ischemic heart disease, angina, MI Flashcards
ischemic heart disease
coronary blood demand exceeds coronary blood flow
myocardial metabolism is aerobic
etiologies of IHD
atherosclerosis hyperthyroidism anemia emotional stress variant angina
ischemic equivalents/associated symptoms
SOB diaphoresis nausea/vomiting dizziness weakness
framingham
1948 5000+ M and F, 30-62 return every 2 years second generation in 1971 third gneration in 2002 omni chohorts in 1994
low risk
<10% 10-year framingham risk
monitor
intermediate risk
10-20% 10 yr framingham risk
further evaluation- EKG, stress test
high risk
> 20% 10 yr framingham risk
aggressive risk modification
metabolic syndrome
insulin resistance hyperglycemia HTN elevated triglycerides low HDL obesity doubles risk for CV disease
conditional risk factors
homocystein
Lp(a)
hsCRP
LDL particle size
conditional preventions
antioxidant therapies
omege-3-FAs
Lp(a)
resembles LDL w/added glycoprotein
few pharmacological agents lower Lp(a)
no research has demonstrated efficacy in CV risk reduction by lowering Lp(a)
hsCRP
high sensitivity C-reactive protein
useful in assessing patients w/intermediate framingham risk scores, reclassifies up to 30% into either low or high risk
reduction of risk
aspirn reduction of BP reduction of hyperlipemia smoking cessation regular exercise weight reduction and reduction of BMI (<25) reduction of psychological stresses
HRmax
220-age
pharmacological stress tests
dobutamine- increase cardiac stress and O2 demand
adenosine/dipyridmole- vasodilate
TIMI trial risk indicators
age >= 65 >= 3 traditional cadiac rsik factors documented CAD w/ >=50% stenosis ST segment abnormalities >=2 anginal episodes in last 24hrs used aspirin in last week elevated cardiac enzymes
TIMI trial risk 0-1
low risk- medical therapy and stress test to evaluate therapy, if stress test abnormal - angiography
TIMI trial risk 3-4
intermediate risk- medical therapy and early angiography
TIMI trial risk 5-7
high risk
medical therapy and immediate angiography
aortic dissection
widened mediastinum on chest x-ray
PE
new onset of A fib
CHF
orthopnea
SOB
timing of thrombolytic therapy
less then 90min
most significant determining factor
absolute contraindications to thrombolytic therapy
intracranial hemorrhage
ischemic CVA in last 3 months
facial trauma in last 3 months
bleeding diathesis
relative contraindications to thrombolytic therapy
after 12 hours chronic, sever, poorly-controlled HTN severe uncontrolled HTN on presentation ischemic CVA>3 months, known intracranial pahtology dementia internal bleeding w/in last 4 weeks pregnancy peptic ulcer disease current anticoagulant use
higher death risk w/thrombolytics
new LBBB Anterior wall mi cardiogenic shock ventricular arrhythmias advanced age >75
early complications of IWMI
bradycardia and AV block- AV nodal perfusion by RCA
right ventricular infarction
hypotension for volume depletion
early complications of AWMI
pump failure and CHF in large area infarcts, cardiogenic shcok
late complications of MI
24-28hrs cardiogenic shock VSD papillary m rupture and MR free wall rupture left ventricular thrombus
cardiogenic shock
due to pump failure and inflammation
VSD
new systolic murmur and thrill on LSB
Papillary m rupture and MR
new systolic murmur, pulmonary edema, thrill, cardiogenic shock
free wall rupture
electromechanical dissociation
first infarction, ant infarction, females, elderly
left ventricular thrombus
blood stasis, endocardial injury and possible inflammation leading to hypercoagulable state
most often located in left ventricular apex
indications for angiography before discharge
EF <40%
Clinically significant ischemia on non-invasive testing
arrhythmias during hospital stay
recurrent chest pain during hospital stay
significant heart failure during stay
mortality intervention
beta blockers aspirin ACE inhibitors HMG-CoA reductase inhibitors intense management of hyperglycemia
coronary revascularization
percutaneous intervention (PCI) coronary artery bypass grafting (CABG)
PCI
shown not to have improvement overall in survival or recurrent acute events, except those w/silent ischemia by non invasive stress testing
primarily reserved for those w/positive stress stess, failure of medical therapy, or poor surgical risk
CABG
in stable CAD is only indicated in patients w/left main disease, left main equivalent, 3 vessel disease, two vessels involving proximal LAD and EF<50%
Left main equivalent
high grade stenosis >70% proximal LAD and Circ
coronary angiography
gold standard
successfully resuscitated for cardiac arrest
life limiting angina despite medical therapy
unclear diagnositc evaluation
ST segment elevation MI
coronary a calcium CT or MRI
highly effective in negative predictive value, also used to evaluate patients w/intermeidate framingham scores
