Unit 2_Coronary Artery Disease and Myocardial Infarction Flashcards by Danielle Pieri

What is a condition brought on by a sudden reduction of blood flow to the heart muscle?
- Unstable angina
- Myocardial Infarction (MI)
STEMI “ST segment elevation MI”
- NSTEM “Non-ST segment elevation MI”
- The primary cause is atheroscerosis

Acute Coronary Syndrome

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What is a thickening and loss of elasticity in the arterial walls? Commonly due to fatty deposits in the lumen. Can also be caused by calcium deposits or thickening (fibrous) of the smooth muscle tissue. Develops from hyperlipidemia and hypertension.

Atherosclerosis

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Cardiovascular Disease

CVD

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Coronary Artery Disease

CAD

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What is the most widely accepted theory explaining the pathogenesis of atherosclerotic disease, including coronary artery disease (CAD) and cerebrovascular disease (CVD)?

Response to Injury Theory

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What are the following steps associated with:
1. Damage to endothelial lining occurs (potential causes - HTN, smoking, high levels of lipids in the blood)
2. Platelets and monocytes adhere to injured area
3. Platelets release PDGF, promoting infiltration of smooth muscle cells from media to intima
4. Plaque composed of smooth muscle cells, connective tissue, and cellular debris forms
5. Lipids (LDL’s) deposited in the plaque

Response to Injury Theory

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What are the following risk factors associated with?
1. Age (83% of deaths from CAD occur in individuals > 65 y/o)
2. Gender (males are at greater risk, especially when compared to pre-menopausal women)
3. Genetics (a family history of premature heart disease is associated with elevated risk)

Non-modifiable CAD risk factors

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What are the following risk factors associated with?
1. HTN – Hypertension (SBP > 130 or DBP > 80 mmHg)*
2. Cholesterol (Total chol. > 200 mg/dl)
3. Smoking (There is no safe amount)
4. Inactivity (Increases risk for many chronic disease conditions including heart disease)
5. Obesity (BMI > 30 kg/m2)
6. Diabetes (fasting glucose level > 126 mg/dl)
7. Stress

Modifiable CAD risk factors

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What is a cluster of risk factors in a single individual and includes three or more of the following:
- Waist > 35” in women, > 40” in men
- Triglyceride levels > 150 mg/dl
- HDL < 50 mg/dl in women, < 40 mg/dl in men
- BP > 130/85 mmHg
- Blood sugar > 100 mg/dl

Metabolic Syndrome

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What is a marker for inflammation (nl = < 10 mg /L)? Elevated levels are associated with an increased risk of MI.

C-reactive Protein

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What is amino acid formed as body metabolizes methionine? Elevated levels seem to be associated with increased risk of CAD.
- B vitamins may help moderate homocysteine levels.
- Recent studies have cast doubt on homocysteine as a CAD risk factor and thus remains somewhat controversial.

Homocysteine

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What is a sub-type of LDL cholesterol associated with increased risk of clotting, atherosclerosis and myocardial infarction (MI)?

Lp(a)

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What is pain associated with cardiovascular (heart) pathology? It’s caused by an imbalance in the oxygen demand and supply for cardiac muscle.

Angina

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What classification of angina is predictably induced with a given level of exertion (same RPE - Rate of Perceived Extertion)? It is treated with rest and/or medications and monitored exercise is safe.

Stable Angina

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What classification of angina may or may not be brought on by exertion? It is characterized by increasing frequency, duration, and intensity of ischemia, and/or a reduced “ischemic threshold”? Physical activity is contraindicated with this classification of angina.

Unstable Angina

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What classification of angina is caused by coronary spasm? Anginal episodes may be cyclical, often occurring at the same time each day. Often occurs in the presence of underlying CAD. Treated with calcium channel blockers.

Prinzmetal/ Variant

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What classification of angina includes up to 70% of ischemic episodes? Common in people with diabetes.

Asymptomatic “Silent Ischemia”

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What are precipitating factors for angina?

Stress
Cold
Physical Exertion

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How is myocardial ischemia diagnosed?

A patient history – personal symptoms, risk factors, family history
A physical exam – HR, BP, auscultation (S3 and S4 sounds may be audible)
Clinical testing – EKG, graded exercise test, radionuclide imaging, echocardiography, catheterization

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What is indicated on the EKG by the presence of:
T wave inversion OR
ST segment depression?

Myocardial Ischemia

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What provides information on blood perfusion throughout the heart? This is commonly included as part of a diagnostic “Graded Exercise Test” (GXT).
Rest images are compared to images taken immediately after stress (“exercise”) to look for evidence of reversible ischemia.

Myocardial Ischemia on a Perfusion Scan

What is an invasive procedure that allows visualization of the coronary arteries and identification of obstructive lesions? Catheter access may be from groin, arm, or neck. A dye is injected that allows for visualization of the coronary arteries using “fluoroscopy”, a specialized type of x-ray that captures real-time video. Stents can be placed to “reopen” arteries.

Cardiac Catheterization “coronary angiography”

What are the most common sites for occlusion?

Left anterior descending
Left circumflex
Right circumflex

What are myocardial ischemia treatments?

Rest
Medication
Percutaneous Transluminal Coronary Angioplasty (PTCA) (“angioplasty”)
Coronary Artery Bypass Graft (CABG)

*Cardiac Rehabilitation after the person is stable

What is it called when during a cardiac catheterization, a small balloon (angioplasty) is used to expand the vessel lumen? A stent can be placed to maintain the lumen.

Percutaneous Transluminal Coronary Angioplasty (PTCA) (“angioplasty”)

What is known as “Open heart surgery”? Vessels are harvested and used to bypass occlusions. Graded 1-5 (single to quintuple bypass).

Coronary Artery Bypass Graft (CABG) - 1

What are the following known as: - Internal mammary (Left internal mammary is preferred bypass vessel for blockages in the LAD) - Radial artery - Saphenous vein Associated with chronic pain post surgery and with physical activity

Commonly used bypass vessels during Coronary Artery Bypass Graft (CABG) - 2

What is where the sternum is separated to allow access to the heart? The sternum is wired closed post operatively. Sternal precautions are post-operative measures to prevent sternal dehiscence (sternal separation).

Sternotomy

What are the following known as: - No lifting, pulling, pushing (10 lb limit) for 6 weeks - Log roll technique in/out bed - No driving (4-8 weeks) ROM exercises – neck, shoulders, torso (“caution with sternectomy”) - Scar mobilization when incision is healed - Be conservative if: osteoporosis, diabetes, advanced age

Sternal Precautions

What implies injury/damage to the heart muscle due to lack of oxygen delivery? Permanent damage (“necrosis”) to heart muscle occurs. Ischemia is often a precipitating factor. Typically, the result of significant CAD that culminates in a complete blockage. Often fatal – the mortality rate for AMI is approximately 30%

Acute Myocardial Infarction (AMI)

What is permanent damage to myocardial (“heart muscle”) tissue due to interrupted blood flow? Two primary types: Transmural - full thickness Subendocardial - partial thickness

Myocardial Infarction

What primary type of Myocardial Infarction is known as full thickness?

Transmural

What primary type of Myocardial Infarction is known as partial thickness?

Subendocardial

What occurs when “ST Elevation Myocardial Infarction” ~70% of AMI’s are this? These are also Transmural - full thickness.

STEMI

What occurs when MI that does not demonstrate ST segment elevation on the EKG? These are also Subendocardial - partial thickness.

Non-STEMI

What occurs when: 1. Plaque forms inside an artery 2. A thrombus forms around the plaque 3. Vessel occlusion occurs 4. Ischemia to the myocardium results 6. Degeneration of myocardial fibers 7. Heart’s ability to pump is compromised - Secondary to scarring and fatty infiltration

Acute Myocardial Infarction (AMI)

How is Myocardial Infarction diagnosed?

- A patient history – personal symptoms - Clinical testing – EKG, Serum markers Personal Symptoms 1. Angina 2. Nausea 3. Diaphoresis (sweating)

What are the following that indicate MI? - Troponin (I and T) – Protein in heart tissue - CPK – MB (Creatine Phosphokinase) - LDH (“flipped ratio”) – Lactate dehydrogenase 1 and 2 - Aspartate transaminase (AST) Hepatic and muscle enzyme. “Formerly known as SGOT” (serum glutamic oxaloacetic transaminase) - Myoglobin – Protein in muscle tissue

Serum markers that indicate MI

Serum markers peak and then decline over time after ________.

necrosis

What develop from loss of cardiac muscle tissue (loss of contractility and changes in HR) and loss of heart structural function? Dysrhythmias - Sudden Cardiac Death Heart Failure (HF) Mural thrombus Ventricular aneurysm Ventricular rupture with tamponade

Post-MI Complications

What occurs when we often see increases in premature ventricular contractions post-MI? - Indicates myocardial irritability, can lead to symptoms if patient is having a significant amount of PVC’s. - May respond to anti-arrhythmic drugs. - Can lead to life-threatening arrythmias: (shockable rhythms)

Dysrhythmias (aka Arrhythmias)

What occurs when blunt force trauma to the pre-cordial chest region occurring during the early ventricular repolarization period can trigger an arrhythmia?

Dysrhythmias – Commotio Cordis

What may develop as a result of myocardial infarction? Diagnosed at hospital admission ~13% of patients. During the hospital stay ~4-28% ~13% at 30 days post discharge ~20–30% at 1 year after discharge *1 year mortality is 16-39%

Heart Failure

What occurs when Thrombi (“clots”) that develop in the heart can increase the risk of: Stroke Sudden cardiac death Heart Failure

Mural Thrombus

What occurs when weakened ventricular wall structure can ”balloon” under pressure = aneurism? Aneurism can burst resulting in ventricular rupture and resulting “cardiac tamponade” (swelling of the pericardial sac) – compresses heart tissue.

Ventricular aneurism and rupture

What disease is treated with rest, O2, medications (decrease myocardial oxygen demand and manage pain and anxiety)?

Myocardial Infarction

What disease is treated to limit damage via medications, surgical intervention (PTCA, CABG)?

Myocardial Infarction

What disease is treated with secondary preventions, such as lifestyle changes, medications, cardiac rehabilitation (20% reduction in risk of subsequent fatal disease amongst those who participate in formal programs post disease)?

Myocardial Infarction

What phase of cardiac rehabilitation (secondary prevention) includes: - Review sternal precautions if post-CABG - Initiate physical activity and provide home exercise/activity guidelines. - Refer to comprehensive out-patient cardiac rehabilitation program *Note: monitor vital signs pre, during, and post exercise.

Phase I = Inpatient phase: (typically 3-7 days)

What phase of cardiac rehabilitation (secondary prevention) includes: - Comprehensive program including individually prescribed and monitored exercise, and individual and group educational sessions aimed at reducing risk factors and secondary events. *Notes: monitor vital signs pre, during, and post exercise.

Phase II = Acute outpatient: (may last up to 12 weeks)

What phase of cardiac rehabilitation (secondary prevention) includes: - A continuation of phase II but patients no longer receive continuous telemetry monitoring during exercise and are more independent. *Notes: monitor vital signs pre, during, and post exercise.

Phase III = Follows phase II: (may last 6 months or more)