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Block 9 Week 1 Meg > Patterson: Case Studies > Flashcards

Patterson: Case Studies Flashcards

1
Q

What is CAD and its underlying mechanism?

A

CAD is coronary artery disease; luminal narrowing of the coronary arteries due to plaque formation

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2
Q

What factors increase the risk for CAD in patients?

A 
Smoking
hypertension
hyperlipidemia
diabetes
older age
inactivity
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3
Q

What is the prevalence of CAD in the US?

A

affects 82 million Americans and causes 33% of all deaths in the US

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4
Q

T/F: Total healthcare inpatient cost for CAD is $72 billion or 1/4 of all healthcare costs

A

True

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5
Q

What is the average age of onset of CAD for women? For men?

A

72; 62

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6
Q

Which ethnic groups have the highest rates of CAD?

A

blacks > whites > hispanic/latino

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7
Q

18% of men and 23% of women 40 years and older will die within the first year after a heart attack. 33% and 43% will die within the first 5 years.
(blank) to prevention strategies can help reduce the rates.

A

adherence

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8
Q

deposits of lipids, macrophages, calcifications in arteries leading to plaque formation

A

atherosclerosis

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9
Q

What causes coronary artery disease?

A

arteriosclerosis and atherosclerosis
formation of plaques +/- stenosis of the lumen
can be stable (asymptomatic/angina) or unstable (acute coronary syndrome)

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10
Q

What is an atheroma?

A

a plug of macrophages, lipids, and fibrous connective tissue

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11
Q

What increases risk for plaque development in arteries?

A

Elevated plasma levels of low-density lipoprotein cholesterol (LDL-C)
Low plasma levels of high-density lipoprotein cholesterol (HDL-C)
Hypertension
Cigarette smoking
Diabetes mellitus
Age greater than 65 **
Male gender
Family history * - first degree relatives - males aged 55 or less, women 65 or less
Obesity / overweight
Sedentary life style

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12
Q

What is the greatest risk factor for plaque development in arteries?

A

age

**If you are over the age of 70% your risk is above 20% no matter what

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13
Q

What can be used to calculate the risk of developing heart disease w/i the next 10 years?

A

Framingham risk calculator

  • *uses age, sex, smoker, systolic blood pressure, total cholesterol, HDL, and treated HTN
  • *low risk 20%
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14
Q

T/F: The Framingham risk calculator may overestimate the risk of heart disease in certain populations, or underestimate.

A

True; despite its faults, it’s still one of the best tools we have to estimate risk

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15
Q

This is another, newer calculator used to estimate risk of developing heart disease

A

ASCVD

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16
Q

Any group of clinical syndromes consistent with myocardial ischemia (or patients with symptoms suggesting an unstable cardiac condition due to ischemia)

A

acute coronary syndrome

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17
Q

What are the three main conditions that are included in acute coronary syndrome?

A

unstable angina
NSTEMI
STEMI

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18
Q

What is ACS usually secondary to?

A

secondary to a ruptured plaque or erosion of a plaque, which releases thrombogenic materials and can lead to thrombus formation and partial or complete occlusion of the vessel

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19
Q

What is unstable angina? Will you see changes on the ECG? Will biomarkers be elevated?

A

reversible ischemia which causes sudden onset chest pain when at rest or during minimal activity; may or may not see T wave inversion or ST depression; biomarkers will not be elevated due to lack of necrosis of myocardium

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20
Q

How is a NSTEMI similar to unstable angina? How is it different?

A

symptoms are indistinguishable;

usu has ECG changes of ST segment DEPRESSION and T wave inversion; biomarkers will be elevated due to myocardial damage

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21
Q

What will you see on an ECG during a STEMI?

A

ST elevation

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22
Q

Why do we not wait for biomarkers in cases of STEMI?

A

time is of the essence here! Need to reperfuse the coronary vessels to minimize tissue loss - no time to wait for labs

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23
Q

Why can it be difficult to diagnose ACS?

A

overlap of non cardiac and cardiac disease symptoms
over-diagnosis due to fear of lawsuits and adverse outcomes
misinterpreting biomarkers or ECG
atypical presentation

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24
Q

When evaluating a patient with chest pain, what are your two main objectives?

A
  1. determine the patient’s risk for ACS

2. determine the short term risk for an adverse event

25
Q

What are some urgent (life threatening) causes of chest pain?

A

aortic dissection
pulmonary embolism
tension pneumothorax
esophageal rupture

26
Q

What are some other, more benign causes of chest pain?

A 
pneumonia
pleurisy
pericarditis
myocarditis
hypertrophic cardiomyopathy
PUD
GERD
esophageal spasm
panic attack
27
Q

What are 5 high yield questions for determining likelihood of ACS?

A
  1. nature of chest pain (PPQRST)
  2. history of CAD
  3. gender/sex
  4. age
  5. number of traditional risk factors for CAD
28
Q

Describe the typical chest pain in ACS

A

heavy/pressure sensation in the sternum or epigastrium
radiates to jaw, neck, throat, back or left arm
lasts 15-20 minutes
not relieved by rest

29
Q

Describe ATYPICAL chest pain in ACS

A

sharp/stabbing
pain reproduced by movement or by touch
pain lasts for seconds
pain described as heartburn or burning in nature

30
Q

What percentage of patients with ACS do not have chest pain as a complaint?

A

25-30% !!!

31
Q

These ACS patients are more likely to have pain in their jaw, neck and back than in their chest…

A

women

32
Q

These ACS patients will complain less about their chest pain

A

older patients

33
Q

Chest pain that radiates to both shoulders increases the likelihood risk of an MI by (blank) fold

A

7

34
Q

T/F: Pleuritic chest pain, chest pain reproduced by palpation, sharp or stabbing chest pain, and positional chest pain decrease the likelihood risk of an MI by .3 fold

A

True

35
Q

What are some red flags for cardiomyopathy with a STEMI?

A 
S3
pulmonary rales
jugular venous distension
hepatojugular reflex
diminished pulse
hypotension
36
Q

What does ST elevation suggest on an ECG?

A

irreversible ischemia from coronary occlusion

**need urgent reperfusion

37
Q

How quickly should you get an ECG after a patient enters the ED with suspected ACS?

A

within 10 minutes!

38
Q

Is an ECG necessary for diagnosis of ACS?

A

well, it can be normal in 20-55% of patients with acute MI so… still do serial ECGs ever 15-30 minutes for pts with likely ACS

39
Q

Can an ECG help determine the location of the vessel occlusion in ACS?

A

yes!

40
Q

Are ST elevation and T wave inversion specific for MI?

A

no!!

**pericarditis, myocarditis and ventricular aneurysm can cause ST segment elevation
T wave inversion can occur with tricyclic and strokes

41
Q

In a patient with chest pain, how do you differentiate UA from STEMI?

A

measure biomarkers!

in NSTEMI, biomarkers will be elevated; in UA, they will not

42
Q

Are biomarkers necessary to make the diagnosis of STEMI?

A

no!

43
Q

This biomarker has high sensitivity and specificity for myocardial damage

A

Troponins I and T

44
Q

When are troponins first present in blood? When do they peak? How long do they remain elevated?

A

2-4 hours; 48 hours; 7-10 days

45
Q

T/F: Troponins can also be elevated in renal disease, tachycardia, A fib, myocarditis, severe cardiomyopathy, GI bleeds, stoke, etc

A

True

***PPV for ACS is highest when the patient is older, has hypertension, and troponin > 1ng/mL

46
Q

This biomarker can be detected w/i 2 hours of an MI; it is undetectable at 72 hours; should be repeated every 6-9 hours in initially negative

A

CK-MB

47
Q

Why is myoglobin not terribly useful as a biomarker?

A

well, its detected w/i the first hour after cardiac injury, but it’s not specific at all

48
Q

What are some risk prediction models that help estimate risk of UA/NSTEMI mortality for patients with unstable angina and non-ST elevation MI?

A

TIMI

GRACE model

49
Q

What kinds of things are included in the TIMI risk prediction model to determine overall risk of adverse outcomes in patients with UA/NSTEMI?

A 
age >65
documented prior coronary artery stenosis
3+ conventional cardiac risk factors
aspirin use in previous 7 days
2+ anginal events in the past 24 hours
ST depression or elevation >1mm
elevated cardiac biomarkers
50
Q

How do you treat patients with chronic stable angina and non diagnostic biomarkers and ECG?

A

cardiac stress test

teach/encourage the pt to modify their risk factors

51
Q

T/F: There are lower rates of adherence to guidelines for treatment of UA/NSTEMI in low risk patients, women, elderly patients, and those of certain race/ethnicity

A

True

52
Q

How to treat UA/NSTEMI?

A 
bed rest
continuous cadiac monitoring (tele)
relief of ischemia using nitroglycerin (vasodilator), beta blockers (decrease HR and O2 demand of cardiocytes)
antithrombotics?
anticoagulants?
53
Q

This is one invasive treatment for UA/NSTEMI

A

coronary angiography with potential revascularization

54
Q

How to treat a STEMI?

A

urgent treatment via restoration of blood flow (use fibrinolytics, heparins, percutaneous coronary intervention, or coronary artery bypass grafting)!! **1/3 of these patients die within the first 24hrs of ischemia

55
Q

Prevention measures for ACS?

A 
aspirin
beta blockers, BP control
stop smoking
manage cholesterol
diet
diabetes control
exercise
56
Q

Promote (blank) in patients with coronary artery disease

A

prevention

57
Q

Obtain (blank) immediately in patients suspected to have ACS

A

ECG

58
Q

Measure (blank) in all patients suspected to have ACS

A

troponin

Block 9 Week 1 Meg (9 decks)

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