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Internal Medicine > JH IM Board Review - Coronary Artery Disease II > Flashcards

JH IM Board Review - Coronary Artery Disease II Flashcards

1
Q

ACS includes (3):

A
  1. UA.
  2. NSTEMI.
  3. STEMI.
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2
Q

All 3 syndromes occur when …

A

A VULNERABLE PLAQUE RUPTURES.

==> PLT activation and aggregation ==> Intracoronary thrombus.

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3
Q

Definition of UA:

A
  1. Angina at rest (>20min).
  2. New-onset exertional angina of at least class III in severity (ie w/ mild exertion).
  3. Preexisting angina that has increased in frequency or duration or that is now brought on w/ less exertion than before.
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4
Q

Definition of NSTEMI:

A

Clinically similar to UA, but distinguished by evidence of myocardial necrosis (ie elevation in serum cardiac enzymes).

ECG does not show ST elevation.

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5
Q

Definition of STEMI:

A

Elevated cardiac enzymes and ECG criteria that include >1mm ST segment elevation in two or more contiguous limb leads.

Or >2mm ST segment elevation in 2 or more contiguous PRECORDIAL leads.

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6
Q

Of note, a new or presumed new LBBB is …

A

NO LONGER considered a STEMI equivalent. (2013 ACC/AHA)

==> Must employ other ECG criteria to diagnose MI in these cases.

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7
Q

NSTEMI vs STEMI - ECG:

A

NSTEMI ==> ST depressions, T inversions, nonspecific ST-T changes.

STEMI ==> ST elevation.

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8
Q

NSTEMI vs STEMI - Vessel at time of catheterization:

A

NSTEMI ==> 30-40% occluded.

STEMI ==> >80%.

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9
Q

NSTEMI vs STEMI - Type of clot?

A

NSTEMI ==> Rich in PLTs (white).

STEMI ==> Rich in fibrin (red).

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10
Q

NSTEMI vs STEMI - Extent of disease?

A

NSTEMI ==> More likely collateral formation and multivessel disease.

STEMI ==> More commonly single vessel.

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11
Q

NSTEMI vs STEMI - Tx:

A

NSTEMI ==> Thrombolysis NOT recommended — GP IIb/IIIa inhibitors can be useful.

STEMI ==> Thrombolysis beneficial — GP IIb/IIIa inhibitors usually not indicated (unless PCI performed).

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12
Q

NSTEMI vs STEMI - Hospital mortality?

A

NSTEMI ==> Lower.

STEMI ==> Higher.

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13
Q

NSTEMI vs STEMI - Reinfarction rate?

A

NSTEMI ==> Higher after d/c.

STEMI ==> Lower after d/c.

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14
Q

NSTEMI vs STEMI - Long-term prognosis?

A

NSTEMI ==> Higher 1y mortality rate after d/c.

STEMI ==> Lower 1y mortality rate after d/c.

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15
Q

Of note, …-…% of ACSs are clinically silent.

A

20-30%.

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16
Q

TIMI (thrombolysis in MI) risk score for UA/NSTEMI - RFs:

7

A
  1. > 65y.
  2. 3 or more coronary artery RFs.
  3. Prior coronary stenosis >50%.
  4. > 2 anginal events in past 24h.
  5. Aspirin use in past 7 days.
  6. ST-segment changes.
  7. Positive cardiac markers.
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17
Q

Risk of adverse cardiac event by TIMI score:

A

0-1 ==> 4.7% (Low risk).

2 ==> 8.3% (Low risk).

3 ==> 13.2% (Intermediate risk).

4 ==> 19.9% (Intermediate risk).

5 ==> 26.2% (High risk).

6-7 ==> 41% (High risk).

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18
Q

Calculate GRACE (Global Registry of Acute Coronary Events) 2.0 risk score.

Incorporates (7):

A
  1. Age.
  2. HR.
  3. SBP.
  4. Killip class.
  5. Presence of cardiac arrest.
  6. ST-segment change.
  7. Troponins.
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19
Q

The GRACE 2.0 score estimates …

A

6mo mortality.

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20
Q

Always consider other diagnoses that can mimic ACS (3):

A
  1. AD.
  2. Acute pericarditis.
  3. PE.
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21
Q

AD - ECG can reveal ST elevations if the …

A

Dissection involves one or more of the coronary arteries.

typically affect the RCA first

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22
Q

Management of UA/NSTEMI - Medical therapy consists of (6):

A
  1. Antiplatelet therapy.
  2. Antithrombotic therapy.
  3. Beta blockers.
  4. Nitrates.
  5. CCBs.
  6. Statins.
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23
Q

UA/NSTEMI - Antiplatelet therapy consists of …

A
  1. Aspirin.
  2. Thienopyridines.
  3. GpIIb/IIIa inhibitors.
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24
Q

UA/NSTEMI - Aspirin leads to more than …% relative reduction in risk of MI and death.

A

50%.

Should be continued INDEFINITELY.

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25
UA/NSTEMI - Thienopyridines - Clopidogrel:
Reduces adverse cardiac events in pts with UA/NSTEMI when given in addition to aspirin. ==> Continue for at least 12mo if PCI with DES. ==> 1 month if PCI with BMS. ==> 9 mo if NO PCI.
26
UA/NSTEMI - Prasugrel should be avoided in pts who may be potential candidates for ...
CABG.
27
UA/NSTEMI - Role of GpIIb/IIIa:
Clear benefit demonstrated in both UA and NSTEMI. ==> The greatest benefit is seen in pts who have positive troponins and are treated with PCI.
28
Abciximab has clear benefit in ...
UA/NSTEMI undergoing PCI. NO BENEFIT in pts with UA/NSTEMI who do NOT require PCI.
29
Antithrombotic therapy is a/w ...
Lower rates of MI and death in pts with ACS.
30
Enoxaparin compared to UFH in UA/NSTEMI?
Superior to UFH in reducing death, MI, and recurrent ischemic events in pts who are treated CONSERVATIVELY. ==> No difference in pts treated invasively, and also a/w higher rate of bleeding.
31
Fondaparinux can be used ...
Both with conservative strategy and as an invasive strategy in pts with UA/NSTEMI. ==> Preferable to UFH or enoxaparin in pts with increased risk of bleeding.
32
Direct thrombin inhibitor - Bivalirudin is an option only in pts in whom ...
An early invasive approach is planned. ==> If high risk of bleeding exists, then bivalirudin monotherapy can be considered instead of heparin/GpIIb/IIIa inhibition combination.
33
Beta blockers in UA?
Reduce ischemia + shown to reduce subsequent infarction.
34
Beta blockers in NSTEMI?
1. Reduce ischemia + infarct size. 2. Help prevent reinfarction. 3. Decr mortality.
35
Administer beta blockers orally if there is no evidence of ...
Acute heart failure.
36
Do not give diltiazem, verapamil, or nifedipine in pt with LVEF
40%.
37
Statins in UA/NSTEMI?
They have been shown to have antiplatelet and antioxidant properties as well.
38
Thrombolytics in UA/NSTEMI?
NOT indicated.
39
Cardiac catheterization in UA/NSTEMI - Emergent indications: | 3
1. Persistent ischemia despite medical tx. 2. Hemodynamic instability. 3. V-tach, v-fib, SCD.
40
Catheterization in UA/NSTEMI - Indications in pts stabilized w/ medication tx:
1. Stress test — positive high-risk results. 2. ECG: ST depression suggesting ischemia in a large territory. 3. ST depression on ECG + elevated enzymes. 4. DM. 5. CKD. 6. Low EF. 7. TIMI risk score: High or intermediate risk. 8. GRACE score >140.
41
Thrombolytic tx in STEMI is successful in ...%
60%.
42
Thrombolytics for STEMI are most effective when given in the first ..., but can be given up to ... after onset of pain.
6h 12h
43
Between ...-..., only consider thrombolytics if there is no available PCI, and the STEMI pt has hemodynamic compromise or a large myocardial area at risk.
12-24h
44
Thrombolytic tx in STEMI — Indication?
Duration of sx <12h.
45
Thrombolytic tx in STEMI — Absolute contra: | 7
1. Hx of ICH. 2. Known cerebral vascular lesion (eg AVM). 3. Known malignant intracranial neoplasm. 4. Ischemic stroke within 3mo. 5. Suspected AD. 6. Active bleeding or bleeding diathesis. 7. Closed-head or facial trauma within 3mo.
46
Thrombolytic tx in STEMI — Relative contra: | 8
1. SBP >180 or DBP >110 AT PRESENTATION. 2. Hx of ischemic stroke >3mo. 3. Prolonged CPR (>10min). 4. Major surgery within <3wks. 5. Recent internal bleeding (within 2-4wks). 6. Pregnancy. 7. Active PUD. 8. For strepto/anistreplase ==> Prior exposure >5 days ago or prior allergic reaction.
47
Thrombolytics a/w hemorrhagic stroke — Which groups are more prone to? (5)
1. Elderly. 2. Women. 3. HTN. 4. DM. 5. Pts w/ previous stroke or treated w/ warfarin.
48
PCI — Major advantages over thrombolytics:
1. Higher reperfusion rates (>90% success rate). 2. Decreased incidence of stroke. 3. More effective than thrombolytics in pts w/ acute decompensated HF, cardiogenic shock, and prior bypass surgery.
49
PCI — Major disadvantages over thrombolytics:
Not available in all hospitals.
50
Terminology — Primary PCI:
Pt w/ STEMI is taken directly to the catheterization lab for PCI instead of receiving thrombolytics.
51
Terminology — Rescue PCI:
Urgent PCI after failure to reperfuse w/ thrombolytics.
52
Terminology — Pharmacoinvasive PCI:
PCI after reperfusion w/ thrombolytics.
53
Approx. ...-...% of pts receiving thrombolytics fail to reperfuse and have high mortality rates. They have better outcomes if they then undergo rescue PCI.
20-30%.
54
Of note, ... suggests successful reperfusion after thrombolytic administration.
Accelerated idioventricular rhythm.
55
Medications NOT recommended for STEMI tx?
1. Empirical antiarrhythmics ==> Proph antiarrhythmic use can actually increase mortality in the peri-MI setting. 2. GpIIb/IIIa inhibitors ==> Only useful if undergoing PCI. Not useful in conjunction w/ thrombolytics.
56
12 complications of MI:
1. Bradyarrhythmias. 2. Mobitz I. 3. Mobitz II. 4. 3o AV block. 5. BBB. 6. Premature ventricular contractions. 7. V-tach or V-fib. 8. Papillary muscle rupture. 9. Ventricular septal rupture. 10. Ventricular free wall rupture. 11. RV infarct. 12. Pericarditis.
57
Bradyarrhythmias are usually seen in the first ...-... for all types.
24-48h.
58
Mobitz I is usually seen w/ ...
IMI ==> Ischemia or increased vagal tone. Conduction block usually in AV node.
59
Mobitz I may cause ...
Asx hypotension.
60
Mobitz I responds to ...
Atropine and usually resolves in 2-3 days.
61
Mobitz II is caused usually by ...
Anterior MI. Block typically INFRANODAL.
62
Mobitz II may cause ...
Asx hypotension.
63
Mobitz II needs ...
Temporary pacer b/c high risk for progression to complete block. ==> Many require permanent pacer.
64
3o degree block is caused by either ...
Anterior MI or IMI.
65
3o degree AV block is treated w/ ...
Permanent pacer usually required w/ AMI. Often resolves spontaneously w/ IMI.
66
BBB is usually caused by ...
Anterior MI.
67
BBB is usually seen during the first ...-... .
24-48h.
68
BBB - Tx?
Temporary pacer indicated for: 1. Alternating LBBB and RBBB. 2. RBBB w/ alternating Left Anterior Fascicular Block (LAFB) + LPFB. 3. LBBB or RBBB w/ 1o AV block. ***BBB a/w higher mortality.
69
Premature ventricular contractions are usually caused by ...
Any MI.
70
Premature ventricular contractions are usually caused during the first ...-... .
24-72h. Usually asx.
71
Tx for premature ventricular contractions:
1. Usually not required. 2. Avoid lidocaine (can incr. mortality). 3. Can use beta blockers.
72
V-tachy/V-fib are caused by ...
MI of any territoery, but commonly AMI.
73
V-tachy/V-fib are usually seen when?
VT in first 24h ==> Usually transient and benign. Late VT ==> Consider recurrent ischemia. Most VF occurs in first 48h.
74
Beta blockers ... the incidence of lethal VFs.
Decrease.
75
Papillary muscle rupture - Tx:
Intra-aortic balloon pump (IABP) ==> To help stabilize. Urgent surgery is required.
76
Ventricular septal rupture - Usually caused by which type of MI?
Both AMI and IMI.
77
Ventricular septal rupture may occur ...-... after MI.
1-20 days.
78
Ventricular free wall rupture may occur ...-... after STEMI.
2-14 days.
79
Which group is at highest risk for ventricular free wall rupture?
Elderly women.
80
Implantable defibrillators — Improve survival in pts w/ ...
Ischemic cardiomyopathy and low EF (even in the absence of V-arrhythmias).
81
Implantable defibrillators — Measure EF at least ... after MI in pts who are being treated w/ goal-directed medical HF tx. ICD indicated if EF
40 days. 30% 35%

Internal Medicine (106 decks)

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