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Advanced Principles C > Ischemic Heart Disease I > Flashcards

Ischemic Heart Disease I Flashcards

1
Q

Risk factors for cardiovascular disease?

A
  • Male
  • Age
  • High cholesterol
  • HTN
  • Smoking
  • DM
  • Obesity
  • Inactivity
  • Genetics
  • Stress
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2
Q

Main cause of ischemic heart disease?

A

Imbalance of myocardial oxygen supply and demand due to occluded coronary artery.

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3
Q

Name the metabolites released from an occluded artery.

A
  • Adenosine
  • Bradykinin
  • Lactic Acid
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4
Q

Description of Angina

A
  • Substernal pain
  • May radiate to neck or arm
  • Lasts minutes
  • Relieved by rest or NTG
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5
Q

Differentiate between chronic (stable) angina and unstable angina

A
  • Chronic: Does not change in intensity or duration over 2+ months.
  • Unstable: Rest pain or increased severity/frequency
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6
Q

Name ways to diagnosis CAD. What is the gold standard?

A
  • Subjective Symptoms
  • EKG
  • Nuclear imaging,
  • Echocardiography
  • Coronary angiography (gold standard)
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7
Q

What EKG pattern correlates with Subendocardial ischemia coinciding with chest pain?

A
  • ST segment depression
  • Transient T-wave inversion
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8
Q

What are the various types of ST segment depression?

Which one has a higher correlation to angina?

A
  • Upsloping
  • Downsloping
  • Horizontal (more likely to be angina related)
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9
Q

Negative Exercise EKG test makes chance of ________ vessel disease unlikely.

A

Three Vessel Disease

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10
Q

What test assess coronary perfusion and provides a greater sensitivity for ischemia than exercise testing?

A

Nuclear Stress Imaging

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11
Q

Tracers in nuclear imaging?

A
  • Thallium
  • Technetium
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12
Q

What does significant tracer uptake in nuclear stress imaging mean?

A
  • Normal circulation
  • Increase circulation with exercise
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13
Q

What does decrease tracer uptake in nuclear stress imaging mean?

A

Perfusion abnormality

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14
Q

What does absent uptake in nuclear stress imaging mean?

A

Old MI

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15
Q

When is pharmacologic stress testing (Nuclear Imaging w/o Exercise) used?

A
  • Musculoskeletal issues
  • Patient is deconditioned
  • PVD
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16
Q

What drugs/methods will produce tachycardia to create cardiac stress in Nuclear Imaging?

A
  • Atropine
  • Dobutamine
  • Pacing
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17
Q

What drugs are given in Nuclear Imagining to dilate coronary arteries?

A
  • Adenosine
  • Dipyridamole (Persantine)

Coronary dilation will be indicated by increased tracer.

No dilation of atheroscolerotic arteries indicated by decreased tracer.

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18
Q

Purpose of echocardiography?

A
  • Detects wall motion abnormalities (site of ischemia)
  • Assess valve function
  • Assess EF
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19
Q

Indications for coronary angiography?

A
  • Diagnosing ischemia
  • Assessing survivors of sudden cardiac death
  • Evaluating revascularization
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20
Q

What prognosis can be made from a coronary angiography?

A
  • Extent of atherosclerosis
  • Left Ventricular Function (EF)
  • Stability of plaque
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21
Q

Describe a “vulnerable plaque” seen in a coronary angiography.

A
  • Large Lipid Core
  • Thin fibrous capsule/cover
  • More likely to rupture and occlude
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22
Q

5 main drug classes used to treat for ischemic heart disease?

A
  • Anti-platelets
  • ACE inhibitors.
  • β-blockers
  • CCB
  • Nitrates
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23
Q

MOA of Aspirin

A

Inhibits COX-1 → Inhibits thromboxane A2 → Inhibits platelet aggregation.

  • Aspirin Dose: 75-325 mg/day
  • Decrease the risk of a cardiac event
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24
Q

MOA of Clopidogrel (Plavix)

A
  • Inhibits ADP receptor (P2Y12) to reduce platelet aggregation
  • Active metabolite variable in action (20% variability)

Clopidogrel is used in patients intolerant of ASA

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25
Clopidogrel's effectiveness is decreased with this drug.
* PPI * PPI inhibit the enzyme that metabolizes clopidogrel from prodrug to active
26
MOA of Prasugrel (Effient)
* Inhibits ADP receptor (P2Y12) to reduce platelet aggregation * Requires P450 enzyme to convert from prodrug to active metabolite
27
Key differences between Prasugrel and Clopidogrel?
* Prasugrel is more rapidly absorbed * Prasugrel has faster onset of action * Prasugrel has less variability, more predictable * Prasugrel is more potent (higher risk of bleeding)
28
Nitrates’ primary effect?
* Dilate coronary arteries * Decrease peripheral vascular resistance * Reduce afterload * Lower myocardial oxygen demand
29
Nitrates effect is synergistic with what drugs?
* β-blockers * CCB
30
Nitrates are contraindicated in patients with these cardiac conditions
* Hypertrophic cardiomyopathy * Aortic Stenosis * Afterload needs to be maintained in these conditions, nitrates will reduce the afterload
31
Why do we need an 8-12 hour window of "nitrate-free" zone?
* To prevent nitrate tolerance * Give time to restore receptor's sensitivity to nitrates (usually bedtime to morning)
32
Principle drug for stable angina
β-blockers
33
Purpose of beta-blockers in ischemia?
* Decrease myocardial oxygen demand * Prolong diastole (↑coronary perfusion) * Decrease re-infarction
34
Name β1-blockers drugs
* Atenolol (**commonly used**) * Metoprolol (**commonly used**) * Bisoprolol * Acebutolol
35
Conditions where β-blockers are contraindicated
* Severe bradycardia * Sick sinus syndrome (SSS) * Severe reactive airways * 2nd/3rd degree heart block * Uncontrolled CHF
36
How does β-blockers mask the signs of hypoglycemia?
β-blockers mask Sx of hypoglycemia by blocking the SNS responses, such as tachycardia, tremors, and sweating, which are typical warning signs of low blood sugar.
37
Three properties of β-blockers
* Anti-anginal * Anti-hypertensive * Anti-dysrhythmic
38
What does the Surgical Care Improvement Project (SCIP) say about patients receiving β-blockers?
* Surgery patients on β-blocker prior to admission must receive dose w/i 24 hr prior to case * No indication for acute initiation of β-blocker therapy …must initiate 1-4 weeks prior to non-cardiac surgery
39
Name the specific channels CCB inhibit.
L-type calcium channels located in smooth muscles, cardiac myocytes, and SA/AV nodes
40
Common CCB used
* Amlodipine (Norvasc) * Nicardipine (Cardene)
41
CCB are most useful in treating this type of angina.
Prinzmetal's ( Variant) Angina
42
Role of calcium channel blockers?
* Decrease vascular tone * Dilate coronary arteries * Improve supply/demand
43
CCB are potent vasodilators which can lead to these effects.
* Hypotension * Peripheral Edema * HA
44
What does ANG II promote?
* Inflammatory response * Atheroma formation * Coronary vasoconstriction * Myocardial hypertrophy
45
ACE inhibitors are indicated for patients with CAD and _______, _______, and/or ________.
* HTN * LV dysfunction * DM
46
Consideration of ACE-inhibitors with anesthesia.
* ACE inhibitors SIGNIFICANTLY increases hypotensive effects of anesthesia. * HOLD 24 HOURS before surgery
47
Patho of acute coronary syndrome
Focal disruption of a plaque → coagulation cascade → thrombus formation → Imbalance of O2 supply/demand → ACS
48
STEMI mortality rate with early perfusion vs without
* Early perfusion: 6.5% * Without: 15-20%
49
What is the prognosis of a STEMI dependent on?
* LV Function * Residual ischemia * Ventricular dysrhythmias
50
What is the first biomarker to peak with an MI? When does this biomarker peak?
* Myoglobin * Peaks at 4-12 hours
51
If a patient came in 3 days after his chest pain? What biomarkers will be elevated if this patient had an infarction?
* LDH * Troponin
52
Order the cardiac biomarkers that peak first to last
* Myoglobin * Total CK * CK-MB * Troponin * LDH
53
Treatment for STEMI
* MONA * Anti-platelet * β-blockers * Reperfusion (thrombolytics, angioplasty, stent, CABG)
54
EKG Diagnosis of a NSTEMI
* ST-depression and/or deep T-wave inversion WITH pain * Elevated biomarkers
55
Treatment for NSTEMI
* O2 * β-blocker * Antiplatelet vs Heparin * Consider early interventions
56
These type of drugs should be avoided in NSTEMI, can increase mortality.
* No thrombolytics for NSTEMI patients * Thrombolytics are only for complete occlusions
57
When does V-fib occur after an MI. Treatment.
* 1st four hours * Defib w/ 200-300 Joules
58
Asymptomatic VT can be treated with what drugs?
* Lidocaine * Amiodarone * Treat symptomatic VT with cardioversion
59
Treatment for A-flutter/A-fib if patient is unstable. What can be given for rate control.
* Cardioversion for unstable patients * β-blockers for rate control
60
MI to what region of the heart will result in Sinus Brady? Treatment for Sinus Brady.
* Inferior Wall * Atropine or Pacing to treat sinus brady
61
When does pericarditis occur after an MI?
* 1-4 days post MI * 10-15% of patients
62
Sx of Pericarditis
* Pain is worse laying down * Pain from inspiration d/t pericardial friction rub * ST-segment changes through 12-lead EKG
63
Treatment for Pericarditis
* Self resolves with time * Treat pain and inflammation w/ ASA, indomethacin, steroids
64
Describe Dressler's Syndrome
* Pericarditis that appears weeks to months after an acute MI * Immune mediated pericarditis
65
How does MI cause mitral regurgitation?
Ischemic injury to papillary muscle will cause them to rupture
66
Treatment for mitral valve regurgitation
* LV afterload reduction (diuretics, nitrates) * IABP to improve coronary perfusion * MR = FAST, FULL, FOWARD
67
If the mitral valve regurgitation is severe what can it lead to?
* Pulmonary Edema * Cardiogenic Shock
68
Cardiogenic shock is usually developed if more than ____-% of the myocardium is infarcted.
40%
69
Treatment for Cardiogenic Shock
* Reverse mechanical complications (pap ruptures, MR) * Improve BP (levo, vaso, dopamine, dobutamine) * Treat pulmonary edema (diuretics, vent) * Restore coronary flow (IABP/LVAD)
70
How does a IABP work?
* Inflates in diastole to improve coronary perfusion * Deflates before systole to reduce afterload and promotes forward flow
71
When will IABP be contraindicated?
* Aortic Insufficiency * Aortic Aneurysm * Severe PVD * Severe Coagulopathy
72
Complications to IABP
* Limb ischemia * Aortic dissection * Hemorrhage from insertion site * Helium emboli * Infection
73
High Lateral Leads: Inferior Leads: Septal Leads: Anterior Leads: Lateral Leads:
High Lateral Leads: Lead I, aVL Inferior Leads: Lead II, Lead III, aVF Septal Leads: V1, V2 Anterior Leads: V3, V4 Lateral Leads: V5, V6
74
The circumflex artery is typically associated with which lead?
* Lateral Leads * Lead I, aVL, V5, and V6
75
The right coronary artery is typically associated with which lead?
* Inferior Leads * Lead II, Lead III, and aVF
76
The LAD is typically associated with which lead?
* Septal and Anterior Leads * V1 to V4
77
* Inverted T-waves seen in V1 to V4 suggesting a NSTEMI * Myocardial Ischemia to LAD **Please note that these interpretations of the 12-Lead EKG reflect my own analysis and have not been independently verified for accuracy**
78
* Widespread ST-elevation throughout * Reciprocal ST-depression in aVR * Pericarditis **Please note that these interpretations of the 12-Lead EKG reflect my own analysis and have not been independently verified for accuracy**
79
* ST-elevation in Lead II, Lead III, and aVF * Reciprocal ST depression in aVL * Inferior STEMI affecting right coronary artery **Please note that these interpretations of the 12-Lead EKG reflect my own analysis and have not been independently verified for accuracy**
80
Which type of PTCA will have a lower incidence of restenosis?
Drug-eluting stents (DES) ## Footnote Although DES have a low rate of stenosis, the risk significantly increases if antiplatelet therapy is d/c in the first year.
81
When will bare metal stents be appropriate?
More appropriate in patients needing urgent surgeries
82
How long does re-endothelialization take for angioplasty, bare metal stents, and drug-eluting stents?
* Angioplasty: 2-3 weeks * Bare metal stents: 12 weeks * Drug-eluting stents: 1 year
83
DAPT recommendation length for angioplasty, bare metal stents, and drug-eluting stents?
* Angioplasty: 2 weeks * Bare metal stents: 6 weeks * Drug-eluting stents: 3 months
84
Adverse effects of Stent Placement
* Thrombosis if DAPT is d/c (↑risk w/ DM, low EF) * Bleeding from operation (increased mortality in spinal cord, aneurysm, and prostatectomy surgery)
85
DAPT Recommendations and Neuraxial Interventions
86
Indications for Routine/Scheduled CABG
* Medical therapy fails * Left main lesion > 50% stenosis * EF <40% with significant disease * Three or more vessels with disease
87
Indications for EMERGENCY CABG
* Failed angioplasty * MI-related septal rupture * MI-related mitral regurgitation * Perforated coronary arteries during stenting * Cardiogenic shock

Advanced Principles C (11 decks)

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