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Physical & Health Assessment COPY - Grayson > Ischemic Heart Disease (Exam II) > Flashcards

Ischemic Heart Disease (Exam II) Flashcards

1
Q

What chemical mediators are released from ischemia that activate cardiac nociceptors?

A

Adenosine and Bradykinin

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2
Q

What is the path for cardiac pain signals to reach the spinal cord?

A

Cardiac nociceptors → Afferent Neurons → T1 - T5 SNS ganglia.

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3
Q

What is the CNS response to cardiac ischemia?

A
  • ↓ AV conduction and thus ↓HR
  • ↓ Contractility
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4
Q

3 physical inducers of angina

A

exertion
emotional tension
cold weather

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5
Q

Differentiate stable vs unstable angina.

A
  • Stable - No change in chest pain severity or frequency in 2-mo period.
  • Unstable - Increasing frequency and severity of chest pain.
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6
Q

Are cardiac biomarkers (troponin) present with unstable angina?

A

NO. If they were, that would be an MI.

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7
Q

What EKG abnormality is associated with old MI’s and/or current ischemia?

A

T-wave inversion

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8
Q

What is nuclear stress testing utilized for?

A

Coronary Perfusion assessment

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9
Q

What is the relationship between ST-segment depression and CAD.

A

The greater the degree of ST-segment depression, the greater the likelihood of significant artery disease

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10
Q

What determines the significance of CAD during a nuclear stress test?

A

Size of the perfusion abnormality

Arrows point to arrows of lesser perfusion.

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11
Q

What test can differentiate a new vs and old perfusion abnormality?

A

Nuclear Stress Testing

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12
Q

What nuclear stress test tracers are used with exercise?

A

Thallium and Technetium

less tracer, less blood flow

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13
Q

What nuclear stress test drugs are used without exercise?

A

Atropine
Dobutamine
Pacing

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14
Q

What test determines location of occlusive disease, diagnoses prinzmetal angina, and assess results of angioplasty/stenting?

A

Coronary angiography

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15
Q

When are adenosine and dipyridamole used with nuclear stress testing? Why?

A

Used after test to dilate normal, non-ischemic areas of the heart.

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16
Q

What test would be useful for imaging wall motion abnormalities or valvular function?

A

Echocardiography

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17
Q

What is Prinzmetal Angina?

A

Coronary Spasm

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18
Q

Differentiate old vs. new plaque

A

Old - lots of collateral blood flow
New - not a lot of collateral blood flow

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19
Q

How do you measure the stability of plaques?

A

You can’t

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20
Q

Non-pharmacologic tx for IHD

A
  • Cessation of smoking
  • Ideal body weight
  • Low-fat/low-cholesterol diet
  • Statins (LDL > 160 mg/dL)
  • Aerobic exercise
  • Tx for hypertension
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21
Q

What is the mechanism of action for aspirin?

A

COX-1 Inhibition → TXA2 inhibition → Plt aggregation inhibition.

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22
Q

Drug therapy for CAD?

A

ASA (75-325 mg/day)
…unless allergic, then: PY12 inhibitor (clopidogrel, prasugrel, or ticagrelor)

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23
Q

How can aspirin be reversed?

A

Trick question. It can’t be, platelets are damaged until they die and are replaced.

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24
Q

What is the mechanism of action of abciximab, eptifibatide, and tirofiban?

A

Platelet glycoprotein IIb/IIIa receptor antagonists

Inhibit platelet activation, adhesion, and aggregation.

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25
Q

What drugs (discussed in lecture) are P2Y12 inhibitors?

A

Clopidogrel and Prasugrel

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26
Q

What common drug class will antagonize P2Y12 inhibitors?

A

PPIs

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27
Q

How does Prasugrel compare to Clopidogrel?

A

More predictable pharmacokinetics but greater bleeding risk.

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28
Q

How do P2Y12 inhibitors work?

A

Inhibit ADP receptor P2Y12 and thus inhibit platelet aggregation.

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29
Q

What drug classes are synergistic with nitrates?

A
  • β-blockers
  • CCBs
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30
Q

When are nitrates contraindicated?

A
  • Aortic Stenosis
  • Hypertrophic Cardiomyopathy
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31
Q

What drug class is the only one proven to prolong life in CAD patients?

A

β-blockers

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32
Q

What properties do β-blockers have?

A
  • Anti-ischemia
  • Anti-HTN
  • Anti-dysrhythmic
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33
Q

Which β blockers are cardioselective?

A
  • Atenolol
  • Metoprolol
  • Acebutolol
  • Bisoprolol
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34
Q

Which β blockers are non-selective?

A
  • Propanolol
  • Nadolol
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35
Q

What risk is associated with non-selective β blockers in asthma patients?

A

↑ risk of bronchospasm in reactive airway disease patients.

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36
Q

What drug class is uniquely effective is decreasing the severity/frequency of coronary vasospasm?

A

CCBs

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37
Q

What drug prevents ventricular remodeling, stablizes electrical activity of re-profused heart, and prevents the occurrence of reprofusion arrhythmias?

A

ACE Inhibitors

also treats hypertension, HF, and cardioprotective

38
Q

Angiotensin II will increase what four things?

A
  • Myocardial hypertrophy
  • Interstitial myocardial fibrosis
  • Coronary vasoconstriction
  • Inflammatory responses
39
Q

Is troponin or CK-MB more specific for myocardial injury?

A

Troponin

40
Q

How soon with troponin start to increase after myocardial injury?

A

3 hours

lasts for 7-10 days

41
Q

What are the 3 categories of acute coronary syndrome?

A

STEMI
non STEMI
Unstable angina

42
Q

What diagnostic studies might indicate a myocardial infarction?

A
  • EKG: abnormality (ex. LBBB)
  • US: Regional wall motion abnormalities
43
Q

What are indications for PCI treatment of an MI?

A
  • Contraindicated tPa therapy
  • Severe HF and/or pulm edema
  • S/S for 2-3 hours
  • Mature clot
44
Q

When is CABG&raquo_space;> PCI

A
  • Significant left main coronary artery disease
  • Three-vessel coronary artery disease
  • Pt’s with DM who have 2 or 3 vessel CAD
45
Q

What risks are associated with PCI (percutaneous coronary intervention) ?

A
  • Endothelial destruction
  • Bleeding*
  • Thrombosis*
46
Q

What is Dual Antiplatelet Therapy (DAPT) ?

A
  • ASA w/ P2Y12
47
Q

How long would one want to wait for elective surgery post angioplasty with no stenting?

A

2 - 4 weeks

48
Q

How long would one want to wait for elective surgery post angioplasty with bare-metal stent placement?

A

At least 30 days (12 weeks preferable)

49
Q

What is responsible for acute thrombus formation?

A

Vulnerable plaques

more prone to rupture w/rich lipid cores and thin fibrous caps

50
Q

How long would you wait for elective surgery post angioplasty with drug-eluting stent placement?

A

At least 6 months (12 months if post ACS)

51
Q

How long would you wait for elective surgery post-CABG?

A

At least 6 weeks (12 weeks preferable)

52
Q

How long would you wait for elective surgery post angioplasty w/o stenting?

A

2-4 weeks

53
Q

How long would you wait for elective surgery post bare metal stent placement?

A

At least 30 days, 12 weeks prefered

54
Q

Is glycopyrrolate or atropine preferred for treatment of bradycardia?

A

Glycopyrrolate

55
Q

Are β blockers or ACE-inhibitors continued peri-operatively?

A

β-blockers

56
Q

Are β blockers or ACE-inhibitors discontinued 24 hours prior to surgery?

A

ACE inhibitors

57
Q

Are statins or ACE-inhibtors discontinued 24hrs prior to surgery?

A

ACE-inhibtors

58
Q

What components are worth 1 point on the Revised Cardiac Risk Index (RCRI) ?

A
59
Q

What % risk of major cardiac events would be conferred by a RCRI score of 0 ?

A

0.4%

60
Q

What % risk of major cardiac events would be conferred by a RCRI score of 1 ?

A

1.0%

61
Q

What % risk of major cardiac events would be conferred by a RCRI score of 2 ?

A

2.4%

62
Q

What % risk of major cardiac events would be conferred by a RCRI score of ≥3 ?

A

5.4%

63
Q

What does 1 MET equal?

A

3.5mLO₂/kg/min

64
Q

What drug is the preferred treatment for tachycardia?

A

Esmolol

65
Q

What anticholinergic is the better option for treatment of bradycardia in CAD patients?

A

Glycopyrrolate > Atropine

66
Q

What coronary artery would you expect to be effected from abnormalities noted on II, III, and aVF?

A

RCA

67
Q

What coronary artery would you expect to be effected from abnormalities noted on I and aVL?

A

Circumflex artery

68
Q

What coronary artery would you expect to be effected from abnormalities noted on V3 - V5?

A

LAD

69
Q

Two biggest risk factors for developing atherosclerosis in the coronary arteries

A

Male gender
Increasing age

70
Q

% of surgical patients w/IHD

A

30%

71
Q

What diagnostic data is indicative of a myocardial infarction, select 2

A
  • Detection of rise and/or fall of cardiac biomarkers
  • Evidence of myocardial ischemia indicated by one of the following… Q waves, symptoms of ischemia, ST changes, etc.
72
Q

What is pseudonormalization of the T wave?

A

Return of T-waves to an upright position after having chronically inverted T waves resulting from a previous MI

73
Q

What is the primary goal for management of STEMI?

A

Reestablish blood flow in the obstructed coronary artery ASAP
time is tissue

74
Q

Drug therapy for MI

A

MONA (Fentanyl better than Morphine)
P2Y12 inhibitors
IIb/IIa inhibitors
Unfractionated heparin
B blockers
RAAS

*ASA

75
Q

In what time frame should tPA be initiated?

A

Within 30-60 min of hospital arrival
Within 12hrs of symptom onset

76
Q

Presentation of unstable angina/STEMI

A

Angina at rest, lasting >10min
Chronic angina pectoris - a crescendo pattern of occurance
New-onset angina that is severe, prolonged, or disabling

77
Q

What therapy is not indicated in unstable angina/NSTEMI?

A

Thrombolytic therapy - increases mortality
Treatment includes: bed rest, oxygen, analgesia, B-blockers, nitro, CCB, ASA, clopidogrel, prasugrel, ticagrelor, and heparin

78
Q

Reendothelialization times….

Ballon angioplasty:
Bare-metal stent:
Drug-eluting stent:

A

Ballon angioplasty: 2-3 weeks
Bare-metal stent: 12 weeks
Drug-eluting stent: 1 year +

*drug-eluting has the longest reendothelialization time

thrombosis is major concern

79
Q

What is the most significant independent predictor of stent thrombosis?

A

P2Y12 inhibitor discontinuation

80
Q

Perioperative glucose goal

A

< 180 mg/dL

81
Q

What are neuroendocrine stress responses that will cause increased cardiac oxygen demand in surgery?

A

↑HR
↑BP
Metabolic changes (↑ blood sugar)
….also postoperative shivering

82
Q

What inflammatory responses caused by surgery might result in a perioperative MI?

A

Hypercoaguable state
Plaque rupture

83
Q

What are examples of high-risk surgery?

A
  • Abdominal aortic aneurysm
  • Peripheral vascular operation
  • Thoracotomy
  • Major abdominal operation
84
Q

What is a good pre-op MET score?

A

= or > 4 METS

raking leaves, gardening

85
Q

What is a MET?

A

Metabolic Equivalent of Task

86
Q

Emergent vs. Urgent vs. Time-Sensitive

A

Emergency - ☠️ or 🦵🏻 threatened if surgery doesn’t proceed within 6hrs
Urgent - ☠️ or 🦵🏻 threatened if surgery doesn’t proceed withing 6-24hrs
Time-sensitive - delays exceeding 1 to 6 weeks would adversely affect patient outcomes

87
Q

In what kind of case would you need to skip a pre-op cardiac assessment?

A

Emergency case

88
Q

How many days should elapse after a recent MI before noncardiac procedure?

A

60 days

in the absence of coronary intervention

89
Q

What are examples of active cardiac conditions?

A
  • Unstable coronary syndrome
  • Unstable or severe MI
  • Decompensated HF
  • Severe valvular disease (aortic/mitral stenosis)
  • Significant dysrhymias
  • Age???
90
Q

Maintain BP/HR within _______ % of normal awake baseline

A

20

91
Q

Why should you avoid hyperventilation when trying to meet myocardial O2 needs?

A

Hypocapnia may cause coronary artery vasoconstriction

92
Q

True/False - The use of nitrogen is contrindicated in patients with CAD

A

FALSE

Physical & Health Assessment COPY - Grayson (24 decks)

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