Ischemic Heart Disease Flashcards by Joysa S.

What is the pathophysiology of stable angina

Fixed atherosclerotic lesions narrowing major coronary arteries, reducing oxygen supply

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What are major risk factors for ischemic heart disease (six)

) Diabetes
) High LDL
) Low HDL
) HTN (most common)
) Age (men > 45, females > 55)
) Family history - first degree relative Men >45, females > 55

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What are two main prognostic indicators of CAD

Ejection fraction

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What are the clinical features that are specific for stable angina

Substernal chest pain lasting 10 to 15 minutes that is brought upon by exertion or emotion, and relieved with rest and nitroglycerin

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Describe the pain that is specific to stable angina that will give you a hint that it is this

Chest discomfort but never sharp nor stabbing, does not change with breathing or body position or chest wall tenderness

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What diagnostic modalities can be used to for coronary artery disease (seven)

) Resting ECG
) Stress ECG - proceed to cath if abnormal
) Stress echo - do before and after exercise - proceed to cath if abnormal
) Stress myocardial perfusion imaging - uses thallium
) Pharmacological stress test - uses IV adenosine, dipyridamole, dobutaine
) Holtor monitor - for silent ischemia (asymptomatic)
) Cardiac catherization with coronary angiography - definitive and to find location and pre-surgery

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What should you see on stress ECG for people with CAD

Subendocardial ischemia producing ST depression (or onset of heart failure/ventricular arrhythmia)

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What would you see on stress echo for people with CAD

Wall motion abnormalities such as akinesis or dyskinesis only seen during exercise

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What are you looking for on myocardial perfusion imaging with thallium

No radioisotope extraction, meaning no blood flow to that area

Also to see if it is reversible ischemia

Reversible means myocardium reperfused after exercise stops, meaning you can do PCI or CABG
Non-reversible means ischemia cannot be reversed, so it is probably already infarcted

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What is the purpose of cardiac catheterization with coronary angiography, and when can it be used?

Definitive test to see location of stenosis, do concurrently with PCI, or CABG if left main/three vessel disease

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The three mainstays of treatment for stable angina are risk factor modification, medical therapy, and revascularization. What should you do for medical therapy

) Aspirin - everyone (reduces morbidity)
) B-blockers - atenolol and metoprolol - everyone
) Nitrates - general vasodilation, reduces preload
) Calcium channel blockers - second line to B-blockers and nitrates, afterload reduction and coronary vasodilation, not routinely used

If CHF present concurrently, ACE inhibitors and diuretics too

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The three mainstays of treatment for stable angina are risk factor modification, medical therapy, and revascularization. What should you do for revascularization

PCI or CABG, only if high risk, improves symptoms but not incidence of MI unlike medical therapy

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How does management differ for stable angina between mild disease (normal EF, one vessel), moderate disease (normal EF, two vessel) and severe disease (decreased EF, three vessel/left main)

Everyone gets aspirin

Mild - Nitrates and B-blockers, Ca blockers second line
Moderate - Above regiment. But if doesn’t work, consider revascularization
Severe - Coronary angiography and consider CABG

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What is the pathophysiology of unstable angina pectoris

Reduced resting coronary flow indicating either thrombosis, hemorrhage, or plaque rupture. But not fully occluded yet

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What is the criteria for diagnosing unstable angina

) Chronic angina increasing in frequency/duration/intensity
) New-onset angina
) Angina at rest

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Unstable angina and non-stemi have the same exact symptoms. What is similar and differentiates them

Similar: No ST segment elevation, no Q waves, same symptoms

Dissimilar: Only cardiac enzymes (troponin and CK-MB)

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What is the importance of diagnosing unstable angina and what should you do in order

To rule out MI

Do medical management before stress testing because can make it worse, or do cardiac catherization initially

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What is the first thing you must do if a patient presents with unstable angina

Admit to the hospital with continuous cardiac monitoring, establish IV access, supplemental oxygen, and pain control with nitrates and morphine (do not admit to hospital for stable angina, this is difference)

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In unstable angina, ACUTELY you want to do medical management like it is an MI except for fibrinolysis. What should you give

) Aspirin + Clopidogrel 9-12 months (important)
) B-blockers and nitrates - both FIRST LINE
) LMWH (enoxaparin) - prevents progression/development of clot, give for 2 days, only follow PTT if heparin and ensure 2-2.5x INR with heparin
) Replace K+ and Mg2+ - usually these go deficient

Medical therapy successful 90% of the times, but if not then proceed to catherization/revascularization (PCI)

Remember to do stress ECG after medical management, not before, to see if cardiac catherization is needed

After you have acutely managed the patient with unstable angina, what medications does the patient continue on

Aspirin, B-blockers, nitrates

Treat hyperlipidemia, diabetes, HTN

What is variant (prinzmetal) angina

Transient coronary vasospasm with fixed atherosclerotic lesion already present

What are the symptoms of variant prinzmetal angina and what is seen on ECG

Symptoms: Chest pain at rest classically during night, ventricular dysarhythmias

ECG: Transient ST segment elevation during chest pain denoting transmural ischemia

What is the definitive diagnostic test for prinzmetal angina and what is the treatment

Definitive diagnostic: Coronary angiography with IV ergonovine to promote chest pain, will see vasospasm

Treatment: Vasodilators: Ca blockers and nitrates (calcium channel blockers become first line in this unlike USA and stable angina)

What is the pathophysiology of MI

Necrosis of myocardium after plaque rupture causing acute coronary thrombosis, occluding vessel 100%

What are the symptoms of an MI

Chest pain with intense pressure radiating commonly to left side or anywhere. Lasts longer and more severe than angina and does not respond to nitroglycerin. Diaphoresis, dyspnea, nausea and vomiting, sense of impending doom

What do people usually die from with MI

Sudden cardiac death due to ventricular fibrillation

What are the ECG findings in the diagnosis of MI, and difference between acute and previous MI

Acute: ST segment elevation indicating transmural injury, T wave inversion Chronic: Q waves denoting previous necrosis

What is the similarity and difference between ST segment elevation infarct and non-ST segment elevation infarct

Similarity: Cardiac enzymes elevated Difference: ST segment elevation: Transmural, larger. Non-ST segment elevation: Subendocardial, smaller, presents like unstable angina

Cardiac enzymes are the gold standard for myocardial injury. What are the two cardiac enzymes, when they start to rise, their peak, and when they return to normal

Troponins (most important) - increases within 3 to 5 hours, peaks in 24 to 48 hours, normal in 5 to 14 days CK-MB - increases 4-8 hours, peaks 24 hours, returns to normal 48 to 72 hours

Which cardiac enzyme can be falsely elevated in renal failure

Troponin I

What is the first thing you must do when a patient presents with MI (unrelated to treatment)

Admit to cardiac floor, establish IV access. Give O2 and analgesics

What are the medical treatments for MI

1. ) Aspirin + clopidogrel - reduces mortality 2. ) B-blockers - reduces mortality 3. ) ACE inhibitors - reduces mortality (this was not in any previous ones) 4. ) Statins - reduces further coronary events (atorvastatin specifically!) O2, nitrates, morphine sulfate (analgesia and venodilation), heparin for all patients (preferably enoxaparin)

Aside from medical treatment, when should revascularization be performed in MI patients

Only if early. and includes thrombolysis, PCI, or CABG 1. ) PCI within 90 minutes over thrombolytics 2. ) CABG only if mechanical complications of acute MI, failure of PCI, cardiogenic shock, arrhythmias

What medications are common between stable angina, unstable angina, non-STEMI infarct, and STEMI infarct

Aspirin, B-blockers, Nitrates

In MI, what are the only three medications that can reduce mortality

Aspirin, B-blockers, ACE inhibitors

The six complications of acute MI are pump failure, arrhythmias, recurrent infarction, mechanical complications, acute pericarditis, and dressler's syndrome. How do you treat pump failure? (CHF)

Mild - ACE inhibitor, diuretic Severe - cardiogenic shock, may need invasive hemodynamic monitoring

The six complications of acute MI are pump failure, arrhythmias, recurrent infarction, mechanical complications, acute pericarditis, and dressler's syndrome. Which arrhythmias do you treat

PVC - nothing Accelerated idioventricular rhythm - nothing VT - Electrical cardioversion vs. IV amiodarone Vfib - Unsychronized defibrillation and CPR Paroxysmal supraventricular tachycardia - treat with IV adenosine Sinus tach - treat underlying cause Sinus brad - nothing, maybe atropine Asystole - transcutaneous pacing AV block - pacemaker temporary in second degree and third degree blocks of anterior MI, if inferior MI then use atropine initially

The six complications of acute MI are pump failure, arrhythmias, recurrent infarction, mechanical complications, acute pericarditis, and dressler's syndrome. What must you monitor and what clues arise for recurrent infarction

Evaluate CK-MB since it returns to baseline faster, if there is repeat ST segment elevation within first 24 hours, probably recurrent infarction and do repeat thrombolysis or PCI

For mechanical complications after infarction, you can get free wall rupture, rupture of interventricular septum, papillary muscle rupture, ventricular pseudoaneurysm, and ventricular aneurysm. What is free wall rupture, when does it occur, its mortality rate, complications, and treatment

First two weeks after MI, with 90% mortality. Leads to hemopericardium and cardiac tamponade Treatment: Hemodynamic stabilization, immediate pericardiocentesis, surgical repair

Better successful therapy than free wall rupture, but still do emergency surgery. 10 days after MI.

Produces mitral regurgitation, must get echo immediately and mitral valve replacement with sodium nitroprusside or IABP

Incomplete free wall rupture, echo may show it, but do surgery anyways because can become free wall rupture Diagnose with MRI/angiography

Rarely ruptures in contrast to pseudoaneurysm, but can lead to ventricular tachyarrhythmias. Diagnose with echo Treat medically or surgery

Another complication of MI is acute pericarditis. What is its treatment and what is contraindicated

Treatment: Aspirin Contraindications: NSAIDs and corticosteroids because hinders scar formation

Another complication of MI is Dressler's syndrome. What is it and how do you treat it?

Immunology syndrome with fever, malaise, pericarditis, etc, weeks and months after MI. Treat with aspirin first line, ibuprofen second line