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Clinical Pop > Lecture 4 > Flashcards

Lecture 4 Flashcards

1
Q

Unstable Angina Pectoris

A
  • unexpected chest pain due to ischemia
  • transientive secclusion (<10 min)
  • followed by spontaneous thrombolysis
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2
Q

Myocardial Infarction

A
  • persisting vessel occlusion ( >60 min)

- resulting in death of myocardial muscle cells

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3
Q

Difference between Unstable Angina Pectoris and Myocardial Infarction

A

disruption of myocyte membrane

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4
Q

Types of Angina

A

Stable and Unstable

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5
Q

Stable Angina

A
  • more common form
  • occurs at given activity level or level of mental stress
  • fibrous cap not ruptured
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6
Q

Unstable Angina

A
  • new onset
  • unpredictable
  • fibrous cap ruptures
  • may lead to heart attack
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7
Q

History of Myocardial Infarction affected:

A

16 million Americans

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8
Q

History of Angina affected

A

~9 million Americans

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9
Q

New acute coronary syndrome affects

A

785,000/year

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10
Q

Recurrent incidents affect

A

470,000/year

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11
Q

Silent Myocardial Infarction affects:

A

195,000/year

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12
Q

Total costs for heart diseases in 2007

A

177.5 billion

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13
Q

Coronary Circulation supplies

A

myocardium with Oxygen

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14
Q

Coronary Circulation in Coronary Arteries

A 
-off the root of aorta
RIGHT CORONARY ARTERY
---RCA
---right atrium and ventricle
LEFT CORONARY ARTERY
---splits
------anterior descending
-----------LAD
------circumflex artery
-----------LCx
---left atrium and ventricle
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15
Q

Coronary Blood Flow (Blood Flow and Metabolism)

A
  • rest
  • —60-90ml/min/100 g
  • exercise
  • —-5-6 times higher
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16
Q

ATP Generation

A
  • mostly aerobic
  • myocardial oxygen uptake
  • –rest: 8 - 10 ml/min/100 g
  • –exercise: 2 - 3 times higher
  • –indirect indicator: RPP
17
Q

Ischemia

A

-O2 supply < O2 demand

ISCHEMIC CASCADE

  • stiffness of left ventricle
  • systolic dysfunction
  • localized hypokinesis
  • left ventricle ejection fraction decreases
  • arrhythmia
  • angina pectoris

SILENT ISCHEMIA

18
Q

risk factors of atherosclerosis

A
  • age
  • male sex
  • family history and genetics
  • smoking
  • pre-diabetes and diabetes
  • obesity
  • metabolic syndrome
  • hypertension
  • dyslipidemia
  • physical inactivity
  • psycho-social factors
  • homocysteine
  • c-reactive protein
  • inflammatory protein
  • fibrinogen
19
Q

Pathophysiology of Atherosclerosis [PROGRESSIVE]

A
  1. Endothelial dysfunction
  2. LDL-C accumulation and oxidation in arterial wall
  3. Injury and inflammation
  4. Monocyte binding and entry into cell
  5. Monocyte differentiation into macrophage
  6. Macrophage engulfs oxidized LDL and creates foam cell
  7. plaque maturation and calcification
20
Q

Trigger for Myocardial Infarction

A
  • exertion
  • emotional stress
  • sympathetic activation [heart rate variability and prognosis]
  • surgery causing blood loss
21
Q

Pathophysiology of Myocardial Infarction

A
  • plaque rupture rulceration in coronary artery
  • –bifurcations
  • thrombosis (blood clotting)
  • blood flow acculsion
  • necrosis of downstream myocardium
  • –protein synthesis
  • —-cardiac tropinin
  • dysrhythmia
  • –ventricular fibrillation
  • –ventricular tachycardia
  • potentially death
22
Q

Complications of Acute Myocardial Infarction

A
  • arrythmias
  • conduction abnormalities
  • cardiogenic shock
  • infarct extension or expansion
  • myocardial rupture
  • new mitral valve regurgitation
  • pericardial effusion and pericarditis
  • post-infarction syndrome
  • left ventricular mural thrombus
23
Q

Prognosis of Acute Myocardial Infarction

A

Factors associated with poor prognosis

  • LIVEF < 5 METs
  • evidence of extensive myocardial ischemia during exercise or pharmacologic stress testing
  • having survived sudden cardiac death
  • servere non-revascularized CAD
24
Q

Protocols from Prognostic GXT-Predischarge

A
  • <7 days post myocardial infarction
  • sub maximal before discharge
  • termination
  • —HRpeak: 120-130
  • —70% age-predicted HRmax
  • —achieving 5 METs
25
Q

Protocols from Prognostic GXT-Symptom Discharge

A
  • 2-3 post-discharge
  • may be combined with nuclear imaging and echocardiogram
  • stronger prognosis evidence
  • –expired gases
26
Q

Long Term Treatment

A
  • medication

- cardiac rehab

27
Q

Cardiac Rehabilitation Multifactoral Program

A
  • exercise training
  • education
  • some times
  • –dietary management
  • –psychological counseling
  • —–depression,stress
  • –smoking cessation
28
Q

Cardiac Rehabilitation Outcomes

A
  • better prognosis
  • –survival; revascularization, subsequent MI
  • better risk factor profile
  • less signs and symptoms
  • improved functional capacity
  • better quality of life
  • return to work and normal lifestyle
  • can be homebased
29
Q

Phases of Cardiac Rehab-Impatient

A

HOSPITAL STAY AFTER MI

  • 2-3 days
  • longer with complications

COMPONENTS

  • avoid bed rest, early ambulation
  • maintain upright posture
  • range of motion exercises
30
Q

Phases of cardiac Rehab-Outpatient

A

should start within two weeks after discharge

31
Q

Outpatient Cardiac Rehab-Multifactorial Program

A
  • exercise training with continuous ECG training
  • education
  • some times
  • —-dietary management
  • —psychological counseling (depression, stress)
  • —smoking cessation
32
Q

The Role of Exercise: Primary Prevention

A

preventing MIs prior to happening

33
Q

The Role of Exercise: Secondary Prevention

A

preventing adverse events after first MI

34
Q

Physical Activity and Risk for MI

A
  • inverse curvilinear relationship
  • populations risk may be reduced dramatically if sedentary people become modestly active
  • pysically inactive people 45% greater risk for developing CAD than active people
35
Q

Exercise and Risk for Subsequent MI

A
  • patients hospitalized for heart attack

- those who were more active had 55% lower risk for another myocardial infarction compared to sedentary

36
Q

GXT prior to Outpatient Cardiac Rehab

A
  • symptom-limited
  • 2-3 weeks following discharge
  • protocol based on
  • —physical examination
  • —risk stratification
  • ramping protocols common
  • record level at which signs or symptoms occurred
  • —angina;dyspnea; 1 mm ST-segment depression
  • –usefulness of RPP
  • —–HR*SBP
  • —–myocardial oxygen demand
37
Q

Exercise Prescription

A
  • impatient rehab
  • initial home prescription
  • outpatient cardiac rehab
  • —-initial assessment
  • —-secondary prevention goals
  • individualized based on
  • –functional capacity
  • –ischemic angina/thresholds
  • –comorbidities
  • –physical activity preferences
  • –vocational requirements
  • –patient goals
38
Q

Aerobic Exercise Program

A 
FREQUENCY: 3-7 days/weel
INTENSITY IF NO GXT
-HR: +20BPM above rest
-RPE: 11-14
BASED ON GXT RESULTS
-40-80% HRR or VO2
-RPE: 11-16
-below ischemic threshold 
---1mm ST-segment depression
DURATION
-start with 5-10 minutes
-gradually progress to 20-60 min
TYPE
-large muscle rhythmic activity

Clinical Pop (6 decks)

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