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Cardiology > Ischemic Heart Disease > Flashcards

Ischemic Heart Disease Flashcards

1
Q

What causes endothelial damage to the vessel wall?

A

-inflammation to the endothelium, LDL accumulates under dissected endothelium. Mfs enter and start trying to remove LDL, these Mfs turn into foam cells. This all causese ongoing inflammation which may be prone to rupture. Once it ruptures a clot is formed.

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2
Q

What is the difference between stable and unstable angina?

A

Unstable angina is when a plaque has ruptured and a clot is formed. May lead to NSTEMI and STEMI.

Stable angina is narrowing of blood vessels, the plaque is stable and is not broken open, its just blocking the vessel enough to where when that person undergoes exertion it causes sx.

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3
Q

Sx of Cardiac Ischemia

A
  • substernal chest pain
  • may radiate to the jaw, shoulders, arms
  • dyspnea
  • nausea
  • diaphoresis
  • syncope
  • threshold for angina less after meals or in the cold
  • may be worse lying down (sign of severe angina, end stage)

*elderly and diabetics have less overwhelming sx typically.

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4
Q

How do you differentiate between stable and unstable angina based on hx questions?

A

Stable angina:

  • predictable pattern
  • sx precipitated by stress or exertion
  • relieved by rest or nitrates
  • long standing greater than 1-2mo

Unstable:

  • chest pain at rest or with minimal exertion
  • new onset angina
  • worsening angina
  • change in pattern of stable angina
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5
Q

Description of cardiac chest discomfort

A
  • tightness
  • squeezing
  • burning
  • pressure
  • choking
  • aching
  • indigestion
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6
Q

Angina:

History MUST contain all these components

A
  • precipitating and alleviating factors
  • characteristics of discomfort
  • location and radiation
  • duration: how long has it been going on, how long is each episode
  • effects of nitro
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7
Q

Classification of typical and atypical angina

A

Typical angina:

  • substernal w/ cardiac characteristics to the pain
  • provoked by stress or exertion
  • relieved by rest or nitro

Atypical:
-chest pain that meets 2 or less criteria above

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8
Q

New York Heart Association FUnctional Status Classification of Angina
-describe each class
(1-4)

A
  1. asymptomatic
  2. mild limitation of exercise tolerance, sx w/ ordinary exertion.
  3. moderate limiation of exercise tolerance, sx with minimal exertion
  4. severe limitation of activities, sx at rest.
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9
Q

Angina:

-PE findings

A
  • Levines signs
  • diaphoresis
  • vital signs
  • S4 (atrial contraction against decreased LV compliance)
  • S3 (decreased systolic function)
  • apical systolic murmur or Mitral regurgitation
  • Paradoxically split S2 (split during expiration, left ventricle not working)
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10
Q

What labs do you need to order for stable and unstable angina?

A

Stable:

  • lipids (updated)
  • CBC
  • TSH
  • DM?
  • BMP (updated)

Unstable:
same as stable + troponin and CMP.

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11
Q

EKG findings suggestive of ischemia

A
  • new BBB
  • T wave inversion, depression, flattening
  • changes from previous EKG
  • ST depression or elevation
  • Q waves
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12
Q

How can EKG be helpful in differentiating between stable and unstable angina?

A
  • helps confirm stable vs unstable.

* chronic stable angina should not have acute EKG changes.

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13
Q

Chronic Stable Angina:

-further work up

A
  • stress testing; determin the severity of limitation of activity, assess prognosis, evaluate response to therapy.
  • generally once chronic stable you dont need to do this test unless they are experiencing sx.

-cardiac catheterization: once stable chronic angina dx has been made you rarely do this.

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14
Q

Indications for cardiac catheterization in patients with chronic stable angina?

A
  • persistent limiting angina despite maximal medical therapy
  • stress test suggestive of high risk dz
  • hx of aortic valve disease to determine if chest pain is ischemic or d/t valve dx
  • worsening sx (b/c we re-categorize them to unstable angina)
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15
Q

Medical therapy for chronic stable angina

A
  • nitrates
  • beta blockers
  • calcium channel blockers
  • sodium channel blockers
  • antiplatelet agents (aspirin/P2Y12)
  • statin

-therapuetic lifestyle changes and coronary revascularization for refractory angina.

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16
Q

What is the goal for medical therapy with stable angina?

A

-prevent chest pain

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17
Q

Medical conditions that may precipitate anginal attacks

A
  • hypertension
  • heart failure
  • tachyarrhythmias
  • emotional upset
  • anemia
  • thyroid disease
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18
Q

What drug could be used for immediate relief of anginal sx?

A

short acting nitrates

-ex: sublingual nitroglycerin tablets or spray (0.4mg)

19
Q

“Only antianginal agents that have been demonstrated to prolong life in patients with CAD post MI”

A

Beta Blockers!!

20
Q

What is the first line therapy for treatment of angina?

A

Beta blockers!

-they decrease myocardial O2 consumption

21
Q

What drug could you add on after all other meds have failed to control chronic stable angina sx?

A

Ranolazine (Ranexa)

-decreases calcium….decreased ventricular tension…..decreases myocardial O2 consumption

22
Q

Ranexa SE

A
  • QT prolongation

* does not lower BP or affect HR.

23
Q

Coronary Vasospasm/Prinzmetals angina/Variant angina

  • what is this?
  • what is found on EKG?
  • who is this most common in?
  • occurrence
  • sx
A
  • this is a spasm in the coronary vessel
  • EKG: ST elevation
  • Most common in young women because they have smaller vasculature.
  • cyclical pain over months
  • Sx: chest pain without precipitating factors, may awaken pt from sleep in early morning hours.
  • will have normal exercise tolerance.
24
Q

Coronary Vasospasm Triggers

A
  • spontaneous
  • exposure to cold
  • emotional stress
  • vasoconstriciting meds (decongestants, cold medicine)
  • cocaine
  • tobacco
  • beta blockers may trigger (b/c the alphas are unopposed.
25
Q

Associated disorders to Coronary Vasospasm

A
  • Migraine Headaches

- Raynauds phenomenon

26
Q

Treatment of Coronary Vasospasm

A
  • rule out obstructive disease with cardiac catheterization
  • Calcium channel blocker and long acting nitrates
  • SL nitro for acute relief
  • avoid beta blockers as they leave the alpha receptors unopposed which leads to vasoconstriction
27
Q

Acute Coronary Syndrome

  • what is the defining factor of this?
  • what are the three conditions associated with this?
A

-defining feature is plaque rupture

  • the three conditions associated with this are
    1. unstable angina
    2. NSTEMI
    3. STEMI
28
Q

What are the high risk features of unstable angina?

A
  • accelerating sx over the last 48 hrs
  • prolonged ongoing rest pain
  • new ST depression
  • percutaneous coronary intervention in last 6mo
  • previous CABG
  • post MI angina
  • arrhythmias
  • recurrent sx despite maximal medical therapy.
29
Q

Definition of MI includes….

A
  • elevated CK-MB and/or Troponin
  • PLUS at least one of the following
  • -sx of ischemia
  • -EKG changes consistent with new ischemia
  • -New Q waves
  • –imaging evidence of n ew wall motion abnormality
30
Q

What is the EKG criteria for dx of NSTEMI

A

-new horizontal or down sloping ST depression greater than 0.5 in 2 contiguous leads

AND/OR
-T wave inversions

31
Q

What is the EKG criteria for dx of STEMI

A
  • ST elevation at the J point in 2 contiguous leads of greater than 1mm
  • ST elevation greater than 2mm in men or 1.5mm in women in leads V2 or V3
32
Q

What condition will you see global ST elevations?

A

pericarditis.

33
Q

NSTEMI and Unstable Angina Medical therapy

A

-oxygen (2L)
*worsening prognosis if not hypoxic and you give them O2)
-nitro
-morphine (2-4mg)
-beta blockers (metoprolol or atenolol)
^^^^^^^^^^^^^^^ relieve ischemic pain and decrease myocardial O2 consumption.

NSTEMI Tx: all of the above plus…

-antiplatelet therapy (P2Y12 receptor blocker; Clopidogrel/Plavix, Prasugrel/Effient, Ticagrelor/Brilinta
+ Aspirin 325mg)

-anticoagulation: Heparin (UFH).. if really bad you can add GPIIb/IIIa; Integrilin

UNSTABLE ANGINA:

  • basics from above plus…
  • lovenox/enoxaparin (LMWH)
  • aspirin 325mg chewable

NSTEMI/UNSTABLE ANGINA:
D/C on high dose statin therapy; lipitor(atorvastatin) 80mg/day

34
Q

Nitro is CI for use in NSTEMI and unstable angina with what coexisting conditions?

A

-RV infarction (RV not working well already, these pts need a high preload to drive the rest of the system forward.)

35
Q

Beta blockers are CI with NSTEMI and unstable angina who exhibit….

A
  • hypotension
  • bradycardia
  • systolic CHF exacerbation
36
Q

What is the TIMI score? What does TIMI stand for?

A
  • score based upon high risk features of acute coronary syndrome, the higher the timi score the higher the all cause mortality rate in 14days.
  • Thrombolysis in Myocardial Infarction
37
Q

how do you treat Cocaine associated MI?

A
  • similar to other ACS patients, but give benzodiazepines

* do not use beta blockers d/t possibility of inducing further coronary vasospasm.

38
Q

STEMI

  • what is this?
  • tx
A

-an MI due to complete obstruction of the coronary artery.

Tx: 
-O2 
-nitro
-morphine
-beta blockers
^^^^^^^^^^^^^^^relief of ischemic pain and decreases myocardial O2 consumption.

plus:
- antiplatelet therapy (P2Y12 inhibitors)
- anticoagulation (UFH*, Angiomax+GPIIb/IIIa, LMWH lovenox)
- fibrinolytic therapy or PCI

  1. PCI is first line therapy, unless not available within 90-120minutes we administer fibrinolytics only if their sx have been less then 12hrs.
39
Q

Fibrinolytics

  • medication
  • MOA
A

Alteplase/tPA

MOA: converts plasminogen to plasmin which binds to fibrin within the thrombus and breaks down the clot.

40
Q

Absolute CI of Fibrinolytics

DO NOT GIVE THEY DIE!

A
  • Hx of intracranial hemorrhage
  • ischemic stroke in last 3mo
  • cerebral vascular malformation
  • primary metastatic intracranial malignancy
  • suspicion for aortic dissection
  • bleeding disorder or active bleeding
  • significant close head injury of facial trauma in last 3 mo.
41
Q

Relative CI to fibrinolytics

A
  • severe uncontrolled HTN
  • ischemic stroke greater than 3 mo
  • dementia
  • intracranial dz
  • traumatic or prolonged CPR
  • major surgery in last 3wks
  • pregnancy
  • internal bleeding within last 2-4wks
  • streptokinase or anistreplase allergy
42
Q

Complications of acute MI

A
  • pump failure; (right or left ventricle failure) CHF, pulmonary edema, cardiogenic shock
  • Mechanical; LV free wall rupture, VSD, papillary muscle dysfunction
  • Pericarditis
  • VEntricular aneurysm: CHF
  • Electrical: arrhythmias, sudden cardiac death
  • Arterial and VEnous thrombosis and embolism; LV mural thrombus
43
Q

Prognosis: MI morality after STEMI & NSTEMI

A

Greater mortality in NSTEMI may be related to the fact that over half of the patients with NSTEMI have multivessel dz and a greater likelihood of residual ischemia.

Cardiology (12 decks)

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