Laflamme- Chapter 2 (CAD and MI) Flashcards by Navraj Malhi

What are the 6 components of the Ischemic cascade?

Cellular Alterations
Perfusion Abnormalities
Relaxation Abnormalities
RWMA
ST changes
Angina

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

> 3%
1-3%
<1%

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What are 2 beta blockers with alpha and beta blockers?

Labetalol

- Carvedilol

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What is the only selective beta blocker with ISA?

-Acebutolol

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What is the only non selective beta blocker with ISA?

-Pindolol

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Name 5 Beta-1 selective BB’s

Metoprolol
Bisoprolol
Atenolol
Acebutolol
Esmolol

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Name 5 beta blockers that accumulate in renal failure?

Nadolol
Sotalol
Atenolol
Bisoprolol
Acebutolol

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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

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How does Ivabradine work?

-sinus node (funny channel) blocker

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How does Ranolazine work?

-Decreased myocyte calcium overload by Ina inhibition

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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

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How does Trimetazedine work?

-Fatty acid oxidation inhibitor

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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

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What is neuromodulation for angina?

-Spinal cord stimulation for decreased nociceptic transmission to CNS

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How does Laser myocardial revacularization during cardiac surgery work?

-Creation of subendocardial channels by left intraventricular laser

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

3VD: 22

- LMCA: 32

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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

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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

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How does mortality of STEMI and NSTEMI compare?

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

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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

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What are the 9 aspects of the GRACE score?

Age
SBP
HR
Kilip class
HF
Arrest
Troponin
ECG/STD
Creatinine

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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)