Ischemic Heart Disease Flashcards
Where do atheroslcerotic plaques tend to form?
sites of increased turbulence
branching points
LDL, when oxidized leads to what three processes that eventually result in non-calcified plaque formation?
- endothelial dysfunction
- fatty streak
- inflammation
Plaque rupture leads to what two severe conditions?
thrombosis and ACS
Presence of three or more of the following results in what condition?
abdominal obesity
HDL < 40 (M) or < 50 (F)
TGs 150 or higher
FBG 110 or higher
HTN
metabolic syndrome
What contributes to the increased mortality of women with IHD?
delayed dx and delayed tx due to atypical sxs
Sxs of IHD in women are induced during what activities?
rest, sleep, mental stress
A patient presents with the following signs/sxs and hx:
Hx of substernal chest pressure for 5-10 minutes
pain began when walking up stairs at office
radiation to jaw
Pain lessened with time
What is your presumptive Dx?
stable angina
What would you expect to find on PE of a patient with stable angina?
tachycardia
HTN
abnormal heart sounds
A clenched fist or hand over the chest is known as…
Levine’s sign
A female patient presents with the following sxs… what should you immediately consider?
dyspnea
nausea
fatigue
faintness
Stable angina
A patient presents to the clinic with the following:
- Sharp chest pain localized with one finger
- pain lasted for seconds and resolved
Do you suspect angina/ischemia?
no
What sxs are not likely to be ischemia or angina related?
sharp, fleeting CP
prolonged ache in left precordial
localization
short lasting or constant pain
A patient presented to the ED with crescendo/decrescendo CP lasting 7 minutes. What tests do you want to order?
EKG
CXR
Cardiac enzymes
Why do we order a CXR for patients with angina?
to rule out other causes of CP like fx or masses
What are you looking for during an exercise stress test on a patient with angina?
EKG changes
decreased perfusion on imaging
SBP drop 10mmHg
sx development
The Bruce Protocol for an exercise stress test states that speed and incline are increased every ______ minutes until HR is at _____% of maximum
3 minutes
85% of max HR
what are the indications for a stress echo?
prior MI
Sxs of heart failure
undiagnosed murmur
complex ventricular arrhythmia
Which medications decrease oxygen demand?
Nitrates
Beta blockers
CCBs
1st line tx for acute angina…
short acting nitrates
Which medications reduce preload?
nitrates
When are long acting nitrates indicated?
chronic angina
1st line tx for chronic angina?
beta blockers
this medication decreases HR, BP, contractility and afterload…
beta blockers
The only antianginal medication proven to prevent re-infarct and improve survival post-MI…
beta blockers
This medication decreases BP, contractility and afterload, but doesn’t lower HR…
CCBs
who is indicated for CCBs with respect to IHD?
non-response to nitrates and beta blockers
Which medications increase oxygen supply via coronary vasodilation?
nitrates
CCBs
what antiplatelet medications can be considered for stable angina?
aspirin
clopidogrel
combo of the two
Why are statins useful in treating stable angina?
reduce clinical events
slow and regress coronary atherosclerosis
What statin dosage should you consider regardless of baseline LDL-C for stable angina?
high intensity
What are the two forms of revascularization?
percutaneous coronary intervention (PCI, angiography)
Coronary artery bypass grafting
What is the most common physiologic process by which ACS/acute MI begins?
plaque rupture with occlusive thrombus
Acute Coronary Syndrome (ACS) is composed of what three conditions?
unstable angina
non-ST Elevation MI
ST Elevation MI
Sxs of Prinzmetal’s angina are secondary to what?
vasospasm
When does CP occur in Prinzmetal’s angina?
at rest
What can be seen on EKG during Prinzmetals angina?
transient ST elevation
young patients with few risk factors and CP should be considered for what condition?
Prinzmetal’s angina
Is stress testing helpful in dx of Prinzmetal’s angina?
no
What can help dx Prinzmetal’s?
coronary angiography
how do you treat Prinzmetal’s Angina?
nitrates and CCBs
A patient presents with the following sxs… what should immediately be considered?
CP
SOB
Weakness
Nausea
Anxiety/Sense of impending doom
ACS
What atypical sxs present in women, DM, and elderly patients?
sudden breathlessness, dyspnea
Dx of unstable angina requires ischemic discomfort and one of which 3 sxs?
occurrence at rest
severe and new onset
crescendo pattern
The diagnostic approach to UA/NSTEMI should include what 5 things?
- clinical Hx
- EKG
- cardiac enzymes/biomarkers
- stress testing if safe
When should you consider stress testing for a patient with potential NSTEMI/UA?
no evidence of infarction/normal cardiac enzymes
unclear diagnosis
What differentiates NSTEMI from UA?
NSTEMI: elevated cardiac enzymes
UA: normal cardiac enzymes
What may be present on EKG of NSTEMI?
ST Depression, T wave inversion
ST elevation typically not present
What can be seen on EKG in UA?
usually normal
may have ST elevation, T wave inversion
How should UA/NSTEMI be managed?
Oxygen
Nitro
antiplatelet therapy
beta blockers
The following criteria make up what test for progression of UA/NSTEMI to STEMI?
Age 65+
3+ CHD risk factors
prior coronary stenosis of 50+%
ST deviation on admission
2+ anginal episodes in previous 24 hours
elevated cardiac enzymes
aspirin use in last 7 days
TIMI variables
What factors precipitate STEMI in 50% of cases?
vigorous exercise
extreme emotional stress
medical/surgical illness
What is the cause of STEMI?
rupture of vulnerable plaque leading to complete occlusion of coronary artery
What diagnostics should you order on a pt. you suspect of STEMI?
EKG
CXR
Cardiac Enzymes
CBC
Coags
electrolytes
Lipid panel
2D echo
ST Elevation and + cardiac enzymes should make you think of…
STEMI
ST depression with (-) cardiac enzymes should make you think of…
UA
no ST elevation with (+) cardiac enzymes should make you think of…
NSTEMI
A patient presents with STEMI. How do you immediately manage the patient?
ASA 325 mg
sublingual nitro
beta blockers
high intensity statin
identify reperfusion strategy
What is the preferred method of reperfusion in STEMI?
PCI
When should you consider fibrinolytic therapy in STEMI?
PCI not available within 120 minutes of first medical contact
sxs < 12 hrs
absence of contraindications
the following are what contraindications to fibrinolysis?
hx of intracranial hemorrhage
hx of stroke in past year
poorly controlled HTN
suspected aortic dissection
internal bleeding
absolute contraindications
the following are what contraindications to fibrinolysis?
current anticoagulation
recent invasive procedure
prolonged CPR
known bleeding
pregnancy
active peptic ulcer
hemorrhagic ophthalmic condition
hx of severe HTN
streptokinase use
allergic rxn
relative contraindications
Can thrombolytics be used in NSTEMI/UA?
no
CP due to pericardial inflammation following MI, CABG, or traumatic injury is known as?
Dressler’s syndrome, pericarditis
What medications should be used after MI tx?
beta blockers
aspirin
A patient is seeing you on f/u after MI. Pt. has LV dysfunction. What can be given?
ACE, ARB
