ischemic heart disease Flashcards
1
Q
Epidemiology of CAD?
A
responsible for 1/3 of all deaths over age of 35
- half of middle aged men will develop sxs
- a 1/3 of middle aged women will develop sxs
- 17.6 mill in US have CAD
2
Q
What is stable angina?
A
- fixed atherosclerotic plaque, increased oxygen demand from exertion, coronary vasospasm (Prinzmetal’s)
3
Q
What is unstable angina?
A
- plaque rupture with thrombus (inflammatory mediators and clotting proteins form clot at plaque rupture)
- arterial dissection - tear in blood vessel and plaque ruptured and lifted up
4
Q
What are the variety of sxs of cardiac ischemia?
A
- substernal chest pain or discomfort
- may radiate to jaw, shoulders, and arms (don’t have to have central chest pain)
- dyspnea
- nausea
- diaphoresis
- syncope
- threshold for angina less after meals for in the cold
- may be worse lying down (severe end stage angina)
5
Q
What populations have less overwhelming sxs of angina?
A
- elderly and diabetics
6
Q
Sxs with stable angina?
A
- predictable pattern
- sxs precipitated by stress or exertion
- relieved by rest or nitrates
- long standing, more than 1-2 months
7
Q
Sxs of untable angina?
A
- CP at rest or with minimal exertion
- new onset angina
- worsening angina (crescendo)
- change in pattern for those with previous hx of stable angina (getting worse) - can’t complete ADLs
- if pt isn’t getting any relief from rest or nitrates - move status from stable to unstable angina
8
Q
Description of cardiac chest discomfort?
A
- tightness
- squeezing
- burning
- pressure
- choking
- aching
- indigestion
9
Q
What should you ask on your hx?
A
- precipitating and alleviating factors
- characteristics of discomfort
- location and radiation
- duration: how long this has been going on, how long each episode lasts
- effects of nitro
10
Q
Typical angina?
A
- substernal in location with cardiac charateristics to pain, provoked by stress or exertion
- relieved by rest or nitro
11
Q
Atypical angina?
A
- CP that meets 2 or less of criteria above
- not relieved by nitro, CP not in typical location
12
Q
New york heart association of functional status classification
A
- class 1: asx but with RFs
- class 2: mild limitation of exercise, sxs with ordinary exertion
- class 3: mod limitation of exercise tolerance, sxs with minimal exertion
- class 4: severe limitationof activities, sxs at rest
13
Q
Diff Dx of CP
A
- any disease in chest, musculoskeletal, GERD, stomach, pulmonary, aortic dissection, esophageal spasm
14
Q
Work up of pt with angina?
A
- hx
- PE
- lab
- EKG
- cardiac dx testing
- CXR to exclude other dxs
15
Q
What is the most impt part of the work up?
A
- Hx!!!!
- listen
16
Q
What should you look for on PE?
A
- levine’s sign
- diaphoresis
- note vital signs (HTN?)
- S4: (atrial contraction against decreased LV compliance)
- S3: decreased systolic function
- apical systolic murmur of MR
- paradoxically split S2 (split on expiration instead b/c ventricle isn’t working)
17
Q
Lab work up of stable angina?
A
- update lipids if needed
- CBC
- TSH
- do they have DM
- update BMP if needed
18
Q
Untable angina lab work up?
A
- troponin 1
- CBC (anemia)
- TSH
- uptdate lipids if needed
- do they have DM
- CMP
19
Q
What would an EKG show that is suggestive of ischemia?
A
- new BBB: new LBBB with CP is an MI until proven otherwise
- T wave inversion, depression or flattening
- changes from previous EKG
- ST depression or elevation
- Q waves (usually late presentation - muscle tissue already necrotic)
20
Q
How would an EKG distinguish b/t stable and unstable angina?
A
- chronic stable angina: shouldn’t have acute EKG changes
- variable degrees of ischemia can be seen with acute sxs
- untable angina: may have transient EKG changes,
- NSTEMI: EKG may be persistent or evolving
- STEMI: EKG changes persistent until revascularization
21
Q
Further workup for stable angina once ACS ruled out?
A
- chronic stable angina - stress testing and or cardiac cath rarely needed
- but stress testing can confirm dx of angina, determine severity of limitation of activity, assess prognosis, and eval response to therapy (based on sxs)
- cardiac cath/coronary angiography indicated: persistent limiting angina despite max medical therapy, stress test suggestive of high risk disease, hx of aortic valve disease to determine if CP is ischemic or due to valve disease
- worsening sxs: failed max med therapy
22
Q
Medical therapy for chronic stable angina?
A
- nitrates
- b blockers
- CCBs
- Na channel blockers
- antiplatelet agents
23
Q
Goal of medical therapy for stable angina?
A
- prevent chest pain
- allow for normal activities with an acceptable degree of CP in terms of frequency and severity for pt
24
Q
What medical conditions need to be controlled that may precipitate anginal attacks?
A
- HTN (increasing O2 demand of heart)
- HF
- tachyarrhythmias (increasing O2 consumption)
- emotional upset: depressed or anxious - release E or NE - increase sxs
- anemia (decrease in O2)
- thyroid disease
25
MOA of nitrates?
- cause both coronary and peripheral vasodilation
| -
26
SEs of nitrates?
- HA, passing out, dizziness
| long term: need to take a break, otherwise develop a tolerance
27
Short acting nitrates?
- used for immediate relief of anginal sxs
- sublingual nitro tablets or spray, 0.4 mg
- repeat in 3-5 min (up to 3x), if sxs not better in 20 min than need to go to ED via EMS
28
What is preload? afterload?
- preload: volume of blood in ventricles at end of diastole (diastolic pressure),
increases in hypervolemia, regurg of valves, and HF
- Afterload: resitance left ventricle must overcome to circulate blood, increased in HTN and vasoconstriction (increasing after load increases cardiac workload)
29
Which med class has the only antianginal agents that have been demonstrated to prolong life in pts with CAD post MI?
- B blockers
| - first line therapy for tx of angina
30
BBs MOA?
- blocks beta receptors in heart causing:
decreased HR, decreased force of contration, decreased rate of AV conduction (all of these decrease BP and myocardial O2 consumption)
31
SEs of BBs?
- bradycardia
- lethargy
- GI disturbance
- CHF
- decrease in BP
- depression
32
CIs to BBs?
- bradycardia, heart block, careful in diabetics (mask sxs of severe hypoglycemia), hypotension, severe bronchospasm (in asthmatics - don't use nonselective B blockers)
33
MOA of CCBs?
- decrease myocardial O2 demand by blocking influx of Ca into cells which decreases afterload, dilates peripheral arterioles
34
What is Ranolazine (Ranexa)?
- unique
- add on after other meds have failed to control sxs
- blocks Na channel into myocyte during repolarization
- results in decreased intracellular Ca due to Na/Ca exchange
- decrease intracellular Ca = decrease in ventricular tension + decrease in myocardial O2 consumption
(doesn't lower BP or HR)
- used as add on to std therapy in refractory angina
- can cause QT prolong
- monitor QT interval when first starting
- leave cardiology to Rx, metabolized in liver ( a lot of drug interactions)
35
Antiplatelets that are used?
- aspirin 81-325 mg daily
0r
- P2Y12 inhibitor daily if aspirin intolerance or allergy
36
What are tx plans are there for angina?
- risk factor reduction through therapeautic lifestyle changes
- stabilization of plaque with statin therapy
- coronary revascularization for refractory angina (CABG, or stent): indicated when on max therapy and worsening sxs
37
What is another name for coronary vasospasm?
- prinzmetal's angina or variant angina
38
What is vasospastic angina? Common in what populations?
- CP w/o usual precipitating factors (stress or exercise0
- assoc with ST elevation during episodes (instead of depression)
- often young women
- May waken pt from sleep in early morning hours
- may be assoc with arrhythmias or conduction defects
- cyclical pain pattern over months
39
Dx signs of vasospastic angina?
- EKG evidence of ischemia during pain: ST elevation
- normal exercise tolerance (stress test will be neg)
- normal coronary angiogram: angiography catheter may induce vasospasm
- should respond to intracoronary nitro or CCB
40
Vasospasm triggers?
- spontaneous
- exposure to cold
- emotional stress
- vasoconstricting meds: cold medicine (decongestant)
- cocaine
- tobacco
- B blockers may trigger (problem is with alpha receotors, if you block B receptors than alpha receptors are unopposed and more likely to cause spasm)
41
What are assocd disorders of vasospastic angina?
- many have concomitant coronary artery disease (up to 60%)
- may also have:
migraine HAs
raynaud's phenomenon
42
Tx of coronary vasospasm?
rule out obstructive disease with cardiac cath
- CCBs and long acting nitrates if needed for prevention
- SL nitro for acute relief
- avoid B blockers (leave alpha receptors unopposed)
43
What are the 3 processes that are considered ACS?
- plaque rupture
| - NSTEMI, unstable angina, and STEMI
44
What are high risk features of UA?
- accel sxs overs last 48 hrs
- prolonged ongoing rest pain
- new ST depression
- PCI w/in 6 months
- previous CABG
- post MI angina
- arrhythmias (myocardium irritated)
- recurrent sxs despite max medical therapy
- these pts should be in the hospital!!!
45
Pts with unstable angina and correlation with CABG?
- the older the saphenous vein graft, the greater the likelihood that sxs result from culprit lesion within graft rather than lesion in native coronary artery
- 92% of lesions after 10 years were result of vein graft
46
Unstable angina may be the precursor to what?
- to an MI
- have to take it seriously
- may have transient EKG changes
- cardiac enzymes are normal
- if not dx and tx properly - may progress to MI
47
Definition of MI?
- elevated CK-MB and/or troponin
- plus at least one of the following:
sxs of ischemia
EKG changes consistent with new ischemia
New Q waves
imaging evidence of new wall motion abnormality (ischemia)
48
EKG criteria for dx of NSTEMI
- new horizontal or down sloping ST depression of more than 0.5 mm in 2 contiguous leads
and/or
T wave inversions
49
EKG criteria for sx of STEMI?
- ST elevation at J pt in 2 contiguous leads of greater than 1 mm
- ST elevation of 2 mm or greater in men and 1.5 mm or greater in women in leads V2 and V3
50
Tx of unstable Angina and NSTEMI goals?
- relief of ischemic pain
- correction of hemodynamic abnormalities (HTN, tachycardia)
- est of risk (TIMI score)
- choice of management strategy - reperfusion?
- antithrombotic therapy
- BB therapy
51
Medical therapy for unstable angina and NSTEMI?
- O2
- nitro
- morphine
- BBs
(all 4 of these relieve ischemic pain, and decrease myocardial O2 consumption)
- antiplatelet therapy
- anticoag
52
O2 therapy?
- 2 L supp O2 via nasal cannula
- may help relieve anginal sxs
- a must for pts who are hypoxic
- no evidence based data to suggest that pts with O2 have better outcomes if their baseline O2 sat was normal
53
Nitro?
- SL nitro: 1 tab or spray at a time, repeat q 3-5 min until relief of CP or 3rd dose
- IV drip if persisent pain after 3 tablets/spray, HTN or CHF
- CI in RV infarction, severe aortic stenosis, recent meds for ED
54
Morphine?
- 2-4 mg for CP or anxiety
- repeat q 5-15 min
- can be given with nitro
55
BBs?
- metoprolol or atenolol
- IV if ongoing CP, HTN, tachycardia
- CI if hypotension, bradycardia, or systolic CHF exacerbation
56
Antiplatelet therapy?
```
- aspirin 325 mg chewed
(non-enteric coated)
+
for NSTEMI add P2Y12 receptor blocker:
clopidogrel (Plavix)
Prasugrel (effient)
ticagrelor (brilinta)
DONT give without checking with cardiologist first (irrerversible platelet inhibition)
```
57
What kind of anticoag med is given in unstable angina?
- Enoxaparin (Lovenox): LMWH
1 mg/kg subq
- essence trial: decreased rate of death, MI, recurrent angina or revascularization procedure at 30 days and 1 year compared to Heparin (UFH)
- no diff in bleeding complications
58
Anticoag for NSTEMI?
- synergy trial: higher incidence of bleeding with enoxaparin compared to UFH and no difference in death or nonfatal MI in 2 groups
- NSTEMI pts receiveing P2Y12 inhibitor along with aspirin (irreversible - account for bleeding) so use heparin to decrease bleeding
- if pt not receiving P2Y12 inhibitor than cardiologist may want to give IV or SQ enoxaparin (CHECK with cardiologist first!!)
59
If an early invasive approach is selected (High risk NSTEMI pt) then what may you want to add on to UFH?
- a GP IIb/IIIa inhibitor:
abciximab (Reo Pro)
eptifibatide (integrilin)
tirofiban (aggrastat)
60
Tx for USA?
- aspirin + lovenox
61
Tx for NSTEMI?
- aspirin + plavix+ heparin
| - if early invasive approach - GP II/IIIa inhibitor also
62
What should pts be d/c on after NSTEMI/USA?
- statin therapy
- trials suggest high dose therapy
- atorvastatin (Lipitor) 80 mg daily
- switch pts who are on alt statins if no CIs
63
What can you use to determine management strategy?
- can be determined after risk stratification
- helps to ID pts at highest risk for further cardiac events who may benefit from an aggressive approach
- TIMI score for risk stratification: % of risk at 14 days of all cause mortalitiy, new or recurrent MI or severe recurrent ischemia requiring urgent revasc.
4 pts - 20%
64
Choice of early cardiac cath is determined by what?
- extent of EKG and cardiac biomarker abnormalities
- evidence of hemodynamic instability
- persistent chest pain despite approp medical therapy
- severe LV dysfxn or HF
- ventricular arrhythmias
- new or worsening mitral regurg or new VSD
65
Person with NSTEMI tx options?
- admit pt to hospital and determine course of action
- early invasive approach (cath and potential reverse)
- or medical therapy only
- or invasive approach just not urgent (within the next day)
- if unstable angina continue checking cardiac biomarkers at least 3 more times and esc therapy if they become positive
66
How do you manage cocaine assoc MI?
- similar to other ACS pts except:
give benzodiazepines early
- don't use BB due to possibility of inducing further coronary vasospasm
67
What is a STEMI?
- MI due to complete obstruction of coronary artery
| - myocardium is at risk
68
First step in tx a STEMI?
- recognizing the problem
- high index of suscpicion
- remember elderly, women and diabetics may present with atypical sxs
- EKG: ST elevation
69
Goals of STEMI therapy?
- relief of ischemic pain
- assessment of hemodynamic state and reversal of abnormalities
- reperfusion therapy with PCI or fibrinolysis
- antithrombotic therapy to prevent rethrombosis
- BB therapy to prevent recurrent ischemia and ventricular arrhythmias
70
Medical therapy for STEMI?
- O2
- nitro
- morphine
- BBs
* all 4 relieve ischemic pain and decrease myocardial O2 consumption
- antiplatelet therapy
- anticoag
- + fibrinolytic therapy or PCI!!!
71
First line therapy for reperfusion in STEMI?
- PCI unless not available within 90-120 minutes
- second line:
fibrinolytics if PCI not available within 90-120 min, sxs less than 12 hrs and no CIs
72
Antiplatelet forSTEMI pt having fibrinolytic?
- clopidogrel (plavix) 300 mg but if 75 or older - 75 mg
73
Antiplatelet for STEMI pt with no reperfusion?
- Ticagrelor (brilinta) 180 mg
74
Antiplatelet therapy for STEMI pt receiving PCI?
- Ticagrelor (Brilinta) 180 mg or
| PRasugrel (Effient) 60 mg
75
antiplatelet tx for STEMI pt with high risk of bleeding
- clopidogrel (plavix) 300-600 mg
| * * always consult with cardiologist when admin P2Y12 inhibitors in STEMI pts
76
Anticoag therapy options for STEMI pts?
- UFH: undergoing PCI and who received fibrinolyis
- Bivalrudin (angiomax) PLUS GP IIb/IIIa inhibitor
- LMWH (enoxaparin/lovenox): small loading dose IV followed by SQ admin - can't reverse lovenox effects, cant do PCI
77
Most common fibrinolytic used?
- Alteplase: tPA
78
MOA of fibrinolytics?
- initiation of local fibrinolysis by binding to fibrin in the thrombus and converts entrapped plasminogen to plasmin
79
Absolute CIs to fibrinolytics?
- Hx of intracranial hemorrhage
- ischemic stroke within last 3 months
- cerebral vascular malformation
- primary metastatic intracranial malignancy
- suspicion for aortic dissection
- bleeding disorder or active bleeding
- sig closed head injury or facial trauma in the last 3 months
80
Relative CIs to fibrinolytics?
- severe uncontrolled HTN: SBP greater than 180 and or DBP greater than 110
- ischemic stroke more than 3 months ago
- dementia
- any known intracranial disease
- traumatic or prolonged (greater than 10 min) CPR
- major surgery within last 3 weeks
- pregnancy
- noncompressable vascular punctures
- internal bleeding within the last 2-4 weeks or active peptic ulcer
- for streptokinase or anistreplase - prior exposure or allergic rxn to these drugs
81
Complications of an AMI?
- pump failure: lead to CHF, pulm edema, cardiogenic shock
- mechanical: LV free wall rupture, VSD, pap muscle dysfxn (acute MR)
- pericarditis: can be early or late
- ventricular aneurysm: CHF, ventricular arrhythmia, thromboemboli
- electrical: arrhythmias, conduction disturbances, sudden cardiac death
- arterial and venous thrombosis and embolism: LV mural thrombus, venous thrombus resulting in PE
82
MI mortality of STEMI and NSTEMI?
- 30 days:
STEMI: 6.1%
NSTEMI: 3.8%
1 year:
STEMI: 9.6%
NSTEMI: 8.8%
2 years:
STEMI: 11%
NSTEMI: 20% - may be due to the fact that pver half of pts with NSTEMI have multivessel disease and greater likelihood of residual ischemia
