Ischemic Heart Disease Part 3 Flashcards
What causes prinzmetal angina?
Spasm of the large coronary arteries leading to decreased coronary blood flow
What can induce vasospasms in Prinzmetal/vasospastic angina?
- Exposure to cold
- Emotional stress
- Spontaneous
- Vasoconstrictive medications (such as ergot-derivative medications)
How is Prinzmetal/Vasospastic angina related to myocardial infarction?
Myocardial infarction may result from spasm in the absence of visible obstructive CHD
What substance can cause myocardial ischemia and infarction and how?
Cocaine
* Causes coronary artery vasoconstriction
or
* increases myocardial energy requirements –> may contribute to accelerated atherosclerosis and thrombosis
What is the presentation of Prinzmetal/Vasospastic angina?
- Chest pain without usual precipitating factors
- Associated with ST segment elevation
- MC women under 50
- Occurs early int he morning, awakening patients from sleep
- Associated with arrhythmias or conduction defects
- No CAD on cardiac catheterization: may actually be able to induce spasm. otherwise, a clinical diagnosis
How is Prinzmetal/Vasospastic angina managed?
- emergent coronary arteriography (if chest pain with ST elevation)
- If stenosis found, aggressive medical therapy or revascularization
- If no lesions and spasm suspected, avoid precipitants such as cigarette smoking and cocaine
- Nitrates for acute spasm symptoms
- Nitrates and Ca channel blockers (dilt, amlodipine, or nifedipine) for chronic therapy
What medication can exacerbate coronary vasospasm in prinzmetal angina/vasospastic angina and is typically not used?
Beta blockers
How is a patient with symptoms suggestive of ischemia or infarction assessed in the ED?
- IV, O2 monitor
- Consider fibrinolytics
- Labs: troponins x 3, electrolytes, coag studies, TSH, lipids, other r/o causes
- 12 lead EKG, CXR
- Targeted H&P
What is the general treatment of ischemia or infarction in the ED?
- Morphine
- O2 4L per NC (if <95%)
- NTG (SL)
- ASA 160-325 mg chewed
A patient with suspected ischemia has ST elevation or new LBBB and is now diagnosed with a STEMI based on ECG, what are you going to add to your initial treatment?
(already have on morphine, ASA, NTG, O2)
* If time from onset of symptoms <12 hrs, door to balloon PCI goal of 90 mins or door to needle goal of 30 mins
* If time from onset of symptoms >12 hrs, NTG, heparin, plavix, consider GP IIB/IIIa, consider PO Bb; admit and continue ASA, heparin; ACE/ARB; statin
A patient with suspected ischemia or infarction has ST depression or T wave inversion on ECG. You are already treating them with morphine, O2, NTG, and ASA. How will you manage them now?
- Suspect High risk USA/NSTEMI
- If troponin increased or high risk, consider early invasive strategy if: refractory ischemic CP, recurrent/persistent ST deviation, VT, hemodynamic instability, signs of HF
- Start adjunctive tx as indicated: NTG, heparin, plavix, GP IIB/IIIa, PO BB
- Admit and continue ASA, heparin; ACE/ARB; statin
A patient has suspected ischemia or infarction and a normal ECG. How do you manage them now?
- Consider admission for observation and monitor serial troponins, repeat ECG, ST segment, consider non-invasive diagnostic test
- If develops 1 or more clinical high-risk features, dynamic ECG changes w/ischemia, or elevated troponin then start adjunctive treatment as needed (NTG, heparin, plavix, GP IIb/IIIa, PO BB)
- If no abnormal labs but abnormal diagnostic noninvasive imaging or physiologic testing, admit and continue ASA, heparin, ACE/ARC, and statin
- If no abnormal tests, DC with f/u
What are the 5 categories of post-MI complications?
- Ischemic
- Mechanical
- Arrhythmic
- Embolic
- Inflammatory
What ischemic complications can occur post-MI?
- Angina
- Reinfarction
- Infarct extension
What mechanical complications can occur post-MI?
- Heart failure
- Cardiogenic shock
- Mitral valve dysfunction
- Aneurysms
- Cardiac rupture
- Cardiac tamponade
What are arrhythmic complications that can occur post-MI?
- Atrial or ventricular arrhythmias
- Sinus or atrioventricular node dysfunction
What are embolic complications that can occur post MI?
- CNS (stroke) or peripheral embolization
What are inflammatory post-MI complications?
pericarditis
What is Dressler’s syndrome?
- Type of pericarditis post MI or CABG
- Believed to be caused by immune system mediated inflammatory response following damage to heart tissue or pericardium
- Occurs between 1 to 12 weeks post MI
- Symptoms include CP and fever
This complication is present in 1/3 of patients with inferior wall infarction
Right ventricular infarction
How does right ventricular infarction present?
- Hypotension with relatively preserved LV function
- Elevated venous pressure and clear lungs
- Hypotension made worse by nitrates and morphine
How is right ventricular infarction treated?
- IV normal saline
- Inotropic agents if necessary
Which patients are more likely to get ventricular free-wall rupture post MI?
- Elderly patients
- poor collateral circulation
- ischemic preconditioning
- first MI
What areas of the heart more commonly have ventricular free-wall rupture?
anterior or lateral wall of LV
What is the presentation of ventricular free wall rupture?
- 1-4 days post-MI or within first 24 hrs
- Mortality very high
- May present as pericardial effusion post-MI or pulseless electrical activity
What is a post-MI ventricular septal defect?
- Rare post-MI complication occurring a few days after cardiac event
- Associated with transmural MI involving septum
- Mortality rate high without surgical intervention
What is the presentation of MV regurgitation from ruptured papillary muscle?
- Rare complication
- 2-7 days post-MI
- Sudden onset decompensated heart failure
- Mortality high without surgery
What changes should post-MI discharge instructions include?
- Dietary changes
- Implementation of an exercise regimen
- Addition of appropriate medications
- Increased frequency/number of follow up care visits
Why is making lifestyle changes important post-MI?
- Lowers risk of another heart attack
- Reduces risk of death from heart disease
- Increases ability to exercise and be active
What should detailed discharge instructions post-MI include?
- Education on medications, diet, exercise, and smoking cessation counseling
- Referral to cardiac rehabilitation/secondary prevention program and scheduling of timely follow-up appointment
- Specific instruction on activities that are permissible and those that should be avoided
–> specific mention of driving, return to work, and sexual activity
What are follow-up guidelines post MI?
- Follow-up with cardiology and PCP
- Low-risk medically treated or revascularized patients should return in 4-6 weeks
- High risk patients should return within 1-2 weeks
- Detailed education should include change in physical activity, new pattern of angina, compliance, modification of risk factors, development of comorbid conditions
What instructions should be given about dietary changes post MI?
- Limit intake of saturated and trans fatty acids, free sugars, and salt
- Increase intake of fruits, vegetables, legumes, nuts, and whole grains
What are examples of dietary changes that could be implemented post-MI?
- Ornish diet/lifestyle
- Mediterranean diet
- DASH diet
- Low-fat/low-cholesterol diet
What instructions about exercise should be provided post-MI?
- Most can exercise safely after a cardiac event but intensity and duration varies
- Exercise should use large muscle groups and include aerobic exercise
- Should include at least 150 minutes of moderate intensity exercise per week or 75 minutes of high intensity exercise per week
What psychosocial issues can occur post MI?
- Debility/decreased exercise tolerance
- Activity/recreation
- Depression
- Sexual activity
- Work/driving
What is the cardiac blues?
- Strong emotional reaction at time of or soon after acute cardiac event
- 3x more common after MI than general population
Why is the cardiac blues a problem?
- Leads to emotional distress and suffering
- Associated with increased risk of having another MI or dying over ensuing months and years
What could account for depressed persons having a poorer prognosis after a heart attack?
- Medication non-compliance
- Continuing to smoke
- Less physical activity
- Increased stress hormone levels
- Increased blood glucose and lipid levels
- Increased tendency of blood to clot
- Increased inflammatory cytokine levels
What should you inform your patients of related to cardiac blues?
- Possibility of depression
- Screen for signs/symptoms at follow up appointments
What education should be provided about sexual activity post-MI?
- Decreased libido/less satisfaction occur in 1/2 to 3/4 of patients post-MI
- Sexual activity is reasonable >1 week after uncomplicated MI if without cardiac symptoms
- If complicated MI (CPR, hypotension/shock, HF, and/or arrhythmias) wait 2 to 3 weeks as long as symptomatic
- No nitro with PDE-5 inhibitors w/i 24 hrs
What are contributing factors to decreased libido/less satisfaction post-MI?
- Drug side effects
- depression
- fear of triggering another heart attack or dying
Which patients are at a intermediate-high risk of heart-related problems during sex and need further evaluation and/or treatment before attempting to have intercourse?
- recurrent CP
- Arrhythmias
- HF
What is cardiac rehab?
- Program to improve cardiac function and reduce mortality/development of complications
- 3 aspects: exercise, education on risk factors, counseling to help deal with stress, anxiety, and depression
What is phase 2 of cardiac rehab?
Outpatient rehab
* 6-8 weeks
* assessment review and follow-up
* physical activity and exercise training
* behavioral modification strategies and risk factor management
* nutritional counseling
* psychological counseling and psychosocial management
What is phase 1 of cardiac rehab?
Inpatient rehab
* basic info and reassurance
* supportive counseling
* guidelines for mobilization
* appropriate discharge planning
* referral to outpatient cardiac rehab
What is phase 3 of cardiac rehab?
- Maintenance
- Sustained activities and behavior
- Reduces risk of future coronary event
- Delay in progression underlying atherosclerotic processes and clinical deterioration
- Reduction in morbidity and mortality
