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RCE Guidelines Studying > Laflamme- Chapter 2 (CAD and MI) > Flashcards

Laflamme- Chapter 2 (CAD and MI) Flashcards

1
Q

What are the 6 components of the Ischemic cascade?

A
  • Cellular Alterations
  • Perfusion Abnormalities
  • Relaxation Abnormalities
  • RWMA
  • ST changes
  • Angina
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2
Q

What is ‘high risk’, ‘intermediate risk, and ‘low risk’ for annual rates mortality based on NIV testing?

A
  • > 3%
  • 1-3%
  • <1%
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3
Q

What are 2 beta blockers with alpha and beta blockers?

A
  • Labetalol

- Carvedilol

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4
Q

What is the only selective beta blocker with ISA?

A

-Acebutolol

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5
Q

What is the only non selective beta blocker with ISA?

A

-Pindolol

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6
Q

Name 5 Beta-1 selective BB’s

A
  • Metoprolol
  • Bisoprolol
  • Atenolol
  • Acebutolol
  • Esmolol
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7
Q

Name 5 beta blockers that accumulate in renal failure?

A 
Nadolol
Sotalol
Atenolol
Bisoprolol
Acebutolol
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8
Q

How do Nitrates work?

A

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

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9
Q

How does Ivabradine work?

A

-sinus node (funny channel) blocker

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10
Q

How does Ranolazine work?

A

-Decreased myocyte calcium overload by Ina inhibition

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11
Q

What are the three mechanisms that Nicorandil works?

A
  • Opening of potassium channels of ischemic cells (mimics ischemic preconditioning)
  • Opening of potassium channels allowing systemic and coronary arterial vasodilation
  • Similar property to nitrates
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12
Q

How does Trimetazedine work?

A

-Fatty acid oxidation inhibitor

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13
Q

What is External counterpulsation?

A

-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

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14
Q

What is neuromodulation for angina?

A

-Spinal cord stimulation for decreased nociceptic transmission to CNS

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15
Q

How does Laser myocardial revacularization during cardiac surgery work?

A

-Creation of subendocardial channels by left intraventricular laser

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16
Q

What is SYNTAX cut off for CABG in 3VD? LMCA?

A
  • 3VD: 22

- LMCA: 32

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17
Q

What are the 3 biomarkers that increase with infarct? Timing of Initial elevation, peak and duration of each

A
  • Troponin: 3-12h, 24h, 7 days
  • CK: 3-12h, 24h, 48-72h
  • Myoglobin: 1-4h, 6h, 24h
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18
Q

What are the 5 types of MI?

A
  • 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
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19
Q

How does mortality of STEMI and NSTEMI compare?

A

Higher in hospital mortality for STEMI (by 50% more) but same at one year

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20
Q

What are the 7 aspects of the TIMI score?

A
  • Age > 65
  • 3 or more RFs
  • Multiple chest pain
  • ECG changes
  • Troponin elevation
  • ASA use in last week
  • Known CAD
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21
Q

What are the 9 aspects of the GRACE score?

A
  • Age
  • SBP
  • HR
  • Kilip class
  • HF
  • Arrest
  • Troponin
  • ECG/STD
  • Creatinine
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22
Q

What are three studies that support an early invasive strategy?

A
  • FRISC
  • RITA 3
  • TACTICS TIMI
23
Q

What is benefit of Early invasive strategy?

A

-Decreased MI, Hosp, Mortality

24
Q

Who would be a candidate for Early invasive strategy? (5)

A
  • Unstable Patient
  • Troponin+
  • Positive ECG
  • High risk (TIMI > 2, GRACE >140)
  • PCI < 6 months or history of CABG
25
Q

What is the MOA for Clopidogrel?

A

-Second generation Thienopyridine which acts as a irreversible ADP P2Y12 antagonist

26
Q

What is unique about the metabolism of Clopidogrel? What consequences can this have

A
  • 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.
27
Q

What is the MOA of Ticagrelor?

A

-It is a reversible direct P2Y12 antagonist with rapid onset of action

28
Q

What are three adverse effects of Ticagrelor?

A
  • Dyspnea
  • Bradycardia/Pauses
  • Creatinine increase (reversible)
29
Q

Name 3 contraindications for Ticagrelor use

A
  • Active bleeding
  • Severe liver disease
  • ICH history
30
Q

What is the MOA of Aspirin

A

-Irreversible inhibitor of COX-1 (and TXA synthesis)

31
Q

How do GPIIB/IIIA inhibitors work?

A

Blocks the formation of bridges between platelets (cross links between GPIIb/IIIa receptors and fibrinogen)

32
Q

What is the dose of UFH used in NSTEACS?

A

-60 IU/kg bolus then 12 IU/KG/Hour to achieve aPTT 1.5-2x

33
Q

How does LMWH work?

A

XA inhibitor and weak thrombin inhibitor (factor IIa inhibitor)

34
Q

What did the SYNERGY trial show?

A

-Enoxaparin vs. UFH -> increased bleeding during early invasive strategy with Enoxaparin

35
Q

How does Fondaparinux work?

A

-Indirect Xa inhibitor

36
Q

How does Bivalirudin work?

A

Thrombin inhibitor (factor IIa inhibitor)

37
Q

What are three trials that show decreased mortaility with Lytic compared to placebo?

A
  • ISIS 2
  • ASSET
  • GISSI
38
Q

What trial validated TNK?

39
Q

What are 8 absolute contraindications for lytic?

A
  • 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
40
Q

How does Prasugrel work?

A

-Third generation Thienopyridine, irreversible inhibition of P2Y12 receptor -> one step activation and metabolism is not affected by genetic polymorphisms or cytochrome P450 enzymes.

41
Q

What are reasons to avoid Prasugrel?

A

> 75 yo, <60 kg, history of TIA

42
Q

What trial showed that Enoxaparin is superior to UFH in STEMI (at cost of more bleeding)?

A

Extract Timi 25

43
Q

How to manage ICH in patients on ACS treatment?

A
  • 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)
44
Q

What are 4 reasons to avoid beta blocker in ACS?

A
  • Signs of HF
  • Signs of Cardiogenic Shock
  • PR > 240 msec
  • 2nd or 3rd degree AV block
45
Q

What are three contraindication to use Nitrates in ACS?

A
  • SBP < 90mmhg
  • PDE5 inhibitor use
  • RV infarct
46
Q

What are the clinical criteria for Cardiogenic shock? (4)

A
  • SBP < 90mmhg
  • Hypoperfusion
  • CI < 1.8 (2.2 with inotropic support)
  • LVEDP/Wedge > 18mmHg
47
Q

How much does IABP increase CO by?

48
Q

Where should an IABP sit on a CXR for good position?

A

-Tip of catheter at the level of the carina (>4 cm below the aortic knob)

49
Q

What are 5 contraindications for IABP placement?

A
  • Severe AR
  • Aortic Dissection
  • AAA
  • Severe PAD
  • Uncontrolled Sepsis
50
Q

What is the timing of LV free wall rupture?

A

-1 to 14 days post transmural infarction

51
Q

What are indications for PPM post Anterior MI?

A
  • 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
52
Q

What are typical results of EST with vasospastic angina?

A

1/3 negative, 1/3 STE, 1/3 STD

53
Q

How do you manage Vasospastic angina? (Lifestyle and medical)

A
  • Smoking cessation
  • Mg supplementation
  • Nitrates
  • Prazosin
  • CCB
54
Q

4 RFs for coronary vasospasm?

A
  • Smoking
  • Raynauds
  • Migraine
  • Meds: Cocaine, Chemo (5FU, Cyclophosphamide)

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