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Cardiology > Ischemic Heart Disease: Part 2 (INC) > Flashcards

Ischemic Heart Disease: Part 2 (INC) Flashcards

1
Q

What do all patients w/ chest pain get?

A

An EKG

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2
Q

Difference between low, intermediate, and high risk patient?

A

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

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3
Q

Why do you use an EKG?

A

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

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4
Q

Who should routinely get EKG?

A

DM, female, and elderly

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5
Q

What is the first presentation of ACS (MI)

A

Peaked T waves

Look it is diffuse, which would be hyperK, or localized ACS

get a BMP

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6
Q

How many leads do you need to diagnose with ACS?

A

ST elevation in 2+ contiguous leads

should know if it is an

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7
Q

If you see ST segment elevation or new LBBB (tombstoning) what do you do?

A

You do NOT order labs - go straight to the cath lab

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8
Q

Evolution of an MI

A

min-hours: St elevation after minutes to hours
1-2 days: ST elevation
Pathological Q wave
Inverted T waves
Scar formation

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9
Q

What is the best cardiac enzyme to diagnose? What are the others?

A

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)

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10
Q

What is Troponin?

A

contractile protein that normally is not found in serum
It is only released when myocardial necrosis occurs

HIGHLY sensitive AND specific

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11
Q

Why would you order other labs for troponin?

A

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

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12
Q

If there is an elevation of troponin, do we know what they have?

A

NO

need differential - just tells you that there is damage to the heart

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13
Q

What can cause false elevation of troponin?

A

If there was surgical procedure

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14
Q

What is considered normal troponin and why is this important to know?

A

Normal = 0 - 0.04

used as a baseline, as there is variance in baseline between patients

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15
Q

Why is Creatine Kinase (CK-MB) use sometimes?

A

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

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16
Q

What are some false positives of Ck-MB and why?

A

Non-cardiac related events that affect muscles

trauma, muscle, disease, DM, PE

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17
Q

How fast is myoglobin released and why is it useful?

A

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

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18
Q

What is LDH used for?

A

Not really useful for MI

could be elevated in acute MI

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19
Q

Why is some other tests better than troponin?

A

If there is new onset of chest pain, because troponin will remain elevated for up to 10 days

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20
Q

Which cardiac enzyme is most appropriate / diagnostic for:

Patient with chest pain for 90 minutes?

A

myoglobin

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21
Q

chest pain for 6 hours

A

Patient with chest pain for 6 hours?

Troponin

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22
Q

Patient with recurrent chest pain 36 hours after having PCI for an MI?

A

CK-MB best

or myoglobin (but may be falling down)

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23
Q

what might you see in CBC for ACS?

A

Leukocytosis

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24
Q

What might you see for CRP and ESR in ACS?

A

May remain elevated

ESR (may remain elevated for 3 days)

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25
Q

What test is the go-to test for ischemic chest pain if it is stable angina?

A

stress test is the most commonly used and recommended initial noninvasive procedure for evaluating inducible ischemia in the patient with angina

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26
Q

How does a stress test work?

A

Either exercise or pharm (if CI to exercise) that will increase demand for O2

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27
Q

When is a patient deemed fit enough to do an exercise stress test?

A

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

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28
Q

Why do you do an exercise stress test?

A

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

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29
Q

What does a stress test monitor?

A

EKG
BP
HR

sees response

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30
Q

What can cause a false positive on a stress chest

A

asthma
sedentary
HTN

there are more false positives than true positives

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31
Q

When is an exercise the most usefl?

A

Low or intermediate pretest prob

Very high pretest = could code

Very low = most likely going to be negative

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32
Q

What can you add to a stress chest to make it more useful?

A

IMAGING

paired with their presentation

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33
Q

When do you stop stress chest?

A

The patient reaches maximum HR
Changes in heart function are detected on the EKG
Patient is symptomatic

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34
Q

What is a positive stress test?

A

ST-segment depression of 1 mm

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35
Q

When do you absolutely stop an exercise stress test?

A
  1. Drop in SBP of >10 mmHg from baseline BP despite increasing workload, when accompanied by other evidence of ischemia or hypoperfusion (should rise)
  2. Moderate to severe angina
  3. Increasing nervous system symptoms (e.g., ataxia, dizziness, near-syncope)
  4. Signs of poor perfusion (cyanosis, pallor)
  5. Technical difficulties in monitoring
  6. Subject’s desire to stop
  7. Sustained ventricular tachycardia (MI)
  8. ST elevation (>1.0 mm) in leads without diagnostic Q-waves
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36
Q

What are the contraindications for a stress test?

A

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

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37
Q

What EKG history will make you not want to do a stress test?

A

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

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38
Q

When do you add imaging for stress test?

A
  1. When the resting ECG makes an exercise ECG difficult to interpret (eg, LBBB, baseline ST–T changes, low voltage)
  2. 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)
  3. To localize the region of ischemia
  4. To distinguish ischemic from infarcted myocardium (if you stop the test, and it starts beating again, then it is iscehmia, not infarction)
  5. To assess the completeness of revascularization following bypass surgery or coronary angioplasty
  6. As a prognostic indicator in patients with known coronary disease
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39
Q

What is an exercise stress test with nuclear imaging?

A

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

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40
Q

How do you do a stress echo? What are you looking for?

A

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

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41
Q

When do you do a pharm stress test?

A

If the patient cannot do an exercise-induced stress test

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42
Q

What is the 1st line pharm stress tests for angina?

A

Vasodilators

adenosine
dipyridamole
regadenoson

43
Q

What is the MOA for vasodilators? Symptoms? CI?

A

direct coronary artery vasodilation
Metallic taste
Bronchospasm (CI)

44
Q

If a patient has bronchospasm, what is the next choice?

A

Adrenergic Stimulating Agents

45
Q

What is the

A

DOBUTAMINE

46
Q

What is the definitive diagnoses of coronary artery disease?

A

Coronary Angiogram /
Cardiac Catheterization

diagnostic and therapeutic!

47
Q

what does a Coronary Angiogram /
Cardiac Catheterization evaluate?

A

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)

48
Q

where does left heart cath go?

A

through the femoral artery

49
Q

How do you prep a coronary angiogram?

A

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)

50
Q

What happens with severe aneurysmal CAD?

A

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

51
Q

What does a ventriculogram do?

A

Measures EF, SV, CO

52
Q

When do you order a coronary angiogram?

A
  1. Life-limiting stable angina despite medical therapy
  2. High pretest likelihood of CAD
  3. Concomitant Aortic Valve disease
  4. Asymptomatic patients undergoing valve surgery
  5. 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
  6. Emergently for revascularization in patients with STEMI (NEED TREATMENT NOWWWWWW)
53
Q

What are the risks of coronary angiogram?

A

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

54
Q

What are some other imaging you can use for CAD?

A

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

55
Q

When do you order a CT of the coronary arteries?

A

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

56
Q

why do you get a CBC for chest pain?

A

to make sure it is not anemia

57
Q

What are troponins for NSTEMI vs unstable angina?

A

NSTEMI = elevated
unstable angina = normal

58
Q

If stable angina, what is the work up?

A

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

59
Q

If you have unstable angina, NSTEMI, STEMI

A

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)

60
Q

What are first line treatment for Unstable Angina / NSTEMI / STEMI

A

Nitroglycerine x 3
ASA (162 - 325) even if they have already had it in the morning. CHEWED

61
Q

Why do you give ASA?

A

antiplatet to stop plaque formation

if allergy: Clopidogrel, parsugrel, or ticagrelor.

62
Q

How do you do pain management for Unstable Angina / NSTEMI / STEMI

A

Morphine for pain refractory to ASA or NTG

63
Q

When do you give BB for Unstable Angina / NSTEMI / STEMI?

A

ALL patients w/in 24 hours unless
HF, bradycardia, or heart block (do not want to slow down)

64
Q

When do you start ACEI for Unstable Angina / NSTEMI / STEMI?

A

w/in 24 hours

ARB if not tolerable

65
Q

When do you start a statin for Unstable Angina / NSTEMI / STEMI?

A

w/in 48 hours

High intensity

66
Q

What is the door-to-ballon PCI goal

A

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

67
Q

What is the door-to-needle goal?

A

30 minutes

Thrombolysis within 30 mins of hospital presentation and 6–12 hrs of onset of symptoms reduces mortality

68
Q

What does NTG do?

A

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

69
Q

When do you use with caution for NTG?

A

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)

70
Q

What are the different NTG you give a patient

A

sublingual, oral agents, NTGointment, spray

If pain persists or recurs, start IV NTG until angina disappears or MAP drops by 10%.

71
Q

What do you monitor for NTG?

A

BP monitoring is required with IV NTG

72
Q

What are the SE of NTG?

A

BP monitoring is required with IV NTG
Adverse effects:
Headache most common – can be SEVERE
Postural hypotension
Tolerance

73
Q

When do you give a break of long acting NTG?

A

Every 8 hours or else angina will be refractory and you will get tolerance

74
Q

What do you not give nitrates with?

A

PDE5 inhibitor (-afil)

leads to severe hypotension

Cannot give NTG if you took within one day

75
Q

What are the advantages of morphine?

A

Reduce pain/anxiety

Decreases
Sympathetic tone
SVR
O2 demand

76
Q

What are the SE of morphine?

A

SE: bradycardia, diaphoresis, nausea, constipation, drowsiness, dizziness, confusion

can further the hypovolemia and hypotension

77
Q

what is the caution of ASA?

A

increase risk of bleeding

leads to GI (ulcers, dyspepsia, hemorrhage), increased bleeding risk

chew (160-325) at presentation

prevention is with 81 mg ASA

78
Q

What are the P2Y12 inhibitors?

A

Clopidogrel
(Plavix)

Prasugrel* (Effient)

Ticagrelor*
(Brilinta)

79
Q

When do you use P2Y12 inhibitors?

A

unable to take a ASA

Load Plavix (600 mg) prior to cardiac cath

80
Q

What do you need to postpone if you are taking a P2Y12 inhibitors?

A

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

81
Q

What are the glycoprotein IIb/ IIa inhibitors?

A

Tirofiban
(Aggrastat)

Eptifibatide
(Integrilin)

Abciximab
(Reopro)

High risk patients with huge thrombus

82
Q

What three meds do you take in preparation of PCI reperfusion?

A

Aspirin
PLavix
Heparin/LMWH

83
Q

Once an MI stable, what should they be on for their heart

A

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

84
Q

What is a CI to BB after stable MI?

A

Acute CHF
heart block
hypotension

85
Q

How to treat chronic agina?

A

Antianginal medication to treat chronic angina

Ranexa (ranolazine)

86
Q

Ranolazine MOA and CI

A

Late sodium channel blocker, decreases intracellular calcium overload

Prolongs QT

87
Q

What is used to reduce fibrosis and remodeling (perserve tissue) after MI?

A

ACE-I
ARBS

88
Q

Other than BB and ACEI/ARB, what should they be on?

A

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)

89
Q

What can be used if someone cannot get a PCI and what’s the risk?

A

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

90
Q

What is added to tPA therapy?

A

Anticoagulant

91
Q

When do you need to get a PCI vs tPA

A

PCI = 90 minutes
tPA = 30 minutes

92
Q

Why do you need to do tPA w/in 30 minutes

A

better success rates - longer you wait, the least likely it will work

mortality tanks w/ time :(

93
Q

What adjunct therapy do you need to administer with tPA other than an anticoag and why?

A

PPI (1st line)
or antacids and H2 blockers

94
Q

What are the absolute CI to thrombolytic therapy?

A

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

95
Q

Is PCI useful for stable CAD?

A

Not anymore than meds

-Aspirin
-Statin
-BB

unstable angina is where it is incredibly useful

96
Q

After you have PCI, what do you need to be on?

A

Dual anti-platelet therapy for 3-12 months

aspirin + P2Y12 inhibitor (plavix, clopidogrel)

97
Q

What are the two types of angioplasty?

A

balloon or stent

stent is a more permanent fix
balloon is when you cannot tolerate a stent

98
Q

what are the risks of balloon PCI?

A

embolism, because the balloon can make it break through

99
Q

What does angioplasty do?

A

makes it to where new blood can flow through by making essentially a pipe

100
Q

What is the preferred stent?

A

Drug-Eluting Stents (DES)

101
Q

What does an atherectomy do?

A

specialized catheters that specifically cut out the clog

102
Q

When do you use CABG (coronary artery bypass grafting)?

A

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

103
Q

What is enhanced external conterpulsation?

A

BP cuffs that pump blood around the lower body and allow perfusion

Cardiology (22 decks)

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