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PNS/Cardiology > Patient with Coronary Artery Disease/Acute Coronary Syndrome > Flashcards

Patient with Coronary Artery Disease/Acute Coronary Syndrome Flashcards

1
Q

What causes myocardial ischemia?

A

Myocardial O2 demands are greater than supply

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2
Q

How does myocardial ischemia differ from myocardial infarction?

A

Ischemia - inadequate oxygen supply to meet demands

Infarction - irreversible necrosis of myocardium that results from prolonged ischemia

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3
Q

What factors determine myocardial oxygen supply?

A

Coronary blood flow

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4
Q

What factors determine myocardial oxygen demand?

A

Heart rate
Contractility
Wall tension (proportional to pressure and volume)

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5
Q

What are the events of the myocardial ischemic cascade,?

A

Ischemia
Switch from aerobic to anaerobic metabolism
Relaxation abnormalities (energy dependent process)
Contraction abnormalities (energy dependent process)
ECG ST changes
Angina

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6
Q

What are the clinical presentations that result from myocardial ischemia?

A

Chronic stable angina
Prinzmetal’s (variant) angina
Acute coronary syndrome

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7
Q

Describe the character and location of chronic stable angina

A

“Visceral” deep discomfort, touches sternum

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8
Q

What precipitates and relieves chronic stable angina?

A

Precipitates: stress (emotional or exertional)

Relieved by: stopping the stress

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9
Q

What is the most common cause of typical effort-related angina?

A

Fixed atherosclerotic lesion narrows a coronary artery (O2 demands > O2 supply)

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10
Q

What are the major risk factors for coronary artery disease?

A 
Hypercholesterolemia
Hypertension
Smoking
Diabetes
Age
Family history
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11
Q

What are the 3 clinical characteristics of Prinzmetal’s angina?

A

Spontaneous (rest) pain
Transient ST segment elevation
Absence of effort pain/not induced by exertion

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12
Q

What is the cause of Prinzmetal’s angina?

A

Coronary artery spasm

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13
Q

What is the treatment of Prinzmetal’s angina?

A

Nitrates or Calcium channel blockers

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14
Q

What are the three subgroups of acute coronary syndrome (acute myocardial ischemia)?

A

STE MI
NSTE MI
Unstable angina

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15
Q

Which of the three presentations of acute coronary syndrome have actual myocardial tissue death?

A

STEMI
NSTEMI

Tissue death makes it a myocardial infarction, otherwise is termed unstable angina.

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16
Q

What is the common cause of acute coronary syndromes?

A

Atherosclerotic plaque rupture, thrombus formation, and coronary occlusion

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17
Q

What are typical symptoms of acute coronary syndrome?

A

Chest pain at rest
Levine’s sign (fist to chest)
Diaphoresis (sweating)

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18
Q

Which type of MI (STEMI or NSTEMI) has greater coronary vessel occlusion?

A

STEMI (red thrombus is more occlusive and longer lasting than white thrombus)

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19
Q

What type of thrombus typically causes NSTEMI/unstable angina?

A

White thrombus

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20
Q

What causes a white thrombus to form?

A

Released collagen causes platelet aggregation

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21
Q

What type of thrombus typically causes STEMI?

A

Red thrombus

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22
Q

What causes a red thrombus to form?

A

Released tissue factor causes red blood cells and fibrin to aggregate

23
Q

How do women present with acute coronary syndrome?

A

Atypical: Shoulder or neck pain, dyspnea, fatigue

24
Q

What does ST segment depression indicate?

A 
Subendocardial ischemia (inner wall)
Transient
25
Q

What does ST segment elevation indicate?

A

Transmural ischemia or infarction

26
Q

What does pathologic Q wave indicate?

A

Prior infarction

27
Q

Which EKG leads will indicate involvement of inferior wall of the heart and which coronary artery does this suggest?

A

2, 3, avF

right coronary artery (RCA)

28
Q

Which EKG leads will indicate involvement of lateral wall of the heart and which coronary artery does this suggest?

A

1, avL, V6

left circumflex coronary artery

29
Q

Which EKG leads will indicate involvement of anterior wall of the heart and which coronary artery does this suggest?

A

V2-V5

left anterior descending (LAD) coronary artery

30
Q

What cardiac enzymes are released upon acute myocardial cell death?

A

Myoglobin
Creatine kinase
Creatine kinase-MB
Troponin T & I

31
Q

Which cardiac enzyme is most sensitive and specific in making a diagnosis of MI and why?

A

Troponin

Because it stays in circulation for 7-10 days, can tell if patient had an event recently

32
Q

What qualifies as a positive EKG exercise stress test?

A

ST segment depression of 1 mm or more

33
Q

What are high risk markers during an EKG exercise stress test?

A

Early onset low HR (7 min)
Large amount of ST depression (>2 mm)
Multiple leads involved - suggest large area of ischemia
Hypotension - if BP does not go up when exercising, indicates large area of ischemia (walls can’t contract, stroke volume goes down)

34
Q

What should you do if a patient exhibits high risk markers during an EKG exercise stress test?

A

Take them to the cath lab for revascularization

35
Q

What does a transient cold spot indicate in a nuclear exercise test?

A

Ischemia

36
Q

What does a fixed cold spot indicate in a nuclear exercise test?

A

Infarction

37
Q

How can you pharmacologically do a stress test?

A

Dobutamine (beta1 agonist - increase BP and HR)

Adenosine (arteriolar vasodilation - increased flow to normoxic areas)

38
Q

What does a transient abnormality during an exercise echo indicate?

A

Ischemia

39
Q

What does a fixed abnormality during an exercise echo indicate?

A

Infarction

40
Q

What are two revascularization techniques?

A

PCI (percutaneous coronary intervention) = angioplasty +/- stent

CABG (coronary artery bypass graft)
- Usually done with saphenous vein or internal mammary artery (IMA is better)

41
Q

What drug is the cornerstone of therapy for coronary artery disease?

A

Nitrates

42
Q

How do nitrates help in coronary artery disease?

A

Cause peripheral venous dilation –> blood pooling in legs –> decrease in ventricular volume (preload) –> decrease wall tension –> decrease O2 demands

Can also increase subendocardial flow

43
Q

What are side effects of nitrates?

A

Headache
Hypotension
Reflex tachycardia
Tolerance

44
Q

What should you do when patient gets syncope due to decreased BP after taking nitrates?

A

Raise legs to get blood back to head

45
Q

How do beta blockers help in coronary artery disease?

A

Decrease HR

Also decrease contractility and wall tension

46
Q

What are side effects of beta blockers?

A

Fatigue
Heart failure
Excessive bradycardia
Bronchoconstriction

47
Q

When should you use calcium blockers for coronary artery disease?

A

When other drugs (nitrates and beta blockers) don’t work

48
Q

What clinical presentation of acute myocardial ischemia are calcium blockers especially helpful for?

A

Prinzmetal’s angina

49
Q

What is the most important medication in coronary artery disease?

A

Aspirin

50
Q

What is the “wavefront” phenomenon of necrosis?

A

The longer a vessel is occluded, the more necrosis of myocardium
Inner endocardium is most vulnerable and necrosis will begin there and spread out to the epicardium

51
Q

When are fibrinolytics indicated?

A

Angina with ST segment elevation within 12 hours of onset

Angina with Left bundle branch block (LBBB - cannot interpret ST segment) within 12 hours of onset

52
Q

Should you use fibrinolytics with NSTEMI or unstable angina?

A

No

53
Q

When should you give fibrinolytics before going to the cath lab to revascularize?

A

If time to cath lab is >90 minutes

PNS/Cardiology (33 decks)

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