MTB Flashcards
What is the worst risk factor for CAD
Diabetes mellitus
What is the most common risk factor for CAD
HTN
Risk factors for CAD
Diabetes mellitus Tobacco smoking HTN Hyperlipidemia FHX - Premature CAD in first degree (M 45, Females >55
Correcting which risk factor has greatest immediate improvement
Stoping smoking
Most dangerous component of lipid profile for CAD
Elevated LDL
Low HDL = poor long-term prognosis
Presentation of Tako-Tsubo Cardiomyopathy
Acute myocardial damage Postmenopausal women Follows stressful event Ballooning and LV dyskinesis Massive catecholamine discharge
TX for Tako-Tsubo Cardiomyopathy
Beta blockers
ACE-I
Unreliable risk factors for CAD
Wrong answers
Elevated homocysteine, CRP
Chlamydia Infxn
Presentation of Inferior Wall ischemia
Vagal reflexes Bradycardia HypoTN Dizziness Fainting
Presentation of ischemic pain
Dull/sore Squeezing/pressure-like Substernal Lasts 20-30 mins Can radiate to neck/arm Sometimes w exertion
Chest pain that is NOT ischemic presentation
Sharp/Pointlike Lasts a few seconds Right or left sided Pleuritic Positional Tender
Chest pain w chest wall tenderness
Most accurate next test?
Costochondritis
PE
Chest pain radiating to back + unequal BP in arms
Most accurate next test?
Aortic Dissection
- Can also present as tearing, sharp pain, radiating to in b/t scapula
CXR shows widened mediastinum
CT, MRI, TEE = confirm
Chest pain worse w lying flat, better sitting up
Most accurate next test?
Pericarditis
EKG shows ST elevation all leads, PR depression
Chest pain worse w inspiration?
Costochondritis
Epigastric discomfort + pain relieved with eating
Test?
Duodenal Ulcer Dz
Endoscopy
Bad taste, cough, hoarseness
Test?
GERD
Response to PPI’s, Al OH, Mg OH
Cough, sputum, hemoptysis
Test?
Pneumonia
CXR
Sudden onset SOB, tachycardia, hypoxia
Test?
PE
Spiral CT
V/Q scan for pregnant women
Sharp, pleuritic pain, tracheal deviation
Test?
Pneumothorax
CXR
How does aortic stenosis present?
Worst prognosis
Angina
Syncope
CHF = worst prognosis
Causes of Pleuritic pain
PE Pneumonia Pericarditis Pneumothorax (PTX) Pleuritis
CKMB
Begin? Peak? Normalizes?
Begins @ 4 hours
Peaks @ 12 hours
Normalizes 3-4 days
Best cardiac enzyme reinfarction
CKMB
Troponin
Accumulates in what pts?
Normalizes?
Pts with renal failure and seizures
2 weeks to normalize
What factors must be present to do a stress test?
- Can read the EKG
2. Pt can exercise = HR > 80% of maximum
Which drugs impact validity of stress test
Beta blockers
Digoxin
High False Positive rates seen in who with stress tests
Asymptomatic young females
High False Negative rates seen in who with stress tests
Pts with known CAD
Workup if positive stress test
Angiogram
- If 3 Vessel DZ or Left Main -> CABG
- If 1 or 2 Vessel dz -> Angioplasty
How to differentiate ischemia v. infarction
Reperfusion images at rest
- Ischemia detected by reversal of decrease in thallium uptake or wall motion returning to normal after rest
Testing for pt that cannot exercise in CAD
Persantine (dipyridamole) OR adenosine with nuclear isotopes (thallium, sestamibi)
Dobutamine Echo
When do we do angiography
What is done
Detect location of CAD
Radiopaque contrast dye injected into blood vessels - imaging w X-ray
Most accurate method to detect CAD
Angiography
When do we use Holter
Rhythm disorders
A fib, A flutter, ectopy - PVCs, V tach
Drugs that lower mortality in chronic Angina
ASA
Beta blockers
Nitroglycerin
Which drugs lower mortality in CAD
ASA Beta blockers Angioplasty TPA Clopidogrel Statins IF LDL > 100 ACE-Inhibitors IF decreased EF
Route of admin of nitroglycerin in chronic Angina
Oral
Transdermal patch
Route of admin of nitroglycerin in acute coronary syndromes
Sublingual
Paste
IV
When is Clopidogrel used
ASA intolerance
Recent angioplasty w stenting
AEs of Prasugrel
Hemorrhagic stroke
AEs of Ticlopidine
Neutropenia
When to use Ticlopidine
Pt allergic to ASA and Clopidogrel
Do ACE I or ARBs cause hyperkalemia
Both b/c they inhibit Aldosterone, which excretes K+ from distal tubule
MOA of Hydralazine
Impact on afterload/preload
Mortality benefit?
Direct acting arterial vasodilator
Decreases Afterload
Mortality benefit in Systolic dysfunction
Used w nitrates to dilate coronary arteries
What is goal LDL in CAD pts?
Less than 100 mg/dL
Which lipid do lifestyle modifications improve the most
HDL
Impact of weight loss on BP
For every kg lost = 1 mmHg Reduction
What are CAD equivalents
PAD
Aortic disease
Diabetes mellitus
Carotid dz
MC AE of statins
Liver Dysfunction
- Test all pts AST and ALT
Rhabdomyolysis = much less common
Statins MOA - 2
- Inhibit HMG-Co A Reductase (RLE in cholesterol synthesis)
2. Antioxidant effect on endothelial ling of coronary arteries
Niacin ass’d with
Glucose intolerance
Elevation of uric acid
Histamine release = itching
Gemfibrozil, Fibric Acid Derivatives
AE
Lower TGs
Myositis
Cholestyramine
AE
GI AE’s
Which drug is NOT used in CAD
DHP CCB’s (Nifedipine, Amlodipine)
- Raise HR = increase myocardial O2 demand
- Reflex tachycardia
When are NDHP CCB’s used in CAD?
Which ones are they?
Severe Asthma
Prinzmetal Angina
Cocaine-induced chest pain
Verapamil, Diltiazem
AE’s of CCBs
Edema
Constipation
Heart block
Indications for CABG
- Three vessel disease
- Left main Coronary occlusion
- Two vessel disease + Diabetes
- Persistent Sx’s despite maximal medical management
Best therapy in acute coronary syndrome
PCI/Angioplasty
