Ischemic Heart Disease/Chest Pain Flashcards
What is the worst risk factor for ischemic heart disease?
Diabetes Mellitus
What is the worst risk factor for ischemic heart disease?
Diabetes Mellitus
What is the most common risk factor for ischemic heart disease?
Hypertension
A patient with coronary artery disease should have an LDL goal of:
The involvement of these vessels in CAD is associated with poor prognosis
Left main coronary artery (covers approx. 2/3 of heart)
** a 2 or 3 vessel CAD is worse prognosis
ECG in stable angina is….
usually normal
Q waves on ECG are consistent with
prior MI
How to calculate maximum heart rate
220-age
Stress test aims to achieve HR that is….
85% of the max heart rate
ECG stress test is considered to be positive (i.e. ischemia is detected) if….
ST segment depression is present
Stress test is generally considered positive if patient develops any of the following:
ST segment depression
Chest pain
Hypotension
Significant Arrhythmia
Stress echocardiography test evaluates presence of ischemia by detecting….
Wall motion abnormalities
How is stress myocardial perfusion imaging conducted?
Via IV administration of radioisotope (Thallium 201) during exercise
***No uptake of the radioisotope in a particular area indicates no blood flow to that area–>Ischemic
How do adenosine and dipyridamole function in stress tests?
They cause generalized coronary vasodilation and thus are helpful in perfusion studies. Diseased arteries are already maximally dilated thus receive relatively less blood flow when the entire coronary system is vasodilated.
How do adenosine and dipyridamole function in stress tests?
They cause generalized coronary vasodilation and thus are helpful in perfusion studies. Diseased arteries are already maximally dilated thus receive relatively less blood flow when the entire coronary system is vasodilated.
What is the most common risk factor for ischemic heart disease?
Hypertension
A patient with coronary artery disease should have an LDL goal of:
The involvement of these vessels in CAD is associated with poor prognosis
Left main coronary artery (covers approx. 2/3 of heart)
** a 2 or 3 vessel CAD is worse prognosis
ECG in stable angina is….
usually normal
Q waves on ECG are consistent with
prior MI
How to calculate maximum heart rate
220-age
Stress test aims to achieve HR that is….
85% of the max heart rate
ECG stress test is considered to be positive (i.e. ischemia is detected) if….
ST segment depression is present
Stress test is generally considered positive if patient develops any of the following:
ST segment depression
Chest pain
Hypotension
Significant Arrhythmia
Stress echocardiography test evaluates presence of ischemia by detecting….
Wall motion abnormalities
How is stress myocardial perfusion imaging conducted?
Via IV administration of radioisotope (Thallium 201) during exercise
***No uptake of the radioisotope in a particular area indicates no blood flow to that area–>Ischemic
What pharmacologic agents can be used in a stress test in lieu of exercise?
Adenosine, Dipyridamole, Dobutamine
How do adenosine and dipyridamole function in stress tests?
They cause generalized coronary vasodilation and thus are helpful in perfusion studies. Diseased arteries are already maximally dilated thus receive relatively less blood flow when the entire coronary system is vasodilated.
Unstale Angina
Chronic angina with increased frequency, duration, or intensity
new onset angina that is severe or worsening
Angina at rest
No ST elevation, no increased cardiac enzymes
What is the most accurate method of determining a specific cardiac diagnosis?
Cardiac Catheterization
What is the most accurate method for identifying presence and severity of CAD?
Coronary Arteriography
What percentage of coronary stenosis may be significant to produce angina?
> 70%
What is the standard of care for stable angina?
Aspirin and Beta Blocker (decrease mortality)
Nitrates for chest pain
Aspiring in stable angina decreases….
it decreases morbidity and risk of MI
First line beta blockers for stable angina are
atenolol and metoprolol
Beta Blocker mechanism of action
Blocks sympathetic stimulation of heart–> decreased HR, BP, Contractility–> decreased cardiac work–> decreased myocardial oxygen consumption
Nitrates work to relieve angina by….
causing generalized vasodilation which decreases preload myocardial oxygen demand
In stable angina, what can be used as secondary treatment when beta blockers and/or nitrates are not fully effective?
Calcium Channel Blockers
***Not routinely used because may increase mortality because they tend to increase HR
What are the side effects of nitrates?
Headache
orthostatic hypotension
tolerance
syncope
main indications for coronary artery bypass grafting
3 vessel disease with >70% stenosis in each vessel
Left main coronary artery disease with >50% stenosis
Left Ventricular dysfunction
Acute Coronary syndrome refers to:
Unstable Angina (no ST elevation or increased enzymes)
NSTEMI (no ST elevation, but increased enzymes)
STEMI (ST elevation with increased enzymes)
Acute Coronary Syndrome is the clinical manifestation of:
Atherosclerotic plaque rupture and coronary occlusion
Unstale Angina
Chronic angina with increased frequency, duration, or intensity
new onset angina that is severe or worsening
Angina at rest
No ST elevation, no increased cardiac enzymes
Distinction between unstable angina and NSTEMI
NSTEMI has elevated tropinin and CK-MB
Medical management of unstable angina includes
Aspirin and Clopidogrel Beta Blockers LMWH Nitrates Glycoprotein IIb/IIIa inhibbitors, especially if PTCA or stenting
Any form of CAD should be started on HMG-CoA reductase inhibitor (statin) regardless of…
LDL level
Variant (prinzmetal) angina
Transient coronary vasospasm, usually accompanied by a fixed atherosclerotic lesion, but can occur in normal coronaries.
Angina at rest, classically at night, and associated with ventricular dysrhythmia
ECG changes indicating a posterior infarct
Large R wave in V1 an V2
ST segment depression in V1 and V2
Upright and prominent T waves in V1 and V2
Treatment for Variant (prinzmetal) angina
Vasodilators: Calcium Channel Blockers/ Nitrates
Sudden Cardiac Death is usually due to
Ventricular Fibrillation
ST segment elevation indicates
transmural injury *with infarction 75% of the time
Q waves are evidence of…
necrosis and occur late and not typically seen acutely
ST segment depression indicates
subendocardial injury (inner 1/3 to 1/2 of wall) *infarction 25% of the time
What should NOT be administered if there is a Right Ventricular Infarct?
Nitrates and diuretics should not be administered because this will cause cardiovascular collapse as this infarct causes the heart to be preload dependent.
Right Vetricular Infarct will present with
Inferior ECG changes Hypotension Increased Jugular Venous Pressure Hepatomegaly Clear Lungs
In MI, what is the most important enzyme test to order?
Troponins (T and I)
What is the MI timeline for Troponins?
Increase within 3-5 hours
Peaks at 24-48 hours
Returns to normal in 5-14 days
Which troponin is more specific to MI and why?
Troponin T is more specific because Troponin I can be falsely elevated in renal failure. *Important to follow trend of levels
What is the MI timeline for CK-MB?
Increase withing 4-8 hours
Peak in 24 hours
Return to normal in 48-72 hours
Which cardiac enzyme is most helpful in detecting acutely recurrent infarction?
CK-MB due to quicker return to baseline than troponins
48-72 hours VS 5-14 days
ECG changes indicating an anterior infarct:
ST segment elevation in V1-V4 (acute/active)
Q waves in V1-V4 (late)
ECG changes indicating a posterior infarct
Large R wave in V1 an V2
ST segment depression in V1 and V2
Upright and prominent T waves in V1 and V2
ECG changes indicating a lateral infarct
Q waves in Leads I and aVL (late)
ECG changes indicating an inferior infarct
Q waves in leads II, III, and aVF (late)
Which pharmacologic agents have been shown to decrease mortality in MI?
Aspirin
Beta Blockers
ACE inhibitors
Cardiac Enzymes should be drawn serially:
once at admission, then every 8 hours until three samples have been obtained
Absolute Contraindications to Thromobolytic Therapy:
Trauma (recent head trauma or traumatic CPR) Prior stroke recent invasive procedure/surgery Dissecting aortic aneurysm Active Bleeding Bleeding diathesis
Dressler Syndrome
Occurs weeks to months after an MI
Fever, malaise, pericarditis, leukocytosis, and pleuritis
*Aspirin is most effective treatment
What is the most common non-cardiac cause of chest pain that presents to the ER?
Gastrointestinal Disorders
Cardiac Causes of chest pain are very unlikely if the pain _____________ or ______________
If the pain changes with body position/breath
or
there is tenderness of the chest wall
ST elevation in V1-V6 with no reciprocal changes on ECG
Anterior MI (LAD artery)
ST elevation in V1-V4 with disappearance of septum Q in V5,V6
Septal MI (LAD septal branches)
ST elevation in I, aVL, V5, V6 and reciprocal ST depression in II, III, aVF
Lateral MI (Left Circumflex artery or MO)
ST elevation in II, III, aVF and Reciprocal ST depression in I, aVL
inferior MI (RCA in 80% or RCX in 20%)
ST elevation in V7, V8, V9 with high R in V1-V3 and reciprocal ST depression in V1-V3 >2mm
Posterior MI (RCX)
ST elevation in V1, V4R with reciprocal ST depression in I, aVL
Right Ventricle MI (RCA)
PTa in I, V5, V6. Reciprocal PTa in I, II, or III
Atrial MI (RCA)
