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Cardio Exam 2 Remediation > Ischemic Heart Disease II > Flashcards

Ischemic Heart Disease II Flashcards

1
Q

Tests which every with chest pain gets

A

EKG and Biomarkers (if we are in the ER)

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2
Q

Best initial test for a patient with chest pain

A

EKG

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3
Q

How fast should a chest pain patient receive an EKG

A

Within 10 minutes of presentation

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4
Q

Intervals for EKG monitoring

A

15-30 minute intervals

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5
Q

First EKG finding for ACS

A

Hyperacute T waves - diffuse may be hyperkalemia

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6
Q

NSTEMI and Unstable Angina EKG

A

ST Depression or T wave inversion in 2 contiguous leads

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7
Q

How to tell a USA and NSTEMI apart

A

USA - Normal Troponins
NSTEMI - Elevated troponins

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8
Q

Evolution of a STEMI - 4 stages with timeframes

A

ST elevation - Minutes to hours after
Pathologic Q wave with inverted T wave - 1-2 days after
ST flattening with pathologic Q wave - 7-10 days
Normalization with persistent Q wave - Months after

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9
Q

Second step in working up chest pain for ACS

A

Draw labs - Cardiac Enzymes

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10
Q

3 Cardiac Enzymes

A

Myoglobin
CK-MB
Troponin

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11
Q

Troponin

A

Extremely sensitive and specific to the heart - best test

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12
Q

Increase, Peak, and Return to Baseline of Troponins

A

Increase: 3-6 hours
Peak - 24-48 hours
Return to Baseline: 5-14 days

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13
Q

Serial monitoring of troponins

A

At presentation
90 minutes after presentation
6-8 hours x3 or until trending down

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14
Q

Other things that can elevate troponins - 6

A

CHF
ESRD
Aortic dissection
PE
Myocarditis
PCI or CABG

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15
Q

How to determine if troponins are related to STEMI

A

Look for a serious trend upwards

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16
Q

CK-MB

A

Less sensitive and specific than troponins, usually use with troponins

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17
Q

Increase, Peak, and Return to baseline of CK-MB

A

Increase - 4-8 hours
Peak - 24 hours
Return - 48-72 hours

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18
Q

Why might we want CK-MB levels

A

Assess for an MI in a patient that has had one in the past two weeks

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19
Q

False positives with CK-MB - Five

A

Exercise, Trauma, Muscle Disease, DM, PE

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20
Q

Positive CK-MB value criteria

A

CK-MB over 5% of total CK

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21
Q

Myoglobin

A

MOST sensitive early marker for a patient having a coronary event - poor specificity - more so than troponin

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22
Q

When would we use myoglobin to test for ACS

A

Only used when they present within the first two hours of onset

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23
Q

Most sensitive early marker of an MI

A

Myoglobin

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24
Q

LDH Rise peak and return to normal in an MI

A

Rise - 24-72 hours
Peak - 3-4 days
Return to normal - 14 days

Not specific

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25
3 other possible lab findings in ACS
Leukocytosis Elevated CRP Elevated ESR
26
Preferred for of stress testing
Exercise stress test
27
Those for whom a stress test can be performed
Can walk for 5 minutes on flat ground or up 1-2 flights of stairs without needing to stop
28
Four Indications for a stress test
Confirm diagnosis of angina Determine severity of limitation due to angina Assess prognosis in patients with known CAD Evaluate response to therapy
29
Purpose of an exercise only stress test
For patients with a low or intermediate pretest probability Often with potential atypical symptoms
30
Goal HR for an exercise stress test
85% max HR
31
In an exercise stress test, intensity is increased until....
Patient reaches max HR Changes are detected on EKG Patient is symptomatic
32
Positive stress test
ST depression of 1mm
33
7 Absolute indications to STOP a stress test
SBP drop over 10mmHg w/ ischemic symptoms Moderate to severe angina Nervous system symptoms - near syncope Cyanosis or Pallor from Poor perfusion Subjects desire to stop Sustained V tach St elevation of 1.0mm+`
34
7 Relative indications to terminate a stress test
SBP drop over 10mmHg w/o ischemic symptoms ST or QRS changes - 2mm of downsloping Non-VT arrhythmias including PVC triplets Fatigue or SOB Development of BBB Increasing chest pain Hypertensive reponse
35
Absolute contraindications for performing a stress test - 8
Acute MI within 2 days High risk unstable angina Uncontrolled symptomatic arrhythmias Severe symptomatic aortic stenosis Uncontrolled symptomatic HF Acute PE or pulm infarction Acute aortic dissection Myocarditis or pericarditis
36
4 things that make doing an exercise stress test difficult - EKG hard to interpret
RBBB WPW syndrome ST depression at rest Electrical testing
37
Main indication for imaging with a stress test
When resting EKG makes stress EKG difficult to interpret (LBBB, WPW) Confirmation of results if uncertain Determine if tissue is ischemic or infarcted Assess efficacy of revascularization
38
Preferred medication class and three medications for an Pharm stress test
Vasodilators: Adenosine Dipyridamole Regadenoson
39
Three Contraindications for Pharm stress test
Bronchospasm Sick sinus SBP under 90
40
Second line pharm stress test agents
Adrenergic stimulating agents Dobutamine +/- Atropine For patients when vasodilators are CI
41
Coronary angiogram
CATH!! Reserved for intermediate to high risk patients Gold standard diagnostic
42
Prep for cardiac cath
NPO for 4-6 hours IV fluids to flush dye HOLD metformin for 48 hours
43
Ventriculogram
Inject dye into ventricle to estimate EF
44
Indications for coronary angiogram (5)
Life limiting stable angina High pretest likelihood of CAD or STEMI Aortic valve disease or undergoing ANY valve surgery Survivors of sudden death Uncertain cause chest pain
45
Femoral pseudoaneurism
Potential complication of a CATH
46
Typical workup for STABLE ANGINA
Normal EKG CBC possibly Troponin Stress test for low to intermediate HEART score Refer to cath for High HEART score Done OUTPATIENT
47
Typical workup for UNSTABLE angina
EKG - ST depression, T wave inversions, could be normal Negative troponins, maybe CK-MB Low HEART score - No further testing - look for other causes Intermediate heart score - Consider stress test, CATH if positive High HEART score - CATH
48
Typical workup for an NSTEMI
EKG - ST depression, T wave inversions, could be normal Positive troponins, may get CK-MB Any heart score - CATH
49
2 goals of stable angina treatment
Manage symptoms Prevent CV events
50
Initial management for USA, NSTEMI, STEMI
Admit and put on telemetry Strict Bedrest Oxygen if under 95% Nitrates - 0.4 x 3 - every 5 minutes - everyone ASA 162-325mg chewed - everyone
51
When to use clopidegrel, etc. for ACS
If truly allergic to aspirin
52
When to use morphine
May be used in pain refractory to NTG and ASA
53
Beta blockers in ACS
Use within 24 hours unless they have HF, Bradycardia, or Heart block
54
ACEI for ACS
Within 24 hours for everyone
55
Statins in ACS
Start within 48 hours or increase intensity
56
Door to balloon goal - CATH/PCI
90 minutes
57
Door to needle - tPA
30 minutes
58
MOA of Nitroglycerin
Converted to nitric oxide and activates cGMP - dilating blood vessels
59
CI of nitroglycerin
Hypotension, bradycardia, tachycardia, RV infarction
60
When not to give nitro
Inferior right sided wall MI
61
Administration of nitro in ACS
3 sublingual tablets, then IV Treat a headache so you can keep giving nitro Don't do high doses or frequent doses for tolerance
62
Drug contraindicated with nitroglycerin
PDE-5 inhibitor
63
Morphine effect in ACS
Pain relief Reduces oxygen demand Reduces blood pressure
64
Aspirin for IHD
160-325 mg immediately chewed for ACS 81mg for long term
65
P2Y12 inhibitors and IHD
Used for cath support if they can't take ASA 3-12 months after ACS Load Plavix before cath
66
P2Y12 inhibitors and CABG
Need to stop 5 (clopidogre/ticegrelorl) or 7 (prasugrel) days before surgery
67
Glycoprotein inhibitors
Can be added on to prevent platelet aggregation after ASA and P2Y12 Tirofiban Eptifibatide Abciximab

Cardio Exam 2 Remediation (7 decks)

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