Ischemic Heart Disease I and II Flashcards
What are 3 possible steps you could take next in the case of Someone complaining of chest pain on exertion?
- Perform a Stress Test
- Possible Coronary Catheterization?
- Give Drugs that reduce Demand
What are you looking for in a stress test of someone who complains of heart pain on exertion?
• what demands are we placing on the heart in a stress test?
- ST depression would be indicative of ischemia occurring from a stable angina
- Increase Heart Rate and Systolic Blood Pressure (afterload)
What should be your next steps if someone complains of chest tightness while sleeping?
- Perform Stress Test
- DO NOT catheterize (only do in ST elevation?)
- Give Drugs that Prevent Clots
What procedure is performed when people have multiple coronary vessels that are occluded?
• Single Vessel
- Coronary Bipass
* Single Vessel then do a stent
If someone walks in with chest pain and ST elevation (II, III, or aVF), what is the 1st thing you should do?
GO TO CATH LAB, you need to place a stent now
What is your Dx. if someone wakes up in the middle of the night with “elephant on their chest” but have no EKG abnormalities?
• what if troponins are positive?
- Acute Coronary Syndrome (non-STEMI)
* Troponin often will be elevated in non-STEMI but its still treated the same way
What is your Dx. if someone complains of tightness in their chest on exertion that goes away when they decrease activity?
• Chronic Stable Angina
What should happen in a normal heart as you increase demand on the heart?
• Coronaries Should Dilate to allow for greater flow
What controls Myocardial O2 supply?
• CORONARY BLOOD FLOW
What are 2 factors that play the predominant role in the Myocardium meeting its O2 demands?
- HEART RATE
- SYSTOLIC BLOOD PRESSURE
- contractile force
- ventricular dimensions
What is the very general problem in the myocardium that results in Chronic Stable Angina?
• O2 Demand ouweighs O2 Supply
What causes Chronic Stable Angina?
• Occlusion of Coronary Arteries with a STABLE ATHEROSCLEROTIC plaque
**What the the KEY things you’re looking for in a patient with Chronic Stable Angina?
Many times they have a heaviness in chest, but not always.
ALWAYS, ALWAYS, ALWAYS:
Timing:
• ALWAYS more than 5 min. NEVER greater the 30 min
Sympathetic Response:
• Sweating, Dyspnea
Cutaneous Symptoms:
• “White as a Ghost”
Patients ALWAYS have to DECREASE activity, if Running they’ll need to walk, if walking they’ll need to sit, if sitting they’ll need to lie down
If we suspect Chonic Stable Angina, what do we look for on EKG?
• Pts. will have a normal EKG unless walking on a treatmill, in this case they’ll have ST Depression
If we see a normal exercising EKG but still suspect an Chronic Stable Angina, what type of imaging can we do to determine if the patient has CSA?
• Nuclear Imaging is good for determining if some part of the heart is not being perfused
What are the steps that lead to ischemia in Chronic Stable Angina?
- Atherosclerotic Lesion present in Vessel
- Episodic Superimposed Vasospasm
- Transient Increased Obstruction
- Ischemia
Who is most susceptible for ACUTE coronary syndromes?
• how do you differentiate this from Chronic Stable Angina?
- Men slightly more than Women
- People OVER 65 years old
Acute Syndrome occurs at rest (at night) with chest pain that last MUCH LONGER than 30 min*
What is the Main Cause of ACUTE coronary Syndrome?
*Ruptured Atherosclerotic Plaque
Results in:
- Platelet Aggregation
- Vasoconstriction
Rank the mortality rates of:
• Acute MI
• Acute Coronary Syndrome (unstable angina)
• Stable Angina
Acute MI > ACS > Stable Angina
What is the Root Cause of Acute Coronary Syndrome?
• what factors increase the risk of this happening?
Cause = ENDOTHELIAL DYSFUNCTION that results in DECREASED NITRIC OXIDE ACTIVITY - “the vessel is the culprit”
Factors: • Lipoproteins • Smoking • Cytokines • Turbulent Flow • ROS • Glucose A1C • HTN
What 2 important things happen as the result of decreased NO production from dysfunctional epithelium?
- VASOCONSTRICTION
* PLATELET AGGREGATION
Differentiate a Stable and an Unstable Plaque.
Stable Plaque have a small lipid core with lots of overlying epithelium
Unstable Plaque • Thin Cap • Large Lipid Core • High Macrophage Content • Low Smooth Muscle Cell Count
Are antiplatelet and anticoagulation drugs more important in Chronic Stable Angina or in Acute Coronary Syndrome?
• Drugs to prevent platelet aggregation or break up clots are more important in ACS. CSA doesn’t involve thrombus formation so these drugs would do much to help these patients
What is the Primary Pharmacological Treatment given to patients with Unstable Angina?
• Asprin + Heparin
**Drugs like clopdigrel are also sometime used
What are some of the pain symptoms of Myocardial Infarction?
SUBSTERNAL chest pain that is crusing or squeezing (like indigestion) - Radiation to Arm, Neck, Jaw, Epigastrium, or between Scapulae
What are some possible outcomes of MI?
- Syncope
- Arrhythmia - VENTRICULAR FIBRILLATION
- Left Heart Failure
- Cardiogenic Shock
- Sudden Death
How long does an MI last?
• symptoms besides Pain
30 minutes to Several Hours
Jugular Venous Distention (MEASURE IT EVERYDAY) S3 Gallop (LISTEN FOR IT EVERYDAY) Anxiety (impending doom) Cold Sweats Nausea Vomiting Pale
How can we differentiate between Ischemia, Cell Damage, and Necrosis on EKG?
Ischemia - Inverted T or ST depression
Cell Damage - ST Elevation
Necrosis - ST elevation with large Q waves
Can tropinin tell you if someone is having an MI?
Not Really, its VERY sensitive so it may be elevated even in trauma or sepsis so use context
What area of infarction leaves people at the highest risk for heart block?
• Infarction in AV area and IV septum get heart block after a very bad MI
What is the most common cause of sudden cardiac death?
• Ventricular Fibrillation
What would you hear on auscultation of someone with a rupture of the IV septum?
• what secondary problem would eventually happen?
- Loud Systolic Murmor
* L to R shunting would cause Right Ventricular hypertrophy and pulmonary edema
What key problem results from tearing a papillary muscle?
- Regurgitation (or mitral or triscupid valves)
* You may also get pulmonary edema from inability of Ventricle to Handle the high EDV that results from Regurgitation
Someone present with a STEMI and systolic pressure below 90 mmHg. State?
Cardiogenic Shock
When is the only time you’ll ever see diastolic pressure greater than systolic pressure?
• Balloon Angioplasty
If you are at a primary care facility 100 miles from anything and someone present with an MI what should you do?
• what is the downfall of this therapy?
- Probably Should Give Stretokinase or Alteplas to break up the clot assuming you don’t have a stent lab
- Downside is that the clot may come back as soon as the thrombolytic wears off
