Ischemic Heart Disease: Part 2 (INC) Flashcards
What do all patients w/ chest pain get?
An EKG
Difference between low, intermediate, and high risk patient?
HEART score to see the risk of the patient and then work them up from there
0-3 = no testing
4-6 = admit for observation (stress test)
7-10 = admit with invasive strategy from cath lab immediately
Why do you use an EKG?
See if there are symptoms of ACS w/in 10 minutes of arrival!!! (time is tissue - dead meat don’t beat)
serially monitor - look for hyperacute T-waves and T wave inversions
let’s you know if there are electrolyte abnormalities as well
Who should routinely get EKG?
DM, female, and elderly
What is the first presentation of ACS (MI)
Peaked T waves
Look it is diffuse, which would be hyperK, or localized ACS
get a BMP
How many leads do you need to diagnose with ACS?
ST elevation in 2+ contiguous leads
should know if it is an
If you see ST segment elevation or new LBBB (tombstoning) what do you do?
You do NOT order labs - go straight to the cath lab
Evolution of an MI
min-hours: St elevation after minutes to hours
1-2 days: ST elevation
Pathological Q wave
Inverted T waves
Scar formation
What is the best cardiac enzyme to diagnose? What are the others?
TROPONIN - specific to cardiac tissue
also myoglobin and CK-MB, but not as specific to the heart
only ordered if no ST elevation (order if there is T wave inversions, hyperacute T-waves)
What is Troponin?
contractile protein that normally is not found in serum
It is only released when myocardial necrosis occurs
HIGHLY sensitive AND specific
Why would you order other labs for troponin?
Due to it’s trend
Increase within 3-6 hrs
Peak at 24-48 hrs
Return to baseline over 5-14 days
Measure troponin levels at presentation and then again 90 minutes
Then every 6-8 hrs after symptom onset x 3 or until trending down
If there is an elevation of troponin, do we know what they have?
NO
need differential - just tells you that there is damage to the heart
What can cause false elevation of troponin?
If there was surgical procedure
What is considered normal troponin and why is this important to know?
Normal = 0 - 0.04
used as a baseline, as there is variance in baseline between patients
Why is Creatine Kinase (CK-MB) use sometimes?
Less sensitive and specific
Increase 4-8 hrs after injury
Peak around 24 hrs
Return to normal by 48-72 hrs
Positive if CK-MB >5% of total CK
need to order a CK and MB and then multiply by 0.05. It is positive if greater than this
What are some false positives of Ck-MB and why?
Non-cardiac related events that affect muscles
trauma, muscle, disease, DM, PE
How fast is myoglobin released and why is it useful?
High sensitivity, poor specificity
May be detected as early as 2 hours after an AMI
It is the MOST sensitive
Only real use is in the very early detection of MI
What is LDH used for?
Not really useful for MI
could be elevated in acute MI
Why is some other tests better than troponin?
If there is new onset of chest pain, because troponin will remain elevated for up to 10 days
Which cardiac enzyme is most appropriate / diagnostic for:
Patient with chest pain for 90 minutes?
myoglobin
chest pain for 6 hours
Patient with chest pain for 6 hours?
Troponin
Patient with recurrent chest pain 36 hours after having PCI for an MI?
CK-MB best
or myoglobin (but may be falling down)
what might you see in CBC for ACS?
Leukocytosis
What might you see for CRP and ESR in ACS?
May remain elevated
ESR (may remain elevated for 3 days)
What test is the go-to test for ischemic chest pain if it is stable angina?
stress test is the most commonly used and recommended initial noninvasive procedure for evaluating inducible ischemia in the patient with angina
How does a stress test work?
Either exercise or pharm (if CI to exercise) that will increase demand for O2
When is a patient deemed fit enough to do an exercise stress test?
In general, if a person can walk for >5 minutes on flat ground or up one to two flights of stairs without needing to stop
It is preferred, the medication SUCKS and hurts like heck
Why do you do an exercise stress test?
To confirm the diagnosis of angina
To determine the severity of limitation due to angina
To assess prognosis in patients with known CAD, including patients recovering from an MI
To evaluate response to therapy
What does a stress test monitor?
EKG
BP
HR
sees response
What can cause a false positive on a stress chest
asthma
sedentary
HTN
there are more false positives than true positives
When is an exercise the most usefl?
Low or intermediate pretest prob
Very high pretest = could code
Very low = most likely going to be negative
What can you add to a stress chest to make it more useful?
IMAGING
paired with their presentation
When do you stop stress chest?
The patient reaches maximum HR
Changes in heart function are detected on the EKG
Patient is symptomatic
What is a positive stress test?
ST-segment depression of 1 mm
When do you absolutely stop an exercise stress test?
- Drop in SBP of >10 mmHg from baseline BP despite increasing workload, when accompanied by other evidence of ischemia or hypoperfusion (should rise)
- Moderate to severe angina
- Increasing nervous system symptoms (e.g., ataxia, dizziness, near-syncope)
- Signs of poor perfusion (cyanosis, pallor)
- Technical difficulties in monitoring
- Subject’s desire to stop
- Sustained ventricular tachycardia (MI)
- ST elevation (>1.0 mm) in leads without diagnostic Q-waves
What are the contraindications for a stress test?
Acute MI (within 2 d)
High-risk unstable angina (pain at rest, high probability on HEART score - should go straight to cath)
Uncontrolled arrhythmias causing symptoms or hemodynamic compromise
Severe symptomatic AS (blood is not going to go across aortic valve well, and it can cause an MI)
Uncontrolled symptomatic HF
Acute PE or pulmonary infarction
Acute myocarditis or pericarditis
Acute aortic dissection
What EKG history will make you not want to do a stress test?
IF the EKG is not interpretable due to baseline abnormalities:
Preexcitation (WPW) syndrome
Electronically paced ventricular rhythm
Greater than 1 mm of resting ST depression
Complete LBBB
When do you add imaging for stress test?
- When the resting ECG makes an exercise ECG difficult to interpret (eg, LBBB, baseline ST–T changes, low voltage)
- For confirmation of the results of the exercise EKG when they are contrary to the clinical impression (eg, a positive test in an asymptomatic patient)
- To localize the region of ischemia
- To distinguish ischemic from infarcted myocardium (if you stop the test, and it starts beating again, then it is iscehmia, not infarction)
- To assess the completeness of revascularization following bypass surgery or coronary angioplasty
- As a prognostic indicator in patients with known coronary disease
What is an exercise stress test with nuclear imaging?
Radiotracers and Protocols
Provides relative perfusion data following injection of a radioactive material before a stress test and then after the stress test
Resting pictures are compared with post-exercise pictures
gives real time slices
How do you do a stress echo? What are you looking for?
Echocardiography can be combined with exercise EKG in an attempt to increase the sensitivity and specificity of the stress test, as well as to determine the extent of myocardium at risk for ischemia
Looking for regional wall motion abnormalities or LV dilation in response to exercise
if it is not contracting it is not perfusing well
When do you do a pharm stress test?
If the patient cannot do an exercise-induced stress test
What is the 1st line pharm stress tests for angina?
Vasodilators
adenosine
dipyridamole
regadenoson
What is the MOA for vasodilators? Symptoms? CI?
direct coronary artery vasodilation
Metallic taste
Bronchospasm (CI)
If a patient has bronchospasm, what is the next choice?
Adrenergic Stimulating Agents
What is the
DOBUTAMINE
What is the definitive diagnoses of coronary artery disease?
Coronary Angiogram /
Cardiac Catheterization
diagnostic and therapeutic!
what does a Coronary Angiogram /
Cardiac Catheterization evaluate?
Evaluate or confirm the presence of coronary artery disease, valve disease, or disease of the aorta
Evaluate heart muscle function
Determine the need for further treatment (PCI or CABG)
where does left heart cath go?
through the femoral artery
How do you prep a coronary angiogram?
NPO for 4-6 hours (will be aspirated)
IV fluids to flush out contrast dye
Hold metformin (because there may be contrast induced nephropathy - caution in DM patients)
What happens with severe aneurysmal CAD?
It might not be worth doing a stent, because it is SO many aneursyms
might do a venous bypass graft if severe instead of taking out the clot
What does a ventriculogram do?
Measures EF, SV, CO
When do you order a coronary angiogram?
- Life-limiting stable angina despite medical therapy
- High pretest likelihood of CAD
- Concomitant Aortic Valve disease
- Asymptomatic patients undergoing valve surgery
- Survivors of sudden death, symptomatic, or life-threatening arrhythmias when CAD may be a correctable cause
6, Chest pain of uncertain cause or cardiomyopathy of unknown cause - Emergently for revascularization in patients with STEMI (NEED TREATMENT NOWWWWWW)
What are the risks of coronary angiogram?
Only 0.1% mortality risk
Surgical risks include: CVA, coronary artery dissection, retroperitoneal hemorrhage, AKI, femoral pseudoaneurysm (go through the femoral artery, the wall weakens, then you get a psedoaneurusym that is dangerous if it ruptures)
Uses IV contrast, so be aware of allergies as well as CKD
Performed under moderate sedation
Invasive and costly, so it is not first-line unless high pre-test likelihood
Relative CI: severe renal disease, anaphylactic allergy to contrast
What are some other imaging you can use for CAD?
CXR
Useful to identify potential pulmonary causes of chest pain and may show a widened mediastinum in patients with aortic dissection
Chest CT with IV contrast
Can help exclude PE and aortic dissection
Transthoracic echocardiography (TTE)
Can identify a pericardial effusion and tamponade physiology
May be useful to detect regional wall motion abnormalities
Can identify a proximal aortic dissection
When do you order a CT of the coronary arteries?
Images the heart with contrast medium and multislice technology
Requires both radiation exposure and contrast load
Uses X-ray to produce images of the heart and heart vessels.
HR must be below 50
No recovery time needed
If positive, should undergo cardiac cath
why do you get a CBC for chest pain?
to make sure it is not anemia
What are troponins for NSTEMI vs unstable angina?
NSTEMI = elevated
unstable angina = normal
If stable angina, what is the work up?
symptom management and prevent CV events
Manage symptoms
Nitroglycerin
Beta blockers**
Calcium channel blockers
Ranexa
Revascularization
Prevent CV events (BP management, smoking cessation, good DM management)
Risk factor modification
Antiplatelet therapy
If you have unstable angina, NSTEMI, STEMI
ADMITTED until we know what it is
All patients should be admitted to the hospital
All patients should be placed on telemetry / cardiac monitoring
Patient should be placed on strict bedrest (movement can dislodge a thrombus)
Supplemental oxygen should be administered for patients with saturations below 95% (only if hypoxemic)
Nitrates are first-line therapy for patients with acute coronary syndromes presenting with chest pain (0.4 mg x 3)
ASA is first-line therapy (162 to 325 mg chewed)
What are first line treatment for Unstable Angina / NSTEMI / STEMI
Nitroglycerine x 3
ASA (162 - 325) even if they have already had it in the morning. CHEWED
Why do you give ASA?
antiplatet to stop plaque formation
if allergy: Clopidogrel, parsugrel, or ticagrelor.
How do you do pain management for Unstable Angina / NSTEMI / STEMI
Morphine for pain refractory to ASA or NTG
When do you give BB for Unstable Angina / NSTEMI / STEMI?
ALL patients w/in 24 hours unless
HF, bradycardia, or heart block (do not want to slow down)
When do you start ACEI for Unstable Angina / NSTEMI / STEMI?
w/in 24 hours
ARB if not tolerable
When do you start a statin for Unstable Angina / NSTEMI / STEMI?
w/in 48 hours
High intensity
What is the door-to-ballon PCI goal
90 minutes to get a balloon or stent
NO MATTER WHAT, even if they need to be sent elsewhere
flip the p and it looks like a 9 for 90 minutes
What is the door-to-needle goal?
30 minutes
Thrombolysis within 30 mins of hospital presentation and 6–12 hrs of onset of symptoms reduces mortality
What does NTG do?
MOA: nitrate enters vascular smooth muscle and is converted to nitric oxide, leading to activation of cGMP and vasodilation
Dilates coronary vessels, increasing blood flow
Decreases SVR and preload
When do you use with caution for NTG?
Use with caution in hypotension (SBP <100), bradycardia, tachycardia, RV infarction (reduces preload and it will kill the patient, as there is no blood to go from the right side of the heart to the left)
First-line therapy for patients with acute coronary syndromes presenting with CP (EXCEPT in patients presenting with IWMI)
What are the different NTG you give a patient
sublingual, oral agents, NTGointment, spray
If pain persists or recurs, start IV NTG until angina disappears or MAP drops by 10%.
What do you monitor for NTG?
BP monitoring is required with IV NTG
What are the SE of NTG?
BP monitoring is required with IV NTG
Adverse effects:
Headache most common – can be SEVERE
Postural hypotension
Tolerance
When do you give a break of long acting NTG?
Every 8 hours or else angina will be refractory and you will get tolerance
What do you not give nitrates with?
PDE5 inhibitor (-afil)
leads to severe hypotension
Cannot give NTG if you took within one day
What are the advantages of morphine?
Reduce pain/anxiety
Decreases
Sympathetic tone
SVR
O2 demand
What are the SE of morphine?
SE: bradycardia, diaphoresis, nausea, constipation, drowsiness, dizziness, confusion
can further the hypovolemia and hypotension
what is the caution of ASA?
increase risk of bleeding
leads to GI (ulcers, dyspepsia, hemorrhage), increased bleeding risk
chew (160-325) at presentation
prevention is with 81 mg ASA
What are the P2Y12 inhibitors?
Clopidogrel
(Plavix)
Prasugrel* (Effient)
Ticagrelor*
(Brilinta)
When do you use P2Y12 inhibitors?
unable to take a ASA
Load Plavix (600 mg) prior to cardiac cath
What do you need to postpone if you are taking a P2Y12 inhibitors?
postpone elective CABG for at least 5 days after the last dose of clopidogrel or ticagrelor and at least 7 days after the last dose of prasugrel due to risk of bleeding
What are the glycoprotein IIb/ IIa inhibitors?
Tirofiban
(Aggrastat)
Eptifibatide
(Integrilin)
Abciximab
(Reopro)
High risk patients with huge thrombus
What three meds do you take in preparation of PCI reperfusion?
Aspirin
PLavix
Heparin/LMWH
Once an MI stable, what should they be on for their heart
BETA BLOCKER W/IN 24-48 hours
Reduces
Infarct size and complications
Rate of re-infarction
Rate of life threatening tachyarrhythmias and thus reduce mortality
Prevent cardiac enlargement and remodeling
NEED TO KNOW
What is a CI to BB after stable MI?
Acute CHF
heart block
hypotension
How to treat chronic agina?
Antianginal medication to treat chronic angina
Ranexa (ranolazine)
Ranolazine MOA and CI
Late sodium channel blocker, decreases intracellular calcium overload
Prolongs QT
What is used to reduce fibrosis and remodeling (perserve tissue) after MI?
ACE-I
ARBS
Other than BB and ACEI/ARB, what should they be on?
Statin
Warfarin (for some)
Aldosterone antagonist (spironlactone for LV dysfunction)
CCB is 3rd line if there is still angina and elevated BP (if ACE/ARB don’t work)
What can be used if someone cannot get a PCI and what’s the risk?
tPA - ONLY for STEMI (not non-STEMI)
not first-line, PCI is
Can lead to bleeding risk and intracranial bleeding, which is why PCI is first-line
What is added to tPA therapy?
Anticoagulant
When do you need to get a PCI vs tPA
PCI = 90 minutes
tPA = 30 minutes
Why do you need to do tPA w/in 30 minutes
better success rates - longer you wait, the least likely it will work
mortality tanks w/ time :(
What adjunct therapy do you need to administer with tPA other than an anticoag and why?
PPI (1st line)
or antacids and H2 blockers
What are the absolute CI to thrombolytic therapy?
Any prior intracranial hemorrhage
Known structural cerebral vascular lesion (AVM)
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke w/in past 3 mo (except acute ischemic stroke w/in 3 hrs)
Active internal bleeding (except menses)
Suspected aortic dissection
Active bleeding or bleeding diathesis (doesn’t include menses)
Significant closed head or facial trauma within 3 mo
has to do with bleeding
Is PCI useful for stable CAD?
Not anymore than meds
-Aspirin
-Statin
-BB
unstable angina is where it is incredibly useful
After you have PCI, what do you need to be on?
Dual anti-platelet therapy for 3-12 months
aspirin + P2Y12 inhibitor (plavix, clopidogrel)
What are the two types of angioplasty?
balloon or stent
stent is a more permanent fix
balloon is when you cannot tolerate a stent
what are the risks of balloon PCI?
embolism, because the balloon can make it break through
What does angioplasty do?
makes it to where new blood can flow through by making essentially a pipe
What is the preferred stent?
Drug-Eluting Stents (DES)
What does an atherectomy do?
specialized catheters that specifically cut out the clog
When do you use CABG (coronary artery bypass grafting)?
If there is a major blockage, you bypass
often use a saphenous vein
open heart surgery
Left main trunk artery stenosis (left anterior descending supplies the LV)
Poor LV function
Significant 3-vessel CAD or 2-vessel disease that involves the proximal LAD
DM with focal stenosis in more than 1 vessel
Concomitant severe valvular disease that necessitates open heart surgery (kill two birds with one stone)
Diffuse disease not amenable to treatment with PCI
What is enhanced external conterpulsation?
BP cuffs that pump blood around the lower body and allow perfusion
