Ischemic Heart Disease Flashcards
What is the biggest difference between unstable angina and both types of STEMI
CARDIAC ENZYME MARKERS UA does not have them YOU NEED TO KNOW THIS
Along with recurrent ischemia and arrhythmia (which are quite obvious) what are other complications post myocardial infarction
- pump failure 2. pericarditis/ “Dresseler’s Syndrome” 3. Mural thrombus (thrombi attached to vessel wall) 4. cardiac rupture/left ventricular aneurysm 5. depression
Who do you give thrombolytics to, a patient with NSTEMI or STEMI
STEMI only (and its a maybe) NSTEMI is a NO
When would you use Coronary Artery Bypass Grafting (CABG)
left main coronary stenosis triple vessel disease
angina pectoris = ________ ischemia myocardial infarction = _________ ischemia
angina pectoris = transient ischemia myocardial infarction = prolonged ischemia
Irreversible death of heart muscle due to prolonged lack of oxygen
Myocardial Infarction (MI)
pathologic process affecting the entire arterial circulation
Cardiovascular disease (CVD)
What happens if endothelial cells become damaged?
nitric oxide not released development of atherosclerosis ***starred on lecture slides
What are the SEVEN factors that get “one point” on the TIMI variable for risk stratification– people who are likely to progress to a STEMI from UA/NSTEMI
- older than 65 2. has 3 or more risk factors for CHD 3. prior coronary stenosis of more than 50% 4. ST segment deviation on admission EKG 5. 2 or more anginal episodes in the last 24 horus 6. increased cardiac enzymes 7. asprin use in the last week
HDL has an atheroprotective role… why?
anti-inflammatory and anti-oxidant properties ***starred on lecture slides
What are the 5 absolute contraindications for thrombolytic therapy for someone with a STEMI
- hx of intracranial hemorrhage 2. hx of stroke 3. poorly controlled HTN (180/110) 4. suspected aortic dissection 5. active internal bleeding
What is Prinzmetal’s Angina
ischemic symptoms secondary to coronary artery vasospasm
What is the typical dose of nitro for someone with stable angina
0.3-0.6 mg SQ or buccal spray at onset of pain and every 5 min for up to 3 doses
What is the “Bruce Protocol”
During stress testing, speed and incline are increased every three minutes until patients heart rate is at 85% of the maximum heart rate predicted for their age ***BOLDED and STARRED ON LECTURE SLIDES
Which type of angina is stress testing actually indicated and useful
stable angina - to reproduce cardiac ischemia
What are the four different ways unstable angina/NSTEMI can occur
- plaque rupture with nonocclusive thrombus 2. coronary artery spasm (Prinzmetal’s angina) 3. atherosclerosis following PCI 4. secondary to tachycardia or anemia
A patient comes into the ED with what might be ischemic heart disease. You do a cardiac enzyme test and they are not elevated. What other diagnostic test could potentially be useful since there is NO evidence of infarction?
stress test
The presentation of unstable angina consists of ischemic discomfort and one symptom of these three:
- occurs at rest longer than 10 min 2. severe and of new onset 3. occurs with crescendo pattern ***** SUPER BOLDED AND RED
What kinds of medications are used in the treatment of stable angina that increase oxygen supply
- nitrates (dilates) 2. calcium channel blockers (vasodilator)
blood typically flows through the coronary arteries from the ________ to the _________
epicardium to the endocardium
What does MONA stand for
Morphine Oxygen Nitro Antiplatelet - Asprin
You do a cardiac enzyme test and you have found evidence of ischemia due to elevated CK-MB and troponin. You do an EKG which tells you your patient has NSTEMI. What did you see on the EKG?
NO ST ELEVATION May have ST depression or T wave inversion ******
Coronary angiography is the gold standard for diagnosing CAD but what pretty important thing does it not tell you about
does not demonstrate the presence of a “vulnerable plaque”
In which situation would you find no elevation of CK-MB or troponin? unstable angina or NSTEMI
unstable angina ***** SUPER BOLDED AND RED
ST Segment elevation with markers =
STEMI ***STARRED ON LECTURE SLIDES
What is the difference between revascularization recommendations for someone with unstable angina/NSTEMI versus someone with STEMI
UA/NSTEMI = later STEMI = early
What is the cold standard for diagnosing coronary artery disease (CAD)
coronary angiography ***** SUPER BOLDED AND RED
For someone with stable angia, what list of medications are you planning on giving them (broad categories)
- meds that decrease oxygen demand 2. meds that increase oxygen supply 3. antiplatelet 4. statin
What is another cause of a STEMI but it is much less likely than a rupture of a vulnerable plaque resulting in complete occlusion of a coronary artery
slowly developing stenosis of a coronary artery
What are the 3 identifiable precipitating factors for STEMI (that happen in about 50% of cases) *** this is not etiology btw
- vigorous exercise 2. extreme emotional stress 3. medical or surgical illness ***I know this question is weird but its bolded and you can’t trust ms black!
What kinds of medications are used in the treatment of stable angina that decrease oxygen demand
- nitrates (preload reduction) 2. beta blockers (afterload reduction) 3. calcium channel blockers (afterload reduction)
What is the most common etiology for a STEMI
rupture of a vulnerable plaque (ASCAD) resulting in complete occlusion of a coronary artery ***** SUPER BOLDED AND RED
What are the two types of revascularization
- percutaneous coronary intervention (PCI) 2. Coronary Artery Bypass Grafting (CABG)
When would you use calcium channel blockers for a patient with ischemic heart disease
If treatment with nitro and beta blockers is not successful
When does myocardial perfusion occur
diastole
What diagnostic test is not helpful for Prinzmetal’s angina? Which diagnostic test IS helpful?
stress test is not helpful angiogram is helpful
Your patient rolls into the ER with a STEMI. What tests do you order (7 things)
First of all, you probably won’t order shit because STEMIs do not go to the side of the ED where PAs work, but whatever let’s go with it. 12 lead EKG chest x-ray cardiac enzymes CBC Lipids Echo Angiogram
If your patient has stable angina, what would you see on EKG?
probably normal may have ST and T wave changes during an episode of chest pain that resolves after
The optimal diet for someone with ischemic heart disease has ____% of calories coming from fat
10-15 %
What are vulnerable plaques filled with
a lipid core and lipid-laden macrophage foam cells and inflammatory cells
Which antiplatelet medications are used in the treatment of stable angina
- asprin (75-325 mg daily) 2. Clopidogrel (Plavix) 3. combo of the two
No ST segment elevation with negative markers =
unstable angina (could also have an ST segment elevation) ***STARRED ON LECTURE SLIDES
The higher you score on the TIMI variable for risk stratification, =
increased number of events at 14 days events mean death, another MI or severe ischemia requiring revascularization
Where are common places for chest pain to radiate to with angina pectoris
shoulder arm neck jaw teeth epigastrum back
What is the main difference in prescribing statins to someone with ischemic heart disease versus due to high LDL/Triglycerides at an office visit on a CBC
intensive dose of statin independent of baseline LDL
coronary artery disease is virtually absent in cultures that
eat primarily plant-based diets
You need to give your patient with unstable angina/NSTEMI some antiplatelet medications. What are the 3 we need to know
- clopidrogrel 2. ticagrelor 3. prasugrel
What time of day is most common for people having a STEMI
within a few hours of awakening in the a.m.
silent myocardial ischemia and mortality resulting from coronary artery disease (CAD)
Coronary heart disease (CHD)
What kind of patients may present with atypical symptoms of ischemic heart disease? (3)
- women 2. elderly 3. people with diabetes
What is tissue factor? What does it stimulate?
Tissue factor is a potent pro-coagulant produced by foam cells within vulnerable plaques stimulates thrombus formation when in contact with blood
What are the three most important things to do for post MI management
- risk stratification (consider stress test) 2. treat risk factors 3. medication management
In which situation would you find definite elevation of CK-MB or troponin? unstable angina or NSTEMI
NSTEMI ***** SUPER BOLDED AND RED
The current treatment for ischemic heart disease is focused on _______ rather than ______
focused on treating the signs and symptoms rather than preventing it
Initial coronary event for patient with coronary heart disease that were not in treatment and asymptomatic
Sudden Cardiac Death (SCD)
No ST segment elevation with markers =
NSTEMI ***STARRED ON LECTURE SLIDES
What are the four “atypical” symptoms of stable angina? Which one is actually common for women?
- dyspnea - common in women 2. nausea 3. fatigue 4. faintness
You do a cardiac enzyme test and there is no evidence of ischemia and you’re pretty sure your patient has unstable angina. You do an EKG and find out you were right. What did you see on the EKG?
May have ST depression or T wave inversion
Patients with a history of MI have a risk of death from coronary heart disease that is ___ x higher than those without known CVD What should they do?
20 times take statins to stabilize plaques ***** SUPER BOLDED AND RED
When would you consider percutaneous coronary intervention (PCI) for someone with stable angina
- hx of angina despite medical treatment 2. evidence of ischemia on stress test
When a patient comes in with angina pectoris (stable angina) how do they usually describe their symptoms
heaviness or pressure “like an elephant on my chest”, rather than pain
What is slowly developing stenosis of a coronary artery much less likely to result in STEMI than a rupture of a vulnerable plaque resulting in complete occlusion of a coronary artery
Collateral vessels usually develop as stenosis increases, providing blood flow to the affected areas
What % of people with a STEMI die before getting to the hospital
20%
A patient comes in complaining of chest pain, what 5 things HAVE to be ruled out?
- aortic dissection 2. pulmonary embolus 3. pneumothrorax 4. perforated viscous 5. cocaine abuse ****STARRED ON LECTURE SLIDES
What do endothelial cells produce
nitric oxide ***starred on lecture slides
What medications are you going to give to your patient post- MI
- beta blockers 2. asprin 3. If LV dysfunction - ACE-I or ARB 4. Other medications that control risk factors such as HTN meds or statins
What are the five major risk factors for ischemic heart disease
diet hypertension diabetes hyperlipidemia cigarette smoking
Prinzmetal’s angina is usually in what type of patients?
younger
In addition to bed rest and MONA, what medications are you going to give to your patient with unstable angina or an NSTEMI?
- beta blockers “-olol”’s 2. calcium channel blockers if beta blockers + nitro not working 3. antiplatelet 4. anticoagulation with heparin 5. statins
What kind of EKG findings would you see with Prinzmetal’s Angina?
transient ST-segment elevation
What can relieve stable angina pain in less than 10 minutes
- rest 2. SQ nitro
Women often present without ________ with ischemic heart disease
chest pain
Where are the main arteries located on the heart
epicardial region
pathologic process affecting the coronary arteries
Coronary artery disease (CAD)
How long does stable angina pain last
2-10 minutes usually less than 5 crescendo-decrescendo
What do foam cells produce
tissue factor
What vessels are used to create an alternative pathway for the blood in Coronary Artery Bypass Grafting (CABG)
saphenous vein internal mammary arteries
What does nitric oxide do
inhibits plaque formation anti-inflammatory properties ***starred on lecture slides
Why do women have increased MORTALITY from ischemic heart disease (not risk)
because they present atypically which delays treatment
Who is at greater risk for ischemic heart disease, men or women?
men
What is another name for angina pectoris
stable angina
clenched fist over sternum
levine’s sign ***STARRED ON LECTURE SLIDES
So along with bedrest and MONA, what is the treatment for a patient with STEMI
- IV access 2. beta blockers 3. calcium channel blockers if beta blockers + nitro not working 4. antiplatelet 5. anticoagulation with heparin 6. statins 7. anti-arrhythmics, as needed 8. ACE inhibitors 9. revascularization
ST segment elevation with negative markers =
unstable angina (could also not have an ST segment elevation) ***STARRED ON LECTURE SLIDES
Which is the more effective treatment for revascularization for a patient with STEMI, PCI or pharmacologic thrombolytic tx
in experienced hands, PCI is more effective (angioplasty and/or stenting)
Where are the most likely areas for atherosclerotic plaques in the coronary arteries?
- sites of increased blood turbulence 2. branching points in EPIcardial arteries
