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Cardio > Ischemic Heart Disease II - Exam 2 > Flashcards

Ischemic Heart Disease II - Exam 2 Flashcards

1
Q

What is the first diagnostic test ordered when working a pt up for Ischemic Heart Disease? How soon after arrival?

A

EKG!! always first

anyone with symptoms of ACS within the first 10 minutes of the pt’s arrival

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2
Q

What do you do if the EKG is not diagnostic but the patient remains symptomatic?

A

serial EKGs (e.g., 15- to 30-min intervals during the for the first 1-2 hrs) should be performed to detect ischemic changes.

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3
Q

What is the earliest presentation of an MI? What do they need to be distinguished from? How long are they present?

A

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

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4
Q

What is the difference between STEMI peaked T waves and hyperkalemia peaked T waves?

A
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5
Q

What is the dx test for MI?

A

cath is dx for MI NOT EKG

EKG is NOT diagnostic for MI

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6
Q

What is ST segment depression or T wave inversion in more than 2 contiguous leads make you think?

A

suspicious for NSTEMI or unstable angina

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7
Q

What does ST segment elevation or new LBBB make you think?

A

suspicious for STEMI

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8
Q

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?

A
  1. ST elevation (minutes to hours)
  2. Pathological Q wave and Inverted T waves (1-2 days)
  3. ST flattening with pathological Q wave (7-10 days)
  4. normalization with persistent Q wave (months)
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9
Q

After a STEMI, when will a Q wave tend to appear? Does it always have to appear?

A

Q waves in leads that previous had the infarction but does NOT always have to appear

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10
Q

What is the second test when working a pt up for a IHD presentation?

A

labs!! aka cardiac enzymes

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11
Q

What are the 3 cardiac enzymes? Which one shows up the earliest?

A

Myoglobin- shows up the earliest but is the least helpful

CK-MB

Troponin I, T

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12
Q

T/F: Myoglobin is found in cardiac and skeletal muscle

A

TRUE!! aka it is not strictly a heart enzyme

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13
Q

What is important to note about myoglobin? What timeframe?

A

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

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14
Q

T/F: Troponin is naturally found in the serum in very small amounts and becomes elevated during a MI

A

FALSE! troponin is normally NOT found in the serum and is only released when myocardial necrosis occurs

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15
Q

What is the preferred marker for myocardial injury? Why?

A

troponin

highly sensitive and specific for even small amounts of cardiac damage

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16
Q

**What is the nature elevation and depression of troponin levels with regards to a MI?

A

Serum levels increase within 3-12 hrs

peak at 24-48 hrs

return to baseline over 5-14 days.

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17
Q

**When should you measure troponin? _____ troponin is worthless

A

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

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18
Q

What is the normal value for troponin? Give both new and old school versions

A

normal is between 12-13 for newer versions

normal is less than .001 for old troponin levels

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19
Q

What does troponin tell you? What does it NOT tell you?

A

elevation indicates the presence of myocardial injury but does NOT tell you the reason why the heart is angry

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20
Q

What effect does blood loss have on troponin?

A

blood loss will elevate troponin levels

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21
Q

How good of a cardiac test is CK-MB when compared to troponin? How long does it take for CK-MB to become elevated?

A

Less sensitive and specific than troponins

Serum levels ↑ 3-12 hrs after injury, peaks around 24 hrs, remains elevated 36-48 hrs

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22
Q

What is considered a positive CK-MB? What can make it appear falsely positive?

A

Positive if CK-MB >5% or total CK and 2 x normal

False positives with exercise, trauma, muscle disease, DM, PE

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23
Q

**Where is Lactate Dehydrogenase (LDH) commonly found? What is the timeframe?

A

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

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24
Q

What cardiac enzyme will stay elevated longer than troponin? Which cardiac enzyme becomes elevated first?

A

total CK stays elevated longer than troponin

myoglobin will become elevated first

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25
Q

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?

A

2 hours- myoglobin

6 hours- troponin

recurrent chest pain 36 hours after having PCI for an MI: CK-MB

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26
Q

What are 3 elevated lab findings that are possible with an MI?

A

leukocytosis

elevated CRP

ESR

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27
Q

What are the 1st, 2nd, and 3rd line testing for a pt with chest pain?

A

1st: EKG
2nd: labs
3rd: stress tests

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28
Q

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?

A

stress test

exercise and chemical

exercise is more accurate

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29
Q

When is stress testing indicated according to ACC/AHA risk guidelines? What age are you considered high risk with typical angina s/s?

A

patients with intermediate or high risk

both men and women 60-69 with typical angina are considered high risk

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30
Q

What is the pt criteria in order to qualify for a stress test?

A

person can walk on flat ground for greater than 5 minutes or climb 1-2 flights of stairs without needing to stop

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31
Q

What is the goal of an exercise stress test? What protocol is followed? What is the formula to calculate max HR?

A

want to acheive 85% of max HR

Bruce TM protocol

max HR= 220- age

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32
Q

During an exercise stress test, the intensity of exercise is increased and continued until what 3 things? **What is considered a positive test?

A

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

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33
Q

What is a draw back of an exercise stress test?

A

Con is more false-positives than true-positives

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34
Q

**What method of calculating HR is used during an exercise stress test? What is the formula?

A

Haskell and Fox

220-age

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35
Q

**What are the absolute indications for terminating an exercise stress test?

A
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36
Q

**What are the absolute CI for exercise stress testing?

A
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37
Q

What are the relative CI for exercise stress testing?

A
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38
Q

** What 4 baseline EKG abnormalities would make an exercise stress test CI?

A

Preexcitation (WPW) syndrome

Electronically paced ventricular rhythm

Greater than 1 mm of resting ST depression

Complete LBBB

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39
Q

When is an EST with imaging indicated? What are the 2 nuclear tracers used?

A

Thallium 201
Technetium:

scan the pt before and after the EST and compare the results

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40
Q
A
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41
Q

When is a stress echo used? What is it usually combined with?

A

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

42
Q

When is a pharm stress test used? **What is it ALWAYS combined with?

A

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

43
Q

**What is 1st line pharm stress test agent? **What drug class? **What is the CI? What are the SE?

A

ADENOSINE

vasodilator

CI: bronchospasms

SE: HA, SOB, flushing, chest pain, dizziness

44
Q

What is the 2nd line pharm stress agent? What drug class? What medication is commonly used as adjunct?

A

DOBUTAMINE

adrenergic stimulating agents

adjunct med: atropine

45
Q

**What is the definitive way to dx CAD? What other types of dz can it confirm the presence of?

A

cardiac cath!!!

Evaluate or confirm the presence of coronary artery disease, severe valvular disease, or disease of the aorta

also evaluates heart muscle function

46
Q

What is the overall mortality risk with cardiac cath? What are the surgical risks?

A

Overall low mortality risk with procedure (0.1%)

Surgical risks include: CVA, coronary artery dissection, retroperitoneal hemorrhage, AKI, femoral pseudoaneurysm

47
Q

When is cardiac cath used as a first line treatment? What is the required prep? **What is the highlighted one?

A

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

48
Q

What is the difference between a LEFT and RIGHT heart cath?

A

left: think cardiac valve, left ventricular function, EF and regional wall motion

right: think pulmonary HTN

49
Q

What access point do they enter for a LEFT cath vs a RIGHT cath?

A

LEFT: femoral or radial

RIGHT: jugular

50
Q

When would a CXR be used in angina? Chest CT? TTE?

A

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

51
Q

When is CT of coronary arteries used? What must the HR be? Who is it NOT indicated for?

A

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

52
Q

Go review the case studies that are in this lecture

A

DO IT!!!

53
Q

What is the Levine sign?

A

patient hunched over clutching their test

54
Q

What is the pharm management for stable angina? **What does everyone with known CAD need?

A

**high intensity statin

55
Q

What 3 conditions are considered acute coronary syndrome? What is the management? What should you give first?

A

acute coronary syndrome is considered:
unstable angina
STEMI
NSTEMI

Give ASA first (chewed) then NTG

56
Q

you are seeing a pt in the PCP setting who is currently having symptoms of acute coronary syndrome. what should you do?

A

ASA and NTG can be given in the outpt setting then call EMS

57
Q

What 2 medications should be started within the first 24 hours of ACS?

A

oral BB

and ACEI- if BP can tolerate without bottoming out

58
Q

When are BB CI in ACS management?

A

Contraindicated in acute HF, bradycardia, heart block

59
Q

What is the STEMI specific management? **What are the associated time frames?

A

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

60
Q

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

A

12 hours

primary PCI

fibrinolytic therapy

90 mins

61
Q

If a pt with s/s of ischemia/infarction present to the ED, what should you do in the first 10 minutes?

A
62
Q

What treatments should you give the pt when they first arrive in the ED?

A

Give ASA and O2 first! then NTG then morphine to control pain

63
Q

EKG comes back as a STEMI, what are the next steps? What EKG finding confirms STEMI?

A

If available and door-to- balloon goal time of 90 minutes -> PCI

Door- to- needle time of thrombolytics is 30 minutes

ST elevation

64
Q

EKG comes back at ST depressions or T wave inversion. What do you do next? What do you NOT give?

A

If high risk symptoms and high heart score, PCI

tPA is ONLY for STEMI!!!!

65
Q

If EKG comes back normal/nondiagnostic, what do you do next?

A

serial troponins

repeat EKG

any abnormal testing comes back, initiate proper protocol

66
Q

_____ MOA Irreversible inhibition of platelet aggregation, stabilize plaque and arrest thrombus, reduce mortality in patients with STEMI

A

aspirin and P2Y12 inhibitors

67
Q

What dose of ASA is given in the ACS setting?

A

162-325mg CHEWED do not matter if planning to use fibrinolytic therapy, everyone gets ASA

68
Q

What should pts with ASA allergy get in ACS setting?

A

P2Y12 inhibitor -> Clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta)

69
Q

a pt with what 3 conditions should you use ASA with caution?

A

active PUD, hypersensitivity, bleeding disorders

70
Q

What is the loading dose of clopidogrel prior to a cardiac cath? How long should a pt remain on P2Y12 inhibitors following an event?

A

clopidogrel 600mg prior to cardiac cath

3-12 mo duration depending on scenario

71
Q

What are the 3 drugs in the P2Y12 inhibitor category?

A

Clopidogrel
(Plavix)

Prasugrel* (Effient)

Ticagrelor*
(Brilinta)

72
Q

When would you use a Glycoprotein
IIb / IIIa Inhibitors?

A

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

73
Q

Tirofiban
(Aggrastat)

Eptifibatide
(Integrilin)

Abciximab
(Reopro

What drug class?
What form do they come in?

A

Glycoprotein
IIb / IIIa Inhibitors

IV anti-platelets

74
Q

When are anticoagulation therapy used in ACS? What do you NOT want to do?

A

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

75
Q

What are the indirect thrombin inhibitors? Which one is preferred?

A

UFH

LMWH (preferred)
Enoxaparin (Lovenox)
Fondaparinux (Arixtra)
Dalteparin (Fragmin)

76
Q

_______ is the direct thrombin inhibitor. Where is it commonly used?

A

Bivalirudin (Angiomax)

only used in the cath lab

77
Q

What is the MOA for nitrates?

A

nitrate enters vascular smooth muscle and is converted to nitric oxide, leading to activation of cGMP and vasodilation. Decreases systemic vascular resistance and preload

78
Q

Under what conditions would you want to be cautious in using a nitrates? What is a common SE?

A

Use with caution in hypotension (SBP <100), bradycardia, tachycardia, RV infarction

HA

79
Q

nitrates are CI with concurrent use of ________. **What type of MI do you NOT want to use nitrates with?

A

PDE-5 INHIBITORS

do NOT use NTG during an Inferior wall MI

80
Q

_______ 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?

A

Isosorbide Mononitrate (Imdur)

must be taken QD- lasts for 8 hours

**HA

81
Q

With regards to tolerance what is important to note about the short- acting and long -acting nitrates?

A

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

82
Q

**What is the NTG pt education point with regards to dosing instructions?

A

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

83
Q

When should BB be used in ACS? What do they decrease the risk of? What are the CI?

A

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)

84
Q

______ is the antianginal medication to treat chronic stable angina usually only when can’t tolerate Imdur. **What is the DDI?

A

Ranexa (Ranolazine)

**DDI: May prolong QT so avoid use with other QT prolongation drugs

85
Q

**_______ MOA acts one the late sodium channel blocker, decreases intracellular calcium overload

A

Ranexa (Ranolazine)

86
Q

Why are ACE/ARBs used post MI?

A

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

87
Q

______ 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

A

STATINS

WARFARIN

ALDOSTERONE ANTAGONISTS

CCB- amlodipine

88
Q

______ are used as “clot busters” in ____ type of MI

A

Fibrinolytic Therapy ( t-PA, ends in -plase)

only in STEMI!!!

89
Q

What is the most serious complication of fibrinolytic therapy? _____ and ______ should be continued after completion of t-PA. What version is preferred?

A

intracranial hemorrhage

ASA and anti-coag

LMWH is preferred to heparin

90
Q

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

A

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

91
Q

**What are the absolute CI for thrombolytic therapy?

A
92
Q

When is PCI beneficial? What are the 2 different types of PCI?

A

only beneficial for those with unstable disease

balloon and stent angioplasty

93
Q

What is happening in a balloon angioplasty?

A

Inflation of a balloon within the coronary artery to compress plaque against the walls of the artery and open the lumen

94
Q

What is happening in a stent angioplasty?

A

use of a small, expandable mesh-like tube of thin wire (‘stent’), along with the balloon

95
Q

What are the 2 different stent types? Which one is preferred?

A

bare metal stents: no coating

drug-eluting stents: Stent that slowly releases a drug to block cell proliferation

drug-eluting stents are preferred!

96
Q

**What is important to note about DES? (drug eluting stents)

A

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)

97
Q

What are the PCI post-procedure instructions?

A
98
Q

How long post PCI do patients need to stay on dual antiplatelet therapy (DAPT)? What medication classes?

A

DAPT for minimum 6-12 months prefer lifelong if they can tolerate it

ASA PLUS P2Y12 receptor blocker (Effient, Brilinta, Plavix)

99
Q

What is an atherectomy? Do pts still need DAPT? When it is commonly used?

A

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

100
Q

What are the indications for CABG?

A
101
Q

What is enhanced external counterpulsation? What is the goal?

A

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

102
Q
A

Cardio (24 decks)

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