Ischemic Heart Disease II - Exam 2 Flashcards
What is the first diagnostic test ordered when working a pt up for Ischemic Heart Disease? How soon after arrival?
EKG!! always first
anyone with symptoms of ACS within the first 10 minutes of the pt’s arrival
What do you do if the EKG is not diagnostic but the patient remains symptomatic?
serial EKGs (e.g., 15- to 30-min intervals during the for the first 1-2 hrs) should be performed to detect ischemic changes.
What is the earliest presentation of an MI? What do they need to be distinguished from? How long are they present?
hyperacute T waves
Must be distinguished from the peaked T waves associated with hyperkalemia.
exist for only 20-30 minutes and are rarely seen in the real world
What is the difference between STEMI peaked T waves and hyperkalemia peaked T waves?
What is the dx test for MI?
cath is dx for MI NOT EKG
EKG is NOT diagnostic for MI
What is ST segment depression or T wave inversion in more than 2 contiguous leads make you think?
suspicious for NSTEMI or unstable angina
What does ST segment elevation or new LBBB make you think?
suspicious for STEMI
What are the 4 stages of EKG changes when talking about the evolution of a STEMI? How long does it take for each change to appear?
- ST elevation (minutes to hours)
- Pathological Q wave and Inverted T waves (1-2 days)
- ST flattening with pathological Q wave (7-10 days)
- normalization with persistent Q wave (months)
After a STEMI, when will a Q wave tend to appear? Does it always have to appear?
Q waves in leads that previous had the infarction but does NOT always have to appear
What is the second test when working a pt up for a IHD presentation?
labs!! aka cardiac enzymes
What are the 3 cardiac enzymes? Which one shows up the earliest?
Myoglobin- shows up the earliest but is the least helpful
CK-MB
Troponin I, T
T/F: Myoglobin is found in cardiac and skeletal muscle
TRUE!! aka it is not strictly a heart enzyme
What is important to note about myoglobin? What timeframe?
High sensitivity, poor specificity and is released more rapidly from infarcted myocardium but is only good for EARLY detection of MI
1-4 hours after an MI
myoglobin: think very early detection of MI and that is basically it
T/F: Troponin is naturally found in the serum in very small amounts and becomes elevated during a MI
FALSE! troponin is normally NOT found in the serum and is only released when myocardial necrosis occurs
What is the preferred marker for myocardial injury? Why?
troponin
highly sensitive and specific for even small amounts of cardiac damage
**What is the nature elevation and depression of troponin levels with regards to a MI?
Serum levels increase within 3-12 hrs
peak at 24-48 hrs
return to baseline over 5-14 days.
**When should you measure troponin? _____ troponin is worthless
at presentation
at 90 minutes
Every 6-8 hrs after symptom onset x 3 or until trending down
one isolated value is worthless!!!! and you must determine the trend to diagnose an MI
What is the normal value for troponin? Give both new and old school versions
normal is between 12-13 for newer versions
normal is less than .001 for old troponin levels
What does troponin tell you? What does it NOT tell you?
elevation indicates the presence of myocardial injury but does NOT tell you the reason why the heart is angry
What effect does blood loss have on troponin?
blood loss will elevate troponin levels
How good of a cardiac test is CK-MB when compared to troponin? How long does it take for CK-MB to become elevated?
Less sensitive and specific than troponins
Serum levels ↑ 3-12 hrs after injury, peaks around 24 hrs, remains elevated 36-48 hrs
What is considered a positive CK-MB? What can make it appear falsely positive?
Positive if CK-MB >5% or total CK and 2 x normal
False positives with exercise, trauma, muscle disease, DM, PE
**Where is Lactate Dehydrogenase (LDH) commonly found? What is the timeframe?
Found in many tissues (kidney, skeletal muscle, brain, blood cells, lungs) so not specific for heart disease.
Level rises within 24 - 72 hours after a heart attack, peaks in 3 - 4 days, and returns to normal in about 14 days
What cardiac enzyme will stay elevated longer than troponin? Which cardiac enzyme becomes elevated first?
total CK stays elevated longer than troponin
myoglobin will become elevated first
Which cardiac enzyme would be most beneficial for a pt with chest pain for 2 hours? for 6 hours? for recurrent chest pain 36 hours after having PCI for an MI?
2 hours- myoglobin
6 hours- troponin
recurrent chest pain 36 hours after having PCI for an MI: CK-MB
What are 3 elevated lab findings that are possible with an MI?
leukocytosis
elevated CRP
ESR
What are the 1st, 2nd, and 3rd line testing for a pt with chest pain?
1st: EKG
2nd: labs
3rd: stress tests
The _____ is the most commonly used and recommended initial noninvasive procedure for evaluating inducible ischemia in the patient with angina. What are the 2 different versions? Which version is more accurate?
stress test
exercise and chemical
exercise is more accurate
When is stress testing indicated according to ACC/AHA risk guidelines? What age are you considered high risk with typical angina s/s?
patients with intermediate or high risk
both men and women 60-69 with typical angina are considered high risk
What is the pt criteria in order to qualify for a stress test?
person can walk on flat ground for greater than 5 minutes or climb 1-2 flights of stairs without needing to stop
What is the goal of an exercise stress test? What protocol is followed? What is the formula to calculate max HR?
want to acheive 85% of max HR
Bruce TM protocol
max HR= 220- age
During an exercise stress test, the intensity of exercise is increased and continued until what 3 things? **What is considered a positive test?
The patient reaches maximum HR
Changes in heart function are detected on the EKG
Patient is symptomatic
positive test: an ST-segment depression of 1mm
What is a draw back of an exercise stress test?
Con is more false-positives than true-positives
**What method of calculating HR is used during an exercise stress test? What is the formula?
Haskell and Fox
220-age
**What are the absolute indications for terminating an exercise stress test?
**What are the absolute CI for exercise stress testing?
What are the relative CI for exercise stress testing?
** What 4 baseline EKG abnormalities would make an exercise stress test CI?
Preexcitation (WPW) syndrome
Electronically paced ventricular rhythm
Greater than 1 mm of resting ST depression
Complete LBBB
When is an EST with imaging indicated? What are the 2 nuclear tracers used?
Thallium 201
Technetium:
scan the pt before and after the EST and compare the results
When is a stress echo used? What is it usually combined with?
Look for regional wall motion abnormalities or LV dilation in response to exercise.
combined with exercise EKG to increase sensitivity and specificity of the stress test
When is a pharm stress test used? **What is it ALWAYS combined with?
when a pt cannot exercise or EST is CI
**Sensitivity of a pharmacologic stress EKG is very low, so these tests are always combined with an imaging modality
**What is 1st line pharm stress test agent? **What drug class? **What is the CI? What are the SE?
ADENOSINE
vasodilator
CI: bronchospasms
SE: HA, SOB, flushing, chest pain, dizziness
What is the 2nd line pharm stress agent? What drug class? What medication is commonly used as adjunct?
DOBUTAMINE
adrenergic stimulating agents
adjunct med: atropine
**What is the definitive way to dx CAD? What other types of dz can it confirm the presence of?
cardiac cath!!!
Evaluate or confirm the presence of coronary artery disease, severe valvular disease, or disease of the aorta
also evaluates heart muscle function
What is the overall mortality risk with cardiac cath? What are the surgical risks?
Overall low mortality risk with procedure (0.1%)
Surgical risks include: CVA, coronary artery dissection, retroperitoneal hemorrhage, AKI, femoral pseudoaneurysm
When is cardiac cath used as a first line treatment? What is the required prep? **What is the highlighted one?
high pre-test likelihood
Patient must be NPO for 4-6 hours
Written consent required
IV fluids (NS) ran for ~24 hours to “flush out” the contrast
Hold Metformin for 48 hours to avoid contrast induced nephropathy
What is the difference between a LEFT and RIGHT heart cath?
left: think cardiac valve, left ventricular function, EF and regional wall motion
right: think pulmonary HTN
What access point do they enter for a LEFT cath vs a RIGHT cath?
LEFT: femoral or radial
RIGHT: jugular
When would a CXR be used in angina? Chest CT? TTE?
CXR: pulmonary causes of chest pain and may show aortic dissection
chest CT: PE and aortic dissection
TTE: pericardial effusion and tamponade
regional wall motion abnormalities
proximal aortic dissection
When is CT of coronary arteries used? What must the HR be? Who is it NOT indicated for?
Images the heart with contrast medium and multislice technology, uses both radiation exposure and contrast to produce images of the heart and heart vessels
HR must be below 50
NOT indicated for people over 65 because it has not been studied
Go review the case studies that are in this lecture
DO IT!!!
What is the Levine sign?
patient hunched over clutching their test
What is the pharm management for stable angina? **What does everyone with known CAD need?
**high intensity statin
What 3 conditions are considered acute coronary syndrome? What is the management? What should you give first?
acute coronary syndrome is considered:
unstable angina
STEMI
NSTEMI
Give ASA first (chewed) then NTG
you are seeing a pt in the PCP setting who is currently having symptoms of acute coronary syndrome. what should you do?
ASA and NTG can be given in the outpt setting then call EMS
What 2 medications should be started within the first 24 hours of ACS?
oral BB
and ACEI- if BP can tolerate without bottoming out
When are BB CI in ACS management?
Contraindicated in acute HF, bradycardia, heart block
What is the STEMI specific management? **What are the associated time frames?
within 12 hours on the onset of s/s: PCI (Percutaneous coronary intervention) within 90 minutes upon arrival is the goal!! or fibrinolytic therapy
need fibrinolytic therapy **within 30 minutes ** of hospital presentation and 6-12 hours of onset of symptoms IF PCI is not an option
Patients with STEMI who seek medical attention within _____ of the onset of symptoms should be treated with immediate reperfusion therapy with ______ or ________.
Primary PCI within ______ of first medical contact is the goal and is superior to thrombolysis
12 hours
primary PCI
fibrinolytic therapy
90 mins
If a pt with s/s of ischemia/infarction present to the ED, what should you do in the first 10 minutes?
What treatments should you give the pt when they first arrive in the ED?
Give ASA and O2 first! then NTG then morphine to control pain
EKG comes back as a STEMI, what are the next steps? What EKG finding confirms STEMI?
If available and door-to- balloon goal time of 90 minutes -> PCI
Door- to- needle time of thrombolytics is 30 minutes
ST elevation
EKG comes back at ST depressions or T wave inversion. What do you do next? What do you NOT give?
If high risk symptoms and high heart score, PCI
tPA is ONLY for STEMI!!!!
If EKG comes back normal/nondiagnostic, what do you do next?
serial troponins
repeat EKG
any abnormal testing comes back, initiate proper protocol
_____ MOA Irreversible inhibition of platelet aggregation, stabilize plaque and arrest thrombus, reduce mortality in patients with STEMI
aspirin and P2Y12 inhibitors
What dose of ASA is given in the ACS setting?
162-325mg CHEWED do not matter if planning to use fibrinolytic therapy, everyone gets ASA
What should pts with ASA allergy get in ACS setting?
P2Y12 inhibitor -> Clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta)
a pt with what 3 conditions should you use ASA with caution?
active PUD, hypersensitivity, bleeding disorders
What is the loading dose of clopidogrel prior to a cardiac cath? How long should a pt remain on P2Y12 inhibitors following an event?
clopidogrel 600mg prior to cardiac cath
3-12 mo duration depending on scenario
What are the 3 drugs in the P2Y12 inhibitor category?
Clopidogrel
(Plavix)
Prasugrel* (Effient)
Ticagrelor*
(Brilinta)
When would you use a Glycoprotein
IIb / IIIa Inhibitors?
In support of PCI intervention as early as possible prior to PCI but NOT REQUIRED in most patients
in high risk patients with ongoing ischemia despite ASA and P2Y12 inhibitors
large thrombus especially if they have not received P2Y12
To stabilize patients who need urgent CABG in place of P2Y12 until surgical indications defined
Tirofiban
(Aggrastat)
Eptifibatide
(Integrilin)
Abciximab
(Reopro
What drug class?
What form do they come in?
Glycoprotein
IIb / IIIa Inhibitors
IV anti-platelets
When are anticoagulation therapy used in ACS? What do you NOT want to do?
Adjunct to surgical revascularization and thrombolytic / PCI reperfusion
Used in combo with ASA and/or other platelet inhibitors
do NOT change from one drug to another drug in the same class
What are the indirect thrombin inhibitors? Which one is preferred?
UFH
LMWH (preferred)
Enoxaparin (Lovenox)
Fondaparinux (Arixtra)
Dalteparin (Fragmin)
_______ is the direct thrombin inhibitor. Where is it commonly used?
Bivalirudin (Angiomax)
only used in the cath lab
What is the MOA for nitrates?
nitrate enters vascular smooth muscle and is converted to nitric oxide, leading to activation of cGMP and vasodilation. Decreases systemic vascular resistance and preload
Under what conditions would you want to be cautious in using a nitrates? What is a common SE?
Use with caution in hypotension (SBP <100), bradycardia, tachycardia, RV infarction
HA
nitrates are CI with concurrent use of ________. **What type of MI do you NOT want to use nitrates with?
PDE-5 INHIBITORS
do NOT use NTG during an Inferior wall MI
_______ is the long acting nitrate and used for chronic stable angina taken as a DAILY medication. How long does it last? **What is the SE?
Isosorbide Mononitrate (Imdur)
must be taken QD- lasts for 8 hours
**HA
With regards to tolerance what is important to note about the short- acting and long -acting nitrates?
short-acting: do not use continously or for prolonged periods of time due to the development of tolerance
long-acting: multi-dose regimens lead to development of tolerance so need to ONLY TAKE QD
**What is the NTG pt education point with regards to dosing instructions?
Nitro 0.4mg sublingual prn for chest pain. Take 1 tablet q5 minutes up to 3 tablets. If you take all 3 tablets and still are experiencing chest pain need to IMMEDIATELY go to nearest ER
When should BB be used in ACS? What do they decrease the risk of? What are the CI?
should be started 24-48 hours after MI once the pt is STABLE
reduces:
-Infarct size and complications
-Rate of re-infarction
-Rate of life threatening tachyarrhythmias and thus reduce mortality
CI: cute CHF, heart block, hypotension)
______ is the antianginal medication to treat chronic stable angina usually only when can’t tolerate Imdur. **What is the DDI?
Ranexa (Ranolazine)
**DDI: May prolong QT so avoid use with other QT prolongation drugs
**_______ MOA acts one the late sodium channel blocker, decreases intracellular calcium overload
Ranexa (Ranolazine)
Why are ACE/ARBs used post MI?
because post MI there is a progressive increase in ACE activity and AT type 1 receptor activity and by using ACE/ARB’s it reduce fibrosis and remodeling at the scar site and remote to the infarct which can help preserve myocardium
BP and renal function must be able to tolerate
______ start in the days immediately following diagnosis of ACS
______ for selected cases with intracardiac thrombus or embolic events
_______ for selected patients with LV dysfunction
_____ are used as 3rd line therapy in patients with continuing symptoms on nitrates and beta-blockers or those who are not candidates for these drugs - antianginal properties
STATINS
WARFARIN
ALDOSTERONE ANTAGONISTS
CCB- amlodipine
______ are used as “clot busters” in ____ type of MI
Fibrinolytic Therapy ( t-PA, ends in -plase)
only in STEMI!!!
What is the most serious complication of fibrinolytic therapy? _____ and ______ should be continued after completion of t-PA. What version is preferred?
intracranial hemorrhage
ASA and anti-coag
LMWH is preferred to heparin
When should you use fibrinolytic therapy in a STEMI? When is t-PA of the greatest benefit? _____ should be started alongside all t-PA for all STEMI pts
if it will take longer than 90 minutes to get to cath lab, then give t-PA
prefer to give t-PA within first 30 minutes
The greatest benefit occurs if treatment is initiated within the first 3 hours after the onset of presentation
PPIs and antithrombotic therapy should be used together
**What are the absolute CI for thrombolytic therapy?
When is PCI beneficial? What are the 2 different types of PCI?
only beneficial for those with unstable disease
balloon and stent angioplasty
What is happening in a balloon angioplasty?
Inflation of a balloon within the coronary artery to compress plaque against the walls of the artery and open the lumen
What is happening in a stent angioplasty?
use of a small, expandable mesh-like tube of thin wire (‘stent’), along with the balloon
What are the 2 different stent types? Which one is preferred?
bare metal stents: no coating
drug-eluting stents: Stent that slowly releases a drug to block cell proliferation
drug-eluting stents are preferred!
**What is important to note about DES? (drug eluting stents)
DES require a longer period of DAPT to prevent stent thrombosis so they aren’t appropriate for all patients
aka these pts have to remain on anti-platelet therapy for longer than bare metal stents (BMS)
What are the PCI post-procedure instructions?
How long post PCI do patients need to stay on dual antiplatelet therapy (DAPT)? What medication classes?
DAPT for minimum 6-12 months prefer lifelong if they can tolerate it
ASA PLUS P2Y12 receptor blocker (Effient, Brilinta, Plavix)
What is an atherectomy? Do pts still need DAPT? When it is commonly used?
Specialized catheters for mechanical removal of plaque from the arterial walls
YES! DAPT is still needed post procedure
commonly done before a stent placement to allow for increased space for the balloon
What are the indications for CABG?
What is enhanced external counterpulsation? What is the goal?
cuffs are placed around the lower extremities and inflate and deflate in rhythm with cardiac cycle. Goal is to reduce cardiac workload and improve blood flow to the heart
ECP has been shown to relieve angina and decrease the degree of ischemia in a cardiac stress test
supposed to help with stable angina
