Ischemic Heart Disease Flashcards
Unstable angina
- Rest
- New onset<2 mos
- Increasing angina by a class
3 kinds
Types of angina
- Typical chest pain with exertion relieved at rest or ntg
- Atypical angina has only 2 of the 3
- Non cardiac chest pain
Anginal equivalents in diabetics, woman, and elderly
Dyspnea
Nausea
Fatigue
Faintness
Types of mi
Type 1 plaque rupture Type 2 increase ischemic burden Type3 death no enzymes Type 4 sp pci Type 4b stent thrombosis Type 5 sp MI
> 75 years
MI usually NSTEMI not STEMI
More likely CHF
Increase mortality
Mi therapy
No nitro if BP is low No iv betablockers Morphine OK No Norvasc Oxygen if o2 below 90 No IV acei iV lopressor only if the pain is persistent Oral acei if EF below 40
Worst prognosis
St-t changes and the level of tropinin CHF PCI <6 mos DM RF
Volume of the contrast
3.7x creatinine clearance
Timacs study
High rusk patients benifit from early invasive therapy
Prasugrel
Only in MI
Only after angio max
Donot pre load in the ER
Dose
Use only 80 mg Asa with ticagrelor
Plavix dose
It could be given in the ER or at PCI both class1
Cure study
Asa and plavix better than asprin alone
Use plavix for 1 year
Oasis7 high dose of plavix 600 and 150 is more effective the 300 and 75 but more bleeding
Triton study
Increase risk of stroke and MI in cyp2c19 carriers than non carriers
Prasugrel
More effective, faster acting, and potent than pkavix.
Don’t use it before you cath and no abciximab in the ER
Triton 38
Don't use in stroke patients Older Less body weight Decreased events in effient groups Decrease stent thrombosis
Ticagrelor
Reversible binds to p2y12 Short acting Less stent thrombosis than pkavix Can give ticagrelor even on pkavix Side effects dyspnea asthma and heart block
Renal failure
Adjust angio max dose
You can give angio max in the ER 2b
Acuity study
More bleeding with UFH and 2b 3a than with angio max
Fondoperimaux can cause increase thrombosis after PCI and according to the guide lines don’t need to be stopped till CABG
Triple anti thrombotic
Afib
CHF
Mechanical valve
Post mi
Flu vaccine
Fish oil
Aldo blockage for low EF
Enzymes
Elevated tropinin for 10 days.
If myoglobin is negative no MI it has high negative predictive value
Thrombolysis and tx in 3-24 hours to pci facility
Horizon study higher TLR with drug eluding vs BMS
Thrombolysis
Thrombolysis
75 yo use 75 mg pkavix
No data on effient or brillinta
After Thrombolysis
PCI24 need 600 plavix
All 2b 3a are class 2a indication sp mi
Sp tnk Thrombolysis
Enoxeparim less tan 75 bolus more than 75 no bolus
So mi
Eplerinone is class 1 for CHF Ephesus study
So mi
IABP no survival benifit
It’s 2a indication
Sp
Mi
Ventricular rupture day 3-5
If they have Thrombolysis 24 hours
MR post medial pap
Class of indication for 2b3a in mi
No class 1 all class2
Highest risk of mi
Black male 65-74
High risk in USA
Tropinin ST depression Age>75 Hypotension Ongoing chest pain pain at the time of the exam Crescendo angina past 48 hours
Duke score
Intermediate score risk 10% over 5 years
No treadmill for
LBBB and WPW STT depression >1mm Paced rhythm LVH Dig
Duke score
Exercise in min-5x max ST depression- 4x angina index 0 no cp 1 non limiting cp 2 limiting cp-
Low score more than +5 one year 1% 5 year 3%
Intermediate risk score 4to -10 one year risk 1-3% five year 9.5%
High risk greater than minus 11 one year 3% and give year 35%
High risk
Inability to achieve 85% HR
Heart rate recovery less than 11 beats a min
VEA VT
Sensitivity and specificity
Stress EKG sen 68% specific 77%
Stress echo sen 80% specific 86%
Nuclear sen 84% specific 77%
Adenosine
Binds to A2A causing increase cAMP and vaso dilatation Myocardial ischemia is rare A1 AV block A3A4 bronchospasm Hypotension 5% No caffeine Don't use HR slow or carotid stenosis
Persantine
Use caution in liver failure
Stress test recommendation
Intermediate risk interpretable EKG standard exercise EKG
Intermediate risk un interpretable EKG do imaging
No stress tet
For low risk
CTA and MR
Low to intermediate risk
No CTA if there are no symptoms
Low risk less than 100 agaston units and less than 50% lesion
Intermediate risk 100-399 one stenosis of 70% or two 50-69%
High greater than 400 and multiple lesions
Swedish trial
Normal LV and stable angina
Decrease mortality and MI
Asprin only
Not nitrates
Not betablockers
Definitely not ca blockers
Betablockers
Sp MI all patients with normal LV and continue for 3 years
Decrease HR beta 1
Decrease after load beta 2
Decrease contractiliry beta 1 and 3
No data on metoprolol tartrate data only on metoprolol succinate
Acei
Clear benifit in mi CHF and HTN
Less clear in motmot endive normal LV
Hope Europa Camelot cv benifit
Pace, transcend and navigator no benifit
Medical therapy vs CABG 1972-79
VA study
European study
Cases
Only sub group benefited are
3 vessel
Left main
EF<50
Acme study
PCI has superior angina relief compared to medical therapy
Small increase in emergency CABG
Restenosis 40%
PCI has no effect on mi or mortality
PTCA vs CABG
RITA ERACI CABRI EAST GABI BARI
Overall rates or mortality same
CABG superior to pci in diabetics mortality
Benifit of CABG in Diabetics due to Lima
Fewer mi cases in CABG
Less frequent angina in CABG
PTCA(balloon)vs bare metal stent
No deference in death mi or emergent CABG
Bare metal stents were helpful in angiographic restenosis and repeat pci
BMS vs CABG
Erica 2 ARTS SoS
Repeat revascularization low but still higher than CABG
No mortality benifit between CABG and pci
Did not achieve complete revascularization with pci
BMS vs medical therapy
Courage 95% male VA study
Class 4 angina medically stable
Excluded ongoing chest pain, low EF,recent pci
Used asprin plavix Betablockers amlodipiine and nitrates Lisinopril Simvastatin Smoking cessation Weight loss
OMT and PCI are superior to OMT alone
Revascularization vs OMT in type 2DM
Bari 2D
Both are identical
Aggressive diabetic control showed no deference
Bari 2 D
PCI reduces angina
PCI does not reduce mi or mortality
Type 2 DM and SIHD revascularization vs medical therapy no change in mortality
CABG vs DES
Syntax
Low syntax scores high strokes with surgery
More repeat procedures with stent group
Higher the syntax score( 22 )more cerebrovascukar complications with pci
Higher MACCE with pci
Overall adverse event rates are higher with pci 27% vs 37%
Neither all cause mortality nor stroke are defferent in both groups
Syntax greater than 33 much higher stroke and all cause mortality with pci
But stroke
Freedom study
DES and CABG
Diabetes
2-3 vessels no left main
Higher death and stroke Higher mi with DES Higher stroke with CABG Higher repeat revascularization with pci Low syntax scores both are same
Stitch
EF <35
No left main medical vs CABG
CABG did not reduce mortality but lower incidence of combined end points with CABG
Myocardial viability was useless
Exercise no more than 30 min
2 drinks a day
1200-1500 cal for woman 1500-1800 for man 69% American are over weight Bmi over 30 All cause mortality 23% Dash <25% cal from fat
Jnc7
No alpha blockers as they worsen CHF
All HAT
Chlorthalidone amlodipine and lisinopril all same
Older patients over 60
Start treating at BP 150
But be aggressive in DM blacks and RF
Metabolic x
Obesity >40 for men High tig Low LDL HTN Hyperglycemia 35% people inUS Doubles the risk
Lipid studies
TNT high and low Lipitor high is better
Woscoos
Low LDL
Decrease mi and CCA by 23%
Lipitor is better than pravastatin
High risk LDL <70
Intermediate risk 2 risk factors
Start at 130 and get to 100
Low (0-1 risk factors) risk start at 190 and get to 160
Statin therapy
Do base line LFTs no need for yearly tests
Zeros no survival data
Niacin no survival data
Pre op high risk
Cad CHF Cva DM Rf Are all high risk No routine pre po beta blockers poise study has increase mortality
Pre op
Do not stop plavix for one year
HTN is not a risk factor in pre op
You can stop Coumadin in mechanical valves
Only of it is aortic and no other issues .
Resume in I week no bridging
After pci
Surgery 14 days after POBA
6 weeks after BMS
12 mos after DES
Intermediate risk for pre op
1-5% mi and death
Horizons study
Angio max
As effective as heparin and 2b 3a but safer less bleeding and less deaths
Lipid therapy
2 risk factors initial LDL therapy at 160
Stress test
Normsl test event rate less than 2% a year
High risk >20 per year
Greater than 50% patients
Will not have classic triad and atypical symptoms
