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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
Q

3 other possible lab findings in ACS

A

Leukocytosis
Elevated CRP
Elevated ESR

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26
Q

Preferred for of stress testing

A

Exercise stress test

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27
Q

Those for whom a stress test can be performed

A

Can walk for 5 minutes on flat ground or up 1-2 flights of stairs without needing to stop

28
Q

Four Indications for a stress test

A

Confirm diagnosis of angina
Determine severity of limitation due to angina
Assess prognosis in patients with known CAD
Evaluate response to therapy

29
Q

Purpose of an exercise only stress test

A

For patients with a low or intermediate pretest probability
Often with potential atypical symptoms

30
Q

Goal HR for an exercise stress test

A

85% max HR

31
Q

In an exercise stress test, intensity is increased until….

A

Patient reaches max HR
Changes are detected on EKG
Patient is symptomatic

32
Q

Positive stress test

A

ST depression of 1mm

33
Q

7 Absolute indications to STOP a stress test

A

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
Q

7 Relative indications to terminate a stress test

A

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
Q

Absolute contraindications for performing a stress test - 8

A

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
Q

4 things that make doing an exercise stress test difficult - EKG hard to interpret

A

RBBB
WPW syndrome
ST depression at rest
Electrical testing

37
Q

Main indication for imaging with a stress test

A

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
Q

Preferred medication class and three medications for an Pharm stress test

A

Vasodilators:
Adenosine
Dipyridamole
Regadenoson

39
Q

Three Contraindications for Pharm stress test

A

Bronchospasm
Sick sinus
SBP under 90

40
Q

Second line pharm stress test agents

A

Adrenergic stimulating agents

Dobutamine +/- Atropine

For patients when vasodilators are CI

41
Q

Coronary angiogram

A

CATH!!
Reserved for intermediate to high risk patients
Gold standard diagnostic

42
Q

Prep for cardiac cath

A

NPO for 4-6 hours
IV fluids to flush dye
HOLD metformin for 48 hours

43
Q

Ventriculogram

A

Inject dye into ventricle to estimate EF

44
Q

Indications for coronary angiogram (5)

A

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
Q

Femoral pseudoaneurism

A

Potential complication of a CATH

46
Q

Typical workup for STABLE ANGINA

A

Normal EKG
CBC possibly Troponin
Stress test for low to intermediate HEART score
Refer to cath for High HEART score

Done OUTPATIENT

47
Q

Typical workup for UNSTABLE angina

A

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
Q

Typical workup for an NSTEMI

A

EKG - ST depression, T wave inversions, could be normal
Positive troponins, may get CK-MB
Any heart score - CATH

49
Q

2 goals of stable angina treatment

A

Manage symptoms
Prevent CV events

50
Q

Initial management for USA, NSTEMI, STEMI

A

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
Q

When to use clopidegrel, etc. for ACS

A

If truly allergic to aspirin

52
Q

When to use morphine

A

May be used in pain refractory to NTG and ASA

53
Q

Beta blockers in ACS

A

Use within 24 hours unless they have HF, Bradycardia, or Heart block

54
Q

ACEI for ACS

A

Within 24 hours for everyone

55
Q

Statins in ACS

A

Start within 48 hours or increase intensity

56
Q

Door to balloon goal - CATH/PCI

A

90 minutes

57
Q

Door to needle - tPA

A

30 minutes

58
Q

MOA of Nitroglycerin

A

Converted to nitric oxide and activates cGMP - dilating blood vessels

59
Q

CI of nitroglycerin

A

Hypotension, bradycardia, tachycardia, RV infarction

60
Q

When not to give nitro

A

Inferior right sided wall MI

61
Q

Administration of nitro in ACS

A

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
Q

Drug contraindicated with nitroglycerin

A

PDE-5 inhibitor

63
Q

Morphine effect in ACS

A

Pain relief
Reduces oxygen demand
Reduces blood pressure

64
Q

Aspirin for IHD

A

160-325 mg immediately chewed for ACS
81mg for long term

65
Q

P2Y12 inhibitors and IHD

A

Used for cath support if they can’t take ASA
3-12 months after ACS
Load Plavix before cath

66
Q

P2Y12 inhibitors and CABG

A

Need to stop 5 (clopidogre/ticegrelorl) or 7 (prasugrel) days before surgery

67
Q

Glycoprotein inhibitors

A

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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