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Cardiovascular > Ischemic Heart Disease Part 3 > Flashcards

Ischemic Heart Disease Part 3 Flashcards

1
Q

What causes prinzmetal angina?

A

Spasm of the large coronary arteries leading to decreased coronary blood flow

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2
Q

What can induce vasospasms in Prinzmetal/vasospastic angina?

A
  • Exposure to cold
  • Emotional stress
  • Spontaneous
  • Vasoconstrictive medications (such as ergot-derivative medications)
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3
Q

How is Prinzmetal/Vasospastic angina related to myocardial infarction?

A

Myocardial infarction may result from spasm in the absence of visible obstructive CHD

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4
Q

What substance can cause myocardial ischemia and infarction and how?

A

Cocaine
* Causes coronary artery vasoconstriction
or
* increases myocardial energy requirements –> may contribute to accelerated atherosclerosis and thrombosis

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5
Q

What is the presentation of Prinzmetal/Vasospastic angina?

A
  • 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
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6
Q

How is Prinzmetal/Vasospastic angina managed?

A
  • 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
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7
Q

What medication can exacerbate coronary vasospasm in prinzmetal angina/vasospastic angina and is typically not used?

A

Beta blockers

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8
Q

How is a patient with symptoms suggestive of ischemia or infarction assessed in the ED?

A
  • 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
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9
Q

What is the general treatment of ischemia or infarction in the ED?

A
  • Morphine
  • O2 4L per NC (if <95%)
  • NTG (SL)
  • ASA 160-325 mg chewed
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10
Q

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?

A

(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

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11
Q

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?

A
  • 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
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12
Q

A patient has suspected ischemia or infarction and a normal ECG. How do you manage them now?

A
  • 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
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13
Q

What are the 5 categories of post-MI complications?

A
  • Ischemic
  • Mechanical
  • Arrhythmic
  • Embolic
  • Inflammatory
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14
Q

What ischemic complications can occur post-MI?

A
  • Angina
  • Reinfarction
  • Infarct extension
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15
Q

What mechanical complications can occur post-MI?

A
  • Heart failure
  • Cardiogenic shock
  • Mitral valve dysfunction
  • Aneurysms
  • Cardiac rupture
  • Cardiac tamponade
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16
Q

What are arrhythmic complications that can occur post-MI?

A
  • Atrial or ventricular arrhythmias
  • Sinus or atrioventricular node dysfunction
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17
Q

What are embolic complications that can occur post MI?

A
  • CNS (stroke) or peripheral embolization
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18
Q

What are inflammatory post-MI complications?

A

pericarditis

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19
Q

What is Dressler’s syndrome?

A
  • 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
20
Q

This complication is present in 1/3 of patients with inferior wall infarction

A

Right ventricular infarction

21
Q

How does right ventricular infarction present?

A
  • Hypotension with relatively preserved LV function
  • Elevated venous pressure and clear lungs
  • Hypotension made worse by nitrates and morphine
22
Q

How is right ventricular infarction treated?

A
  • IV normal saline
  • Inotropic agents if necessary
23
Q

Which patients are more likely to get ventricular free-wall rupture post MI?

A
  • Elderly patients
  • poor collateral circulation
  • ischemic preconditioning
  • first MI
24
Q

What areas of the heart more commonly have ventricular free-wall rupture?

A

anterior or lateral wall of LV

25
Q

What is the presentation of ventricular free wall rupture?

A
  • 1-4 days post-MI or within first 24 hrs
  • Mortality very high
  • May present as pericardial effusion post-MI or pulseless electrical activity
26
Q

What is a post-MI ventricular septal defect?

A
  • Rare post-MI complication occurring a few days after cardiac event
  • Associated with transmural MI involving septum
  • Mortality rate high without surgical intervention
27
Q

What is the presentation of MV regurgitation from ruptured papillary muscle?

A
  • Rare complication
  • 2-7 days post-MI
  • Sudden onset decompensated heart failure
  • Mortality high without surgery
28
Q

What changes should post-MI discharge instructions include?

A
  • Dietary changes
  • Implementation of an exercise regimen
  • Addition of appropriate medications
  • Increased frequency/number of follow up care visits
29
Q

Why is making lifestyle changes important post-MI?

A
  • Lowers risk of another heart attack
  • Reduces risk of death from heart disease
  • Increases ability to exercise and be active
30
Q

What should detailed discharge instructions post-MI include?

A
  • 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
31
Q

What are follow-up guidelines post MI?

A
  • 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
32
Q

What instructions should be given about dietary changes post MI?

A
  • Limit intake of saturated and trans fatty acids, free sugars, and salt
  • Increase intake of fruits, vegetables, legumes, nuts, and whole grains
33
Q

What are examples of dietary changes that could be implemented post-MI?

A
  • Ornish diet/lifestyle
  • Mediterranean diet
  • DASH diet
  • Low-fat/low-cholesterol diet
34
Q

What instructions about exercise should be provided post-MI?

A
  • 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
35
Q

What psychosocial issues can occur post MI?

A
  • Debility/decreased exercise tolerance
  • Activity/recreation
  • Depression
  • Sexual activity
  • Work/driving
36
Q

What is the cardiac blues?

A
  • Strong emotional reaction at time of or soon after acute cardiac event
  • 3x more common after MI than general population
37
Q

Why is the cardiac blues a problem?

A
  • Leads to emotional distress and suffering
  • Associated with increased risk of having another MI or dying over ensuing months and years
38
Q

What could account for depressed persons having a poorer prognosis after a heart attack?

A
  • 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
39
Q

What should you inform your patients of related to cardiac blues?

A
  • Possibility of depression
  • Screen for signs/symptoms at follow up appointments
40
Q

What education should be provided about sexual activity post-MI?

A
  • 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
41
Q

What are contributing factors to decreased libido/less satisfaction post-MI?

A
  • Drug side effects
  • depression
  • fear of triggering another heart attack or dying
42
Q

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?

A
  • recurrent CP
  • Arrhythmias
  • HF
43
Q

What is cardiac rehab?

A
  • 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
44
Q

What is phase 2 of cardiac rehab?

A

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

44
Q

What is phase 1 of cardiac rehab?

A

Inpatient rehab
* basic info and reassurance
* supportive counseling
* guidelines for mobilization
* appropriate discharge planning
* referral to outpatient cardiac rehab

45
Q

What is phase 3 of cardiac rehab?

A
  • 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
46
Q
A

Cardiovascular (17 decks)

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