Laflamme- Chapter 2 (CAD and MI) Flashcards
What are the 6 components of the Ischemic cascade?
- Cellular Alterations
- Perfusion Abnormalities
- Relaxation Abnormalities
- RWMA
- ST changes
- Angina
What is ‘high risk’, ‘intermediate risk, and ‘low risk’ for annual rates mortality based on NIV testing?
- > 3%
- 1-3%
- <1%
What are 2 beta blockers with alpha and beta blockers?
- Labetalol
- Carvedilol
What is the only selective beta blocker with ISA?
-Acebutolol
What is the only non selective beta blocker with ISA?
-Pindolol
Name 5 Beta-1 selective BB’s
- Metoprolol
- Bisoprolol
- Atenolol
- Acebutolol
- Esmolol
Name 5 beta blockers that accumulate in renal failure?
Nadolol Sotalol Atenolol Bisoprolol Acebutolol
How do Nitrates work?
Converted to NO in the cell -> increased intracellular cGMP -> smooth muscle relaxation (by decreasing intracellular Ca2+) -> results in venoldilation, coronary vasodilation and systemic arterial vasodilation
How does Ivabradine work?
-sinus node (funny channel) blocker
How does Ranolazine work?
-Decreased myocyte calcium overload by Ina inhibition
What are the three mechanisms that Nicorandil works?
- Opening of potassium channels of ischemic cells (mimics ischemic preconditioning)
- Opening of potassium channels allowing systemic and coronary arterial vasodilation
- Similar property to nitrates
How does Trimetazedine work?
-Fatty acid oxidation inhibitor
What is External counterpulsation?
-35 one hour treatments for 7 weeks, there are cuffs on the lower limbs that inflate in early diastole and deflate in pre-systole, this will increase collateral circulation and or angiogenisis and improvement of endothelial function
What is neuromodulation for angina?
-Spinal cord stimulation for decreased nociceptic transmission to CNS
How does Laser myocardial revacularization during cardiac surgery work?
-Creation of subendocardial channels by left intraventricular laser
What is SYNTAX cut off for CABG in 3VD? LMCA?
- 3VD: 22
- LMCA: 32
What are the 3 biomarkers that increase with infarct? Timing of Initial elevation, peak and duration of each
- Troponin: 3-12h, 24h, 7 days
- CK: 3-12h, 24h, 48-72h
- Myoglobin: 1-4h, 6h, 24h
What are the 5 types of MI?
- Type 1: Plaque rupture
- Type 2: Demand mismatch
- Type 3: Cardiac Arrest
- Type 4: a) secondary to PCI b) secondary to ISR
- Type 5: CABG
How does mortality of STEMI and NSTEMI compare?
Higher in hospital mortality for STEMI (by 50% more) but same at one year
What are the 7 aspects of the TIMI score?
- Age > 65
- 3 or more RFs
- Multiple chest pain
- ECG changes
- Troponin elevation
- ASA use in last week
- Known CAD
What are the 9 aspects of the GRACE score?
- Age
- SBP
- HR
- Kilip class
- HF
- Arrest
- Troponin
- ECG/STD
- Creatinine
What are three studies that support an early invasive strategy?
- FRISC
- RITA 3
- TACTICS TIMI
What is benefit of Early invasive strategy?
-Decreased MI, Hosp, Mortality
Who would be a candidate for Early invasive strategy? (5)
- Unstable Patient
- Troponin+
- Positive ECG
- High risk (TIMI > 2, GRACE >140)
- PCI < 6 months or history of CABG
What is the MOA for Clopidogrel?
-Second generation Thienopyridine which acts as a irreversible ADP P2Y12 antagonist
What is unique about the metabolism of Clopidogrel? What consequences can this have
- It’s a prodrug, which requires 2 metabolism and activation steps through the cytochrome P450 (Genetic Polymorphisms in this enzyme in patients of asian decent)
- This can result in these individuals having ‘clopidogrel resistance’ where less than standard (50-60%) platelets are inhibited.
What is the MOA of Ticagrelor?
-It is a reversible direct P2Y12 antagonist with rapid onset of action
What are three adverse effects of Ticagrelor?
- Dyspnea
- Bradycardia/Pauses
- Creatinine increase (reversible)
Name 3 contraindications for Ticagrelor use
- Active bleeding
- Severe liver disease
- ICH history
What is the MOA of Aspirin
-Irreversible inhibitor of COX-1 (and TXA synthesis)
How do GPIIB/IIIA inhibitors work?
Blocks the formation of bridges between platelets (cross links between GPIIb/IIIa receptors and fibrinogen)
What is the dose of UFH used in NSTEACS?
-60 IU/kg bolus then 12 IU/KG/Hour to achieve aPTT 1.5-2x
How does LMWH work?
XA inhibitor and weak thrombin inhibitor (factor IIa inhibitor)
What did the SYNERGY trial show?
-Enoxaparin vs. UFH -> increased bleeding during early invasive strategy with Enoxaparin
How does Fondaparinux work?
-Indirect Xa inhibitor
How does Bivalirudin work?
Thrombin inhibitor (factor IIa inhibitor)
What are three trials that show decreased mortaility with Lytic compared to placebo?
- ISIS 2
- ASSET
- GISSI
What trial validated TNK?
-Assent-2
What are 8 absolute contraindications for lytic?
- History of ICH
- Any CNS lesion/AVM/Tumor
- Active bleeding
- Aortic dissection
- Facial injury/fracture
- Severe refractory hypertension
- Intracranial or spinal surgery within 2 months
- Stroke within 3 months
How does Prasugrel work?
-Third generation Thienopyridine, irreversible inhibition of P2Y12 receptor -> one step activation and metabolism is not affected by genetic polymorphisms or cytochrome P450 enzymes.
What are reasons to avoid Prasugrel?
> 75 yo, <60 kg, history of TIA
What trial showed that Enoxaparin is superior to UFH in STEMI (at cost of more bleeding)?
Extract Timi 25
How to manage ICH in patients on ACS treatment?
- Stop all blood thinners
- Brain imaging
- Neuro consult
- 10 units cryo, 2 units FFP, Protamine (1mg for every 100units heparin over 4 hours), transfuse platelets
- Decrease ICP (Hyperventilation, Mannitol, HOB to 30)
What are 4 reasons to avoid beta blocker in ACS?
- Signs of HF
- Signs of Cardiogenic Shock
- PR > 240 msec
- 2nd or 3rd degree AV block
What are three contraindication to use Nitrates in ACS?
- SBP < 90mmhg
- PDE5 inhibitor use
- RV infarct
What are the clinical criteria for Cardiogenic shock? (4)
- SBP < 90mmhg
- Hypoperfusion
- CI < 1.8 (2.2 with inotropic support)
- LVEDP/Wedge > 18mmHg
How much does IABP increase CO by?
10-15%
Where should an IABP sit on a CXR for good position?
-Tip of catheter at the level of the carina (>4 cm below the aortic knob)
What are 5 contraindications for IABP placement?
- Severe AR
- Aortic Dissection
- AAA
- Severe PAD
- Uncontrolled Sepsis
What is the timing of LV free wall rupture?
-1 to 14 days post transmural infarction
What are indications for PPM post Anterior MI?
- 2nd degree AV block with alternating branch block
- Complete heart block
- Persistent 2nd or 3rd degree heart block with symptoms
- High grade transient infranodal 2nd degree or 3rd degree heart block with associated branch block
What are typical results of EST with vasospastic angina?
1/3 negative, 1/3 STE, 1/3 STD
How do you manage Vasospastic angina? (Lifestyle and medical)
- Smoking cessation
- Mg supplementation
- Nitrates
- Prazosin
- CCB
4 RFs for coronary vasospasm?
- Smoking
- Raynauds
- Migraine
- Meds: Cocaine, Chemo (5FU, Cyclophosphamide)
