Ischemic heart disease Flashcards
Classification of angina
I: strenous exercise
II: Slightly limitation of normal exertion
III: Every day limitation
IV: Always limitations
Provoking factors for angina
Anemia, HTN, Fever, hypertrhyreosis, hypoxemia
Tachyarrhythmia, bradyarrhythmia, HOCM (Hypertrophic cardiomyopathy), aortic valve disease
Symptoms of stable angina
Squeezing discomfort in chest that is relieved with relaxation or NTG
Dyspnea, nausea, sweating, fitness, anxiety
Atypical = no relation to exertion.
Treatment of stable angina
A = Aspirin B = β-blockers C = Cigarette smoking and cholesterol lowering (Statins) D = Diet + DM E = education and exercise
Coronarygraphy - ↓ EF, angina after PCI or CABG, therapy resistant
Prinzmetal angina
Transient ST elevation due to coronary spams.
NTG restore blood flow.
In middle aged women and smokers
May lead to malignant arrhythmia.
Stress test and angio are normal.
Treat with CCB or nitrates
Definitive diagnosis: meta choline during angiography -> trigger vasospasm
Treatment of non-ST segment elevation
In acute, use: M= morphine O= oxygen N= nitroglycerin A= aspirin
Invasive
Other drugs:
- ASA/clopidogrel (anti platelet)
- LMWH (anticoagulant)
- β -blockers
- NTG
- Fibrinolysis - STEMI only!
- Statins and ACE-inhibitors
«BASH» = β-blocers, ACEi, Statins, heparin
GRACE score
Estimates admission to 6 months mortality for patients with ACS or occurrence of MI w/ or without death.
Bases on:
- Age, HR, SBP, Creatine level, CHF
- If patient had cardiac arrest during admission
- If ECG shows ST segment abnormalities
- If there are changes on cardiac biomarkers.
Score above 140 indicates invasive strategy.
What are the high risk criteria - indicative for emergency PCI
- Ongoing/recurrent ischemia
- Dynamic spont ST changes
- Hemodynamic instability
- Major ventricular arrhythmia
- Deep ST depression in V2-V4 indicating ongoing post-transmural infarction.
Symptoms of STEMI
Dyspnea, sweating, angina, fear of death, cyanosis, periodic resp, orthopnea
Treatment of STEMI
Pre-hops: MONA In hospital: - Best with PCI - Thrombolysis if PCI not available. - Emergency CABG if PCI failed
4-7 days after do a stress test to see if the patient need bypass.
Discharge with:
- Aspirin -> 75-325mg/day
- Clopidogrel -> in intolerant to aspirin or as an alternative for 9-12 months.
- β-blockers -> indefinitely
- ACE inhibitors -> added for CHF or left ventricular dysfunction (EF <40%) is present
- Statins -> should be started in the hospital.
- Nitrates -> short-acting as a rule. Long-acting only if chest pain is persistent.
Complications of MI
- Arrhythmias
- Ventricular failure
- Mechanical complication (papillary rupture, septal/wall rupture)
- Ventricular aneurysm
- Pericarditis
- Dressler syndrome (Due to autoimmune reaction to material from necrotic myocytes)
- Recurrent MI
- Unstable MI
- SCD (sudden cardiac death)
Drugs given during and after heart catherization
During: GP IIa/GP IIIa, thrombolytics After: - ACEi/ARB -BB -Statins - Clopidogrel + aspirin - 6 weeks or 3 months or more - depending on the procedure.
What methods can be used to measure the blood flow at different places?
BP - cuff
Doppler flow (flow, CO, pressure gradients, pathologic flow)
Arterial pulse pressure - use a tonometer on the skin surface above any artery.
How is a PCI performed?
- Percutaneous puncture
- Sheath introducer
- Guiding catheter
- Visulization by X-ray
- Coronary guide wire
- Angioplasty/ Balloon catheter
- Inflation of balloon
Types of stent
Bare metal stent
Drug-elution stents
- Sirolimus - macrolide derivative
- Paclitaxel - prevent restenosis
