Lecture 11 - Ischemic Heart Disease Part 3 Flashcards
Review: what is prinzmetal angina
Spasm of the large coronary arteries → decreased coronary blood flow
can occur spontaneously or may be induced by cold, stress, or meds.
Remember MI may occur as a result of the spasm in the absence of visible obstructive CHD
review: what can induce myocardial ischemia and infarction by causing vasoconstriction or increasing myocardial energy requirement
cocaine!
may contribute to accelerated atherosclerosis and thrombus!
review: what is the typical presentation of prinzmetal / vasospastic angina
- Chest pain occurs without the usual precipitating factors
- Associated with ST-segment elevation rather than depression
- Often affects women under 50
- Characteristically occurs in the early morning, awakening patients from sleep
- Associated with arrhythmias or conduction defects
- No CAD on cardiac catheterization
review: how should you manage prizmetal / vasospastic angina
- if they have associated ST elevation, they should undergo emergent coronary arteriography
- if stenosis found, do revascularization
- if no significant lesions are found and spasms are suspected, then you should avoid precipitants such as:
- cigarettes
- cocaine
review: what is used for prinzmetal/vasospastic angina symptoms
- nitrates
- CCB added for chronic therapy
- BB ARE TYPICALLY NOT USED d/t exacerbated coronary vasospasms
review: what is the suggested general tx for ishcemia or infarction on arrival to the ED
- morphine
- O2 4L NC
- NTG SL
- ASA 160-325
how do ischemic post-MI complications manifest
- angina
- reinfarction
- infarct extension
how do mechanical post-MI complications manifest
- heart failure
- cardiogenic shock
- mitral valve dysfunction
- aneurysms
- cardiac rupture
- cardiac tamponade
how do arrhythmic post-MI complications manifest
- atrial or ventricular arrhythmias
- sinus or atrioventricular node dysfunction
how do embolic post-MI complications manifest
- CNS (stroke)
- peripheral embolization
how do Inflammatory post-MI complications manifest
pericarditis
what is dressler’s syndrome
- aka postpericardiotomy, post-MI syndrome, and post cardiac injury sydrome
- this is a type of pericarditis that occurs post-MI or CABG (1-12 weeks post MI)
what are the symptoms of Dressler’s syndrome and what is it caused by
- symptoms are CP and fever
- Believed to be caused by an immune system mediated inflammatory response following damage to heart tissue or the pericardium
How common is RV infarction and how does it present
- 1/3 of patients with inferior wall infarction
- presents as hypotension with relatively preserved LV function
when should RV infarction be considered
whenever patients with inferior infarction present with hypotension, elevated venous pressure, and clear lungs (which is different than LV failure from anterior MI)
how do you treat RV infarction
- tx hypotension with IV saline (bolus then continuous infusion)
- use inotropic agents if necessary
- hypotension can be made WORSE by nitrates and morphine
where is ventricular Free-wall rupture MC? who is it MC in?
- MC in the anterior or lateral wall of the LV
- associated with elderly patients, poor collateral circulation, ischemic preconditioning and first MI
what is the timeline of ventricular free-wall rupture? How does it present?
- Can occur 1-4 days post-MI, but most commonly w/in 24 hours
- presents as pericardial effusion or pulseless electrical activity
- mortality rate is EXTREMELY HIGH
what is Post-MI ventricular septal defect? (rare/common, timeline, association, mortality rate)
- a rare post MI complication ocurring a few days following initial cardiac event
- associated with transmural MI involving the septum
- Mortality rate is high without surgical intervention.
What is MV regurg from ruptured papillary muscle? (rare/common, timeline, presentation, mortality rate)
- rare complication
- typically occurs 2-7 days post-MI
- presents as sudden onset
- mortality rate high w/o surgical intervention
what big changes should occur in a patients life after a cardiac event
- Dietary changes
- Implementation of an exercise regimen
- Addition of appropriate medications
- Increased frequency/number of follow up care visits
what should detailed discharge instructions include?
- medication education
- diet education
- exercise ed
- smoking cessation counseling ed
- referral to rehab/secondary prevention program
- specific instructions on activities that are permissible and activities that should be avoided.
- ALWAYS address instruction on permissible/avoidance of driving, returning to work, and sexual activity!
when should a high risk v low risk post MI patient follow up?
- low risk - 4-6 weeks
- high risk - 1-2 weeks
what general diet changes should Post MI patients make
- limit intake of saturated and trans fatty acids, free sugars, and salt
- increase fruits, veggies, legumes, nuts and whole grains
- ex. is ornish diet/lifestyle (diet/lifestyle rich in powerful foods for anti-cancer anti-heart disease ect)
what is the exercise reccomendation post MI
- 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
- patients should be able to increase intensity and duration of exercise with time
what are some psychosocial issues that you may see in a patient Post-MI
- Debility / Decreased exercise tolerance
- Activity / Recreation
- Depression (cardiac blues)
- Sexual activity
- Work / Driving
what are the cardiac blues?
- Many patients experience a strong emotional reaction at the time of or soon after an acute cardiac event
- 3x more common in patients after an MI than in the general population (15-20% of MI victims qualify for.a dx of MDD)
- cardiac blues are associated with increased MI repeat risk and increased risk of dying over the ensuing months/years
what are some characteristics of cardiac blues that could lead to poor prognosis after a MI
- 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
what factors into sexual activity in post-MI patients?
- 1/2 to 3/4 patients have deceased libido or less satisfaction in sex after MI
- contributors to this could be drug SE (BB), depression, fear of triggering another MI
when is sexual activity resumption recommended in complicated v uncomplicated MIs
- > 1 week after uncomplicated MI if pt is w/o cardiac symptoms during activity
- 2-3 weeks after complicated MI as long as asymptomatic!
what makes an MI complicated
- Associated CPR
- hypotension/shock
- HF
- arrhythmias
who is at intermediate-to high-risk of heart-related problems during sex
- patients with recurrent CP, arrhythmias, or HF
- these pts need further evaluation and/or treatment before attempting to have intercourse
- remember!!! they can have ED meds but NO PDE-5 INHIBITORS + NITRO!!!
what is included in cardiac rehab and what is the goal?
- includes Exercise, education to help reduce risk factors, counseling for stress, anxiety and depression
- The program can improve cardiac function and reduce mortality / development of complications
