/12 mo of dual antiplatelet therapy is likely to be problematic
  3. Scheduled to undergo surgery requiring cessation of dual antiplatelet Tx w/in the year
  4. Pt at higher risk of bleeding
51
Q

What factors can induce a coronary vasospasm?

A
  1. exposure to cold, emotional stress or vasoconstrictive agents
  2. Cocaine can lead to ischemia or MI due to coronary vasoconstriction
52
Q

What can a coronary vasospasm lead to?

A
  1. ischemia or MI
53
Q

What are the characteristics of coronary vasospasm?

A
  1. Often affects women < 50 yrs
  2. Characteristically occurs in early morning hours
  3. Chest pain
  4. ↑ ST segment - characteristic finding
54
Q

How is coronary vasospasm treated?

A
  1. Pts with ST segment elevation should undergo coronary angiography to determine if stenotic lesions are present
  2. If no stenotic lesions, avoidance of precipitants is essential:
    A. Stop smoking
    B. Stop cocaine
  3. CCB used prophylactically to treat vasospasm
    A. Nifedipine (Procardia) or diltiazem (Cardizem) commonly used

Gen Med Unit 7: Cardio (13 decks)

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