Step 2 CK Flashcards
GI disorders associated with chest pain
ulcer disease, cholelithiasis, duodenitis, gastritis
Benefit a pt risk of coronary disease
Exercise. Increase heart rate shows clear benefit in cardiac outcome
CAD risk factors
DM, smoking, HTN (140/90), HL, FMH of premature CAD, men>45, women >55
Tako-Tsubo cardiomyopathy
acute myocardial damage most often occur in post menopausal women immediately after an overwhelming event or news (stress). Leads ballooning and left ventricular dyskinesis.Manage with ACE and Beta blockers. Revacularization will not help because coronary arteries (angiography) are normal
Ischemic pain
dull or sore; squeezing or pressure
3 features of CP tell whether or not the pain is ischemic in nature
- changes with respiration (pleuritic)
- changes with the position of the body
- changes with touch of the chest wall (tenderness)
Costochondritis
chest wall tenderness
Test: PE
Pericarditis
pain worse with lying flat, better sitting up, young (<40)
Test: ECG with ST elevation everywhere, PR depression
Aortic dissection
radiation to the back, unequal bld pressure between arms
Test: Chest Xray with widened mediastinum, chest CT, MRI, TEE confirms disease
Duodenal ulcer
epigastric discomfort, better when eating
test: endoscopy
GERD
bad taste, cough, hoarseness
Test: response to PPIs or antacids (aluminum hydroxide and magnesium hydroxide)
Pneumonia
cough, sputum, hemoptysis
test: CXR
PE
sudden onset of SOB, tachycardia, hypoxia
Test: spiral CT, V/Q scan
Pneumothorax
sharp, pleuritic chest pain, tracheal deviation
test: CXR
Ischemia EKG
ST depressions
best methods for detecting ischemia w/o the use of EKG because of a baseline abnormality
- nuclear isotope uptake or sestamibi
2. ECG detection of wall motion abnormalities
Reasons for baseline EKG abnormalities
left bundle branch block, left ventricular hypertrophy, pacemaker use, or the effect of digoxin
Exercise tolerance
determine presence of ischemia
ST segment depression
Exercise thallium
normal myocardium will pick up thallium in the same way that potassium is picked up by Na/K ATPase.
ischemia will have decrease uptake of nuclear isotope
ECHO
normal myocardium will move on contraction.
abnormalities will be detected by seeing a decreased wall motion (dyskinesis, akinesis, or hypokinesis)
Dipyridamole thallium
inability to exercise to target heart rate.
dec uptake of nuclear isotope
Dobutamine ECHO
increase myocardial oxygen consumption and provoke ischemia detected as wall motion abnormalities.
may provoke bronchospasm (no bueno asthmatics)
Angiography
detect the anatomic location of coronary artery disease
determines bypass surgery versus angioplasty.
70% intervention
Holter monitor
detects rhythm disorders ( Afib, flutter, ectopy (premature beats, v tachy).
does not detect ischemia
Chronic Angina tx
Beta blockers, aspirin, nitroglycerin [oral (sub-lingual, IV and paste= acute) or transdermal]
(B.A.N)
best mortality benefit is aspirin and beta blo
Clopidegrel
aspirin intolerance (allergy) recent angioplasty with stenting
Prasugrel
antiplatelet medication
pt who are undergoing angioplasty and stenting
dangerous in pt 75 or older b/c inc risk of hemorrhagic stroke
Ticlopidine
inhib plt
pt who are intolerant to both aspirin and clopidogrel
causes neutropenia and TTP
ACEI
SE: cough, hyperkalemia
Hydralazine
direct acting arterial vasodilator
dec afterload, clear benefit in pt with systolic dysfunction
National Cholesterol Ed Program
CAD and LDL above 100 to 130=statin
goal to get LDL <100
CAD equivalents
PAD, carotid disease (not stroke), Aortic disease, DM
STATINS
- antioxidant effect on the endothelial lining of the coronary arteries in addition to lowering LDL.
- elevations of transaminases (check ALT and AST at intiation, before dosage inc and periodically. an in >3x reduce or w/draw meds)
- also causes myositis, elevation of CPK, and rhado
Niacin
- inc HDL
- ass with glu intolerance (inc glucose), elevation of uric acid level, and an uncomfortable itchiness from transient release of histamine
Gemfibrozil
- lower triglycerides
- inc risk of myositis when used with statins
Cholestyramine
- bile sequestrate also has significant interactions with other medications in the gut (block absorption)
- GI discomfort, bad taste, cramping, flatus
When to use CCBs (verapamil/diltiazem) in CAD only…..
severe asthma precluding the use of beta blockers, prinzmetal variant angina, cocaine induced chest pain (BB are CI), inability to control pain with maximum therapy
Coronary artery bypass grafting
lowers mortality in
- 3 vessels with at least 70% stenosis in each vessel
- left main coronary artery occlusion
- 2 vessel disease in a pt with DM
- persistent sx despite maximal medical therapy
- **internal mammary artery grafts last 10yrs before occluding, saphenous veins 5yrs
Percutaneous coronary intervention (angioplasty)
-best in acute coronary syndromes (ST segment elevations)
S4 gallop
-sound of atrial systole as bld is being ejected from the atrium into a stiff ventricle
associated with ACS because of ischemia leading to noncompliance of the left ventricle
Pulsus paradoxus
dec of bld pressure of greater than 10mmHg on inspiration.
ass with cardiac tamponade
Kussmaul sign
inc in jugulovenous press on inhalation
displaced point of maximal impulse
-characteristic of left ventricular hypertrophy, dilated cardiomyopathy
LEADS
- V2 to V4=anterior wall of the LV. ST elevation signifies acute MI. untx 20-40% mortality
- II, III, avF ST elevation =acute MI of the inferior wall. untx <5% mortality
- V1 and V2=ST depressions are suggestive of posterior wall MI. very low mortality.
ACS
-aspirin (chew) within 1hr, call cath lab (PCI w/in 90min), transfer to ICU
-angioplasty (PCI) is superior to thrombolytics in terms of survival and mortality benefit, fewer hemorrhagic complications
MONA (morphine, O2, nitroglycerine, and aspirin). beta blockers at some point during admission
most common cause of death s/p MI
ventricular arrhythmia (Vtach, Vfib)
complications of PCI
rupture, restenosis-throbosis of the vessel, hematoma at the site of entry
prevent restenosis with placement of drug eluting stent (paclitaxel, sirolimus) which inhib the local T cell response . Heparin is used at the time of the procedure. Warfarin doesn’t help because its not a venous problem
CI to thrombolytics
major bleeding into the bowel or brain recent surgery (w/in 2wks) severe HTN (180/110) nonhemorragic stroke w/in 6mo
Pulmonary capillary wedge pressure
- indirect measure of the left atrial pressure, indirect indicator of left ventricular filling pressure or preload. When the balloon of the PA catheter is inflated, a branch of the pulmonary artery is occluded. The pressure that is transmitted by the pulmonary vein is approximately the same as the lead atrial pressure because there are no valves is the lung vasculature that would create a change in pressure between the left ventricle and the pulmonary vein.
- Normal: 8-12mmHg
- Increase in PCWP: Intravascular Volume Overload, Mitral Valve Stenosis, Left Ventricular Failure, Cardiogenic Shock, High PEEP (to estimate PCWP when pt. is on PEEP: PCWP - 1/2PEEP = corrected PCWP), pulmonary edema
- Decrease in PCWP: Hypovolemia, Right Ventricular Infarction
