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Cardio All > Ischemic Heart Disease, MI, Anti-clotting drugs, Vasodilators > Flashcards

Ischemic Heart Disease, MI, Anti-clotting drugs, Vasodilators Flashcards

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2
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What is important to remember about Aerobic Energy Production?

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O2 is needed

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3
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What are the Primary Cardiac Fuel Sources?

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4
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What is the requirement for Mitochondrial Energy Production?

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5
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What are the Effects of Ischemia & Reperfusion on Aerobic Energy Production?

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7
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What are the Consequences of Reperfusion?

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8
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What are the Reactive Oxygen Species?

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9
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Describe a ROS mediated reperfusion injury

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10
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What is the relationship between Infarct Size and Time

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11
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Describe Ischemic Conditioning and Reperfusion Injury

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12
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Describe Energy Transfer via Creatine Kinase

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13
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Describe the components of Creatine Kinase

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14
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Describe the Plasma Levels of CK-MB and Cardiac Troponin Following MI

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17
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What are the Consequences of Hypoxia?

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  • Aerobic glycolysis and fatty acid oxydation slow down
  • ATP in short supply
  • Anaerobic glycolysis speeds up (if glucose available, normally comes from blood)
  • Cardiac cells have limited glycogen stores (compared to skeletal muscle)
  • Lactate increases and pH drops
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18
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What is Percutaneous Coronary Intervention (PCI)?

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19
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Describe the Treatment of Stable Angina

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  • Treatment of aggravating symptoms
  • Adaption of activity
  • Treatment of risk factors
  • Beta-Blockers
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20
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Describe the ECG progression in STEMI

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21
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Describe the common PTs who have Silent Ischemia/Asymptomatic Ischemia

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More common in women later decades
More common in diabetics

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22
Q

Describe the Physical Exam for IHD

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  • BP and Pulse
  • New Murmurs
  • Aortic Stenosis can be associated with angina and syncope
  • Carotid bruit
  • S4 can be associated with IHD (nonspecific)
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23
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What are the differences in NSTEMI vs STEMI

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  • EKG ST elevation (STEMI)
  • Enzymes elevated
  • Occasional develop Q wave
  • Tx antiplatelet, heparin, admission (NSTEMI)
  • Tx Reperfusion (STEMI)
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26
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Describe the Exercise Stress Test

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  • Reach 85% of max HR
  • 12 ECG and BP monitoring
  • ST depression 2mm
  • Ventricular Tachyarrhythmia
  • Limitations: abnormal ECG baseline, cannot exercise
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27
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Describe an Inferior STEMI

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28
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Relate Unstable Angina and NSTEMI

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EKG may show ST depression
Angiogram - partial obstruction
ENZYMES ELEVATED - only NSTEMI

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30
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What is Acute Coronary Syndrome (ACS)?

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33
Describe a Lateral Wall MI
35
Describe Unstable Angina
* increased intensity or frequency, does not go away with demand reduction, or occurs at rest * ST depression or Normal ECG
36
How do CCBs relate to Stable Angina?
Second line if Beta-Blockers are not tolerated
37
How do NSAIDs relate to Stable Angina?
Small but finite increased risk of myocardial infarction and mortality
41
What are the Ischemic Heart Disease Risk Factors?
* FmHx premature CAD 1st degree relative * male \< 55 female \< 65 * Tobacco products * Diabetics 2-4 times the risk
42
Describe an Anterior STEMI
43
Describe the relationship between Nitrates and Stable Angina
* Systemic venodilation * Dilation of coronary vessels and collateral * Short acting - NTG spray/tablets * Long acting - Transdermal paste/patches * Tablets - isosorbide dinitrate
44
Describe what a Coronary Artery Bypass Graft (CABG) is
* Bypass portion of artery with segment of donor artery or vein * Left internal mammary artery is preferred over saphenous vein * Artery \> Vein
45
How do you dx an MI?
47
What are the Tests for IHD?
* Exercise Stress Test * Stress Echo * Stress Radionuclide Myocardial Perfusion Scan * CT for Calcium scoring * Angiography (CT or Coronary)
48
What are the Anginal Equivalents and what is Atypical Presentation?
* Indigestion * Nausea * SOB * Diaphoresis * Dizziness * Syncope * Fatigue
50
Describe an Angiography
Visualizing vessel lumen Contrast agent with XR, CT or MRI
52
Describe the relationship between Women and Heart Disease
* More likely atypical presentation * 5-10 years older at time of presentation * Higher incidence of vasospastic heart disease * Less likely to undergo procedures
53
Describe what a Coronary Angiography is
* Catheter placed in arterial circulation and advanced to coronary arteries both right and left * Injection of contrast * Measure EF (ventriculogram) * 70% obstruction considered significant
54
What is Revascularization?
CABG and PCI (percutaneous coronary intervention)
55
What is a Stress Radionuclide Myocardial Perfusion Scan?
Compares Rest and Exercise images Inability to dilate shows less uptake of radioactive tracer
56
What is a Stress Echocardiogram?
* Ischemia presents as wall motion abnormality (US) * Dobutamine and Adenosine for pt who cannot exercise
57
Describe the relationship between Antiplatelets and Stable Angina
* Aspirin * P2Y12 Inhibitors (ADP receptor antagonists) * Clopidogrel
58
Describe what Reperfusion Treatment Therapy is
* Tx within 3 hours = 50% reduction in mortality * Can treat up to 12 hours after onset * Limit infarct size and preserve LV function
59
Relate Fibrinolysis and MI Treatment
* Administer in less than 30 minutes * tPA, TNK, rPA * Administer along with ASA and/or P2Y12 Inhibitor and Heparin * Only effective in case of a STEMI
60
What are the Indications for thrombolytic therapy?
* STEMI onset within 12 hours * Most effective in 90 minutes * ST elevation of at least 1 mm in 2 contiguous leads * 2 mm in leads V2 and V3 for men, 1.5 for women * New LBBB
61
What are the Fibrinolysis Contraindications and major risk?
* Intracranial hemorrhage in approximately 1% of patients treated with fibrinolytics for MI * Higher risk in patient's over 75 yo * Use PCI instead
62
Describe PCI: post op care
Dual antiplatelet therapy for 12 months, ASA and P2Y12 inhibitor
63
When do you use PCI or Fibrinolytics?
When PCI cannot be done in 120 minutes use FIBRINOLYTICS Any contraindications for fibrinolytics or cardiogenic shock use PCI
64
When do you use PCI or Fibrinolytics?
When PCI cannot be done in 120 minutes use FIBRINOLYTICS Any contraindications for fibrinolytics or cardiogenic shock use PCI
65
Describe PCI: post op care
Dual antiplatelet therapy for 12 months, ASA and P2Y12 inhibitor
66
Describe the uses of Cardiac US and Echocardiography
View for regional or global wall abnormalities Ischemic muscle - wall motion abnormalities
67
Describe the how Pericarditis relates to MI
* Pain decreases with sitting up * Dressler Syndrome - post MI syndrome * Pericardial and pleural effusions * May be inflammatory or immune related with fever and malaise
68
Describe a Right Ventricular Infarct
* RCA 85%, LCX 15% * Fluid back up in systemic circulation * Distended neck veins * Hypotensive * Right sided EKG, elevation RV4 * IV fluid bolus without NITRATES (AVOID)
69
Describe a Right Ventricular Infarct
* RCA 85%, LCX 15% * Fluid back up in systemic circulation * Distended neck veins * Hypotensive * Right sided EKG, elevation RV4 * IV fluid bolus without NITRATES (AVOID)
70
What are the Q Wave ECG Findings?
* consistent with previous MI * Transmural ischemia * 1mm wide * 1/3 amplitude of R wave
71
What is the treatment for Post-MI Infarction?
* Lifelong aspirin and/or P2Y12 inhibitor * Stent placed - aspirin and P2Y12 inhibitor for a year * Beta-blocker within first 24 hours unless contraindicated * Lifelong high intensity statin * Cardiac rehab program
72
What is the treatment for Post-MI Infarction?
* Lifelong aspirin and/or P2Y12 inhibitor * Stent placed - aspirin and P2Y12 inhibitor for a year * Beta-blocker within first 24 hours unless contraindicated * Lifelong high intensity statin * Cardiac rehab program
73
What are the Q Wave ECG Findings?
* consistent with previous MI * Transmural ischemia * 1mm wide * 1/3 amplitude of R wave
74
Describe the how Pericarditis relates to MI
* Pain decreases with sitting up * Dressler Syndrome - post MI syndrome * Pericardial and pleural effusions * May be inflammatory or immune related with fever and malaise
75
Describe the uses of Cardiac US and Echocardiography
View for regional or global wall abnormalities Ischemic muscle - wall motion abnormalities
76
What are the Fibrinolysis Contraindications and major risk?
* Intracranial hemorrhage in approximately 1% of patients treated with fibrinolytics for MI * Higher risk in patient's over 75 yo * Use PCI instead
77
What are the Indications for thrombolytic therapy?
* STEMI onset within 12 hours * Most effective in 90 minutes * ST elevation of at least 1 mm in 2 contiguous leads * 2 mm in leads V2 and V3 for men, 1.5 for women * New LBBB
78
Relate Fibrinolysis and MI Treatment
* Administer in less than 30 minutes * tPA, TNK, rPA * Administer along with ASA and/or P2Y12 Inhibitor and Heparin * Only effective in case of a STEMI
79
Describe what Reperfusion Treatment Therapy is
* Tx within 3 hours = 50% reduction in mortality * Can treat up to 12 hours after onset * Limit infarct size and preserve LV function
86
Describe an MI Complication AV Block
* RCA supplies blood flow to the SA and AV nodes * Block may be transient and related to vagal tone * May respond to atropine since it is at the AV level
87
Describe MI Complications of LBBB
* Damage to conducting system * Presents with new LBBB * Clinical symptoms of MI and new LBBB treat as MI
88
Describe MI Complications of LBBB
* Damage to conducting system * Presents with new LBBB * Clinical symptoms of MI and new LBBB treat as MI
89
Describe an MI Complication AV Block
* RCA supplies blood flow to the SA and AV nodes * Block may be transient and related to vagal tone * May respond to atropine since it is at the AV level
91
What are the pitfalls of ECG?
Diagnostic in 50% of AMI cases Entirely normal in 20% of AMI cases
92
What are the pitfalls of ECG?
Diagnostic in 50% of AMI cases Entirely normal in 20% of AMI cases
93
What are the steps of Hemostasis?
95
What are the "substances"?
96
What receptor do platelets use to attach to one another?
97
What are the 2 substances responsible for stimulating platelet aggregation?
98
What molecules do Antiplatelet agents inhibit?
99
What inhibitor platelet aggregation drug does this describe? Blocks ADP receptors on platelets
100
What inhibitor platelet aggregation drug does this describe? Blocks the receptor used for platelet aggregation
101
What is the MOA for Aspirin?
102
What is aspirin used for? What are its PKs?
103
What are the DDIs and ADRs for aspirin?
104
How does aspirin affect Cox-1 vs Cox-2?
105
What are the ADP Receptor Antagonists?
Clones Prepared to be ADePt Tony the Tiger reversed Ticagrelor is reversible
106
What is the MOA for ADP Receptor Antagonists?
Irreversibly inhibit ADP receptor on surface of platelets (necessary for platelet aggregation)
108
What are ADP Receptor Antagonists used for?
109
What are PKs for ADP Receptor Antagonists?
110
What are the DDIs and ADRs for ADP Receptor Antagonists?
111
What are the GP IIb/IIIa Receptor Antagonists?
ATE GP
112
What is the MOA for GP IIb/IIIa Receptor Antagonists?
114
Describe the PKs and ADRs for GP IIb/IIIa Receptor Antagonists
115
What are the types of Anticoagulants and what are they used for?
116
Where is heparin found? What are the types of Heparin?
117
What is the MOA of Heparin?
118
What is the MOA of Unfractionated heparin (HMW)? What effect does it have on factor Xa? What are its drawbacks?
119
* What is the MOA of Low molecular weight heparin (LMW)? * What drug is an example of it * What effect does it have on factor Xa? Thrombin? * What are its drawbacks? advantages?
120
What are the DDIs and ADRs for Low molecular weight heparin (LMW)?
121
What are the Factor Xa Inhibitors? What DDI do they all share?
Fondaparinux Rivaroxaban Fond of Rivers
122
Describe the MOA and PK for Fondaparinux
123
Describe the MOA, PK, and ADRs for Rivaroxaban
124
What are the Direct thrombin inhibitors and their PKs?
Dab Again
125
What are the uses of Direct thrombin inhibitors? What use is specific for Dabigatran?
126
What are the ADRs of Direct thrombin inhibitors?
127
What are these examples of?
Warfarin
128
What is the MOA for Warfarin?
129
What are the PKs for Warfarin? What do you need to monitor? What is it used for?
130
What are the DDIs for Warfarin?
131
What are the Pharmacogenomic Considerations: for Warfarin
132
What are the ADRS for Warfarin? Describe Warfarin reversal
133
What are the Fibrinolytics/Thrombolytics?
ART PLASE
134
What is the MOA for Fibrinolytics/Thrombolytics?
135
What are the uses and PKs for Fibrinolytics/Thrombolytics?
136
What is Streptokinase? Describe its PKs and ADRs
137
What are the Hemostatics? What are they used for and what their MOAs?
139
What inhibitor platelet aggregation drug does this describe? Blocks formation of TxA2
Aspirin
148
What is Ticagrelor?
A reversible ADP receptor antagonist
154
What do you use GP IIb/IIIa Receptor Antagonists for?
Patients with recent MI or stroke or PCI
155
Describe the Mechanisms of Ischemia
156
Describe the Clinical Utility of Vasodilators
157
What is the The “Steal Phenomenon”
159
Describe the Blockade of endogenous vasoconstrictors
160
Describe the Direct relaxation of vascular smooth muscle
161
Describe the Non-endothelium-dependent vasodilators
162
Describe what Sodium Nitroprusside is used for
163
Describe what Nitroglycerin is what its MOA
164
Describe the PKs and ADRs of Nitroglycerin
165
Describe Isosorbide dinitrate
166
Describe Nifedipine
167
Describe Dipyridamole
168
What are the "Other Vasodilators"
169
Describe EDRF and Endothelin
● Endothelin has structural similarities to venom of the Israeli burrowing asp ○ Victims die of heart attack (likely due to severe vasoconstriction)
172
What are the Vasodilator Mechanisms?
* Blockade of endogenous vasoconstrictors * Direct relaxation of vascular smooth muscle * Non-endothelium-dependent vasodilators
184

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