How do P2Y12 inhibitors work?

Inhibit ADP receptor P2Y12 and thus inhibit platelet aggregation.

Ischemic Heart Disease (Exam II) Flashcards by Jeremy Steele

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

Adenosine and Bradykinin

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

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

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What is the CNS response to cardiac ischemia?

↓ AV conduction and thus ↓HR
↓ Contractility

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Differentiate stable vs unstable angina.

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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Physical exertion, emotional tension, and cold weather may

induce angina

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Angina can present as retrosternal chest discomfort, pain, pressure, or heaviness that may radiate to any

dermatome from C8 to T4

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Are cardiac biomarkers (troponin) present with unstable angina?

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

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

T-wave inversion

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What is nuclear stress testing utilized for?

Coronary Perfusion assessment

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Cardiac angiography does NOT

measure stability of plaque

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Cardiac angiography is used for

Determining location of occlusive disease
Diagnose prinzmetals angina
Assesses results of angioplasty/stenting

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

Size of the perfusion abnormality

Arrows point to arrows of lesser perfusion.

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

Nuclear Stress Testing

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What nuclear stress test tracers are used with exercise?

Thallium and technetium

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What nuclear stress test drugs are used without exercise?

Atropine
Dobutamine
Pacing

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

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

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

Echocardiography

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What is Prinzmetal Angina?

Coronary Spasm

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What is the mechanism of action for aspirin?

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

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How can aspirin be reversed?

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

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The lifespan of a platelet is

7-14 days

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

Platelet glycoprotein IIb/IIIa receptor antagonists

Inhibit platelet activation, adhesion, and aggregation.

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What drugs (discussed in lecture) are P2Y₁₂ inhibitors?

Clopidogrel and Prasugrel

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Prasugrel (Effient®) is more potent than

Plavix

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What common drug class will antagonize P2Y₁₂ inhibitors?

PPIs

How does Prasugrel compare to Clopidogrel?

More predictable pharmacokinetics but greater bleeding risk.

How do P2Y₁₂ inhibitors work?

Inhibit ADP receptor P2Y₁₂ and thus inhibit platelet aggregation.

What drug classes are synergistic with nitrates?

- β-blockers - CCBs | Must continue B-blockers or give dose in OR

When are nitrates contraindicated?

- Aortic Stenosis - Hypertrophic Cardiomyopathy

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

β-blockers

What properties do β-blockers have?

- Anti-ischemia - Anti-HTN - Anti-dysrhythmic

Which β blockers are cardioselective? (4)

- Atenolol - Metoprolol - Acebutolol - Bisoprolol

Which β blockers are non-selective?

- Propanolol - Nadolol

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

↑ risk of bronchospasm in reactive airway disease patients. (Asthma, COPD)

What drug controls HR well but does not effect contractility

Esmolol

Most commonly given b-blocker in the OR

Labatolol | Why?

What drug class is uniquely effective is decreasing the severity/frequency of coronary vasospasm? Aka prinzmetal's/variant angina?

CCBs

Angiotensin II will increase what four things?

- Myocardial hypertrophy - Interstitial myocardial fibrosis - Coronary vasoconstriction - Inflammatory responses

Statins decrease

Lipid Oxidation Inflammation Matrix metalloproteinase Cell Death

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

Troponin | CK-MB looks at all muscles not cardiac specific

How soon with troponin start to increase after myocardial injury?

3 hours

What diagnostic studies might indicate a myocardial infarction?

- EKG: abnormality (ex. LBBB) - US: Regional wall motion abnormalities

What are indications for PCI treatment of an MI? (4)

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

What to check before giving a pt tPa?

C-xray and blood pressure in both upper extremeties to ensure they are equal to ensure pt does not have an **anyursm**

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

- Endothelial destruction - Bleeding - Thrombosis

What is Dual Antiplatelet Therapy (DAPT) ?

- ASA w/ P2Y₁₂

How long after PCI does the vessel take to Reendothelialize after **balloon angioplasty? **

2–3 weeks

How long after PCI does the vessel take to Reendothelialize after **bare-metal stent placement? **

12 weeks

How long after PCI does the vessel take to Reendothelialize after **drug-eluting stent?**

- a full 1 year or longer

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

2 - 4 weeks

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

At least 30 days (12 weeks preferable)

How long would one want to wait for elective surgery post angioplasty **with drug-eluting stent placement**?

At least 6 months (12 months if post ACS)

How long would one want to wait for elective surgery post-CABG?

At least 6 weeks (12 weeks preferable)

Discontinuation of ________ is the most significant independent predictor of stent thrombosis

**P2Y12 inhibitor**

Is glycopyrrolate or atropine preferred for treatment of bradycardia intraop for ischemic heart disease surgery?

Glycopyrrolate

What is usually always given with Glycopyrrolate?

Neostigmine

with peds you want to ensure that you maintain the

1:1 ratio of Glyco to Neostigmine effect to avoid bradycardia since they have less ability to adapt the SV via contractility

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

β-blockers

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

ACE inhibitors

What components are worth 1 point on the Revised Cardiac Risk Index (RCRI) ? (6)

Who would get a CABG first instead of a PCI?

> 50% of L main artery occlusion > 70% epicardial artery occlusion - impaired EF <40%

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

0.4%

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

1.0%

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

2.4%

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

5.4%

What does 1 MET equal?

3.5mLO₂/kg/min

What drug is the preferred treatment for tachycardia?

Esmolol

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

**Glycopyrrolate** > Atropine

DOC for hypotension and bradycardia??

Ephedrine

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

RCA

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

Circumflex artery

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

LAD

An emergent surgery needs to be performed within

6 hrs or less

Urgent Sx need to be performed within

6-24 hours

Time-sensitive Sx needs to be performed within

1-6 weeks

two most important risk factors for the development of atherosclerosis involving the coronary arteries are

**male gender and increasing age**

Be sure to put a note in as to why you

Cancelled the case

Ways to blunt the SNS repsonse from intubation (6)

Laryngotracheal lidocaine IV lidocaine esmolol fentanyl remifentanil dexmedetomidine

tPa or thrombolytic therapy is not indicated in

unstable angina or NSTEMI has shown to increase mortality

Which angina pts could require fentanyl?

New onset angina with severe, prolonged, or disabling pain

30% of all surgical pts have _____

Ischemic heart disease

What three active cardiac conditions present the highest risk for mortality if we proceed with surgery?

Decompensated HF Severe valvular disease Significant Dysrhythmias