Unstable Angina Flashcards
On the EKG, inversion of T waves and, when more severe, displacement of ST segments is indicative of what?
ischemia;Transient T-wave inversion probably reflects nontransmural, intramyocardial ischemia; transient ST-segment depression often reflects patchy subendocardial ischemia; and ST-segment elevation is thought to be caused by more severe transmural ischemia.
Most patients who die suddenly from IHD do so as a result of ischemia-induced what?
ventricular tachyarrhythmias
Transient T-wave inversion probably reflects nontransmural, intramyocardial ischemia - what does transmural mean?
through the septal wall
when myocardial ischemia leads to electrical instability, what are the three consequences in terms of rhythm that will happen?
vtach, vfib, and pvc - esp the first two represent ischemic ventricular rhythms
what does the EKG tell you about the pulse of a patient who is experiencing angina?
NOTHING - EKG does not measure pulse!! you can have no pulse and have normal sinus rhythm
what is the radiation pattern of angina with MI?
radiations to neck, jaw, shoulder, arm
what happens to patients lung sounds when they have UA? why?
wide basilar rales, due to left ventricular failure; patients also will develop acute CHF and hypotension
what is the best lead to look at for myocardial ischemia?
5
new t wave inversion of what size is diagnostic of myocardial ischemia?
> .3mV
your patient presents as pain free and have negative biomarkers, do you send them for a stress test?
YES
your patient presents with no pain, but has positive biomarkers, do you send them for a stress test?
NO
what are your seven factors that comprise the TIMI? ‘Thrombolysis In Myocardial Infarction’
A Age, Aspirin, Angina B Biomarker C CAD risk factors D Diagnosis of CAD E EKG changes; age 65 years (A), three or more risk factors for CAD (C), documented CAD at catheterization (D), development of UA/NSTEMI while on aspirin (A), more than two episodes of angina within the preceding 24 h (A), ST deviation 0.5 mm (E), and an elevated cardiac marker (B)
chest pain early in the morning (MONDAY) within a few hours of waking is indicative of what?
MI
Although STEMI may commence at any time of the day or night, _______ have been reported such that clusters are seen in the morning within a few hours of awakening.
circadian variations (remember, your heart rate and metabolic rate slows down when you are sleeping)
what are the 5 differential diagnoses of pain of STEMI?
acute pericarditis, PE, acute aortic dissection, costochondritis, and gastrointestinal disorders. Lau also included GERD, and variant angina.
The combination of substernal chest pain persisting for >30 min and diaphoresis strongly suggests what?
STEMI
_____ is essential in the management of patients with suspected STEMI and is effective across the entire spectrum of acute coronary syndromes.
aspirin; but remember, pts must chew the aspirin so the saliva can activate the enzymes!!!! DO NOT give water, b/c you don’t want them to swallow
_______ (treatment) can be given safely to most patients with STEMI. Up to THREE doses of___mg should be administered at about 5-min intervals.
sublingual nitroglycerin; .4mg
nitroglycerin may be capable of doing what to preload? and myocardial o2 demand? and myocardial o2 supply? How does it do all of these?
nitroglycerin may be capable of both decreasing myocardial oxygen demand (by lowering preload) and increasing myocardial oxygen supply (by dilating infarct-related coronary vessels or collateral vessels)
Therapy with nitrates should be avoided in patients who present with what? (2)
low systolic pressures (less than 90mmHg); suspicion of right ventricular infarction
Nitrates should not be administered to patients who have taken what other drugs? why?
phosphodiesterase-5 inhibitor sildenafil (viagara) for erectile dysfunction within the preceding 24 h, because it may potentiate the hypotensive effects of nitrates.
what is the antidote for accidentally giving a pt nitrate with viagara?
IV atropine
_____(drug) is a very effective analgesic for the pain associated with STEMI, but what is the one requirement for the patient profile? why?
morphine; good BP (cannot have low BP); b/c morphine may reduce sympathetically mediated arteriolar and venous constriction, and the resulting venous pooling may reduce cardiac output and arterial pressure
morphine is a good DOC for what other major heart disease? THINK …
CHF b/c of it’s venodilator effects
beta blockers or ccb for use during acute setting MI? and why?
Beta blocker! b/c ccb can cause vasodilation which can promote CHF which is already a big problem post MI.
PVA doc of what? what’s the next line therapy? (prinzmetal variant angina)
CCB; nitro
what drug should absolutely not be given to pts suffering from PVA? (prinzmetal variant angina) why?
aspirin. b/c may actually increase the severity of ischemic episodes, possibly as a result of the exquisite sensitivity of coronary tone to modest changes in the synthesis of prostacyclin.
how can you tell the difference between a person having unstable angina and pva? (prinzmetal variant angina)
you cannot tell! best bet is to coronary angiography.
any pt that comes into the ER with chest pain must be treated with what?
aspirin - even though if the person has PVA it might actually make it worse
what do you give a patient who comes in with chest pain, but is allergic to aspirin? (both names)
Plavix (clopidogrel) -keeps the platelets in your blood from coagulating (clotting) to prevent unwanted blood clots that can occur with certain heart or blood vessel conditions.
The proportion of painless STEMIs is greater in patients with ______ and it increases with age.
diabetes mellitus; this patient may present with diaphoresis
Intermittent claudication is significant for what?
peripheral vascular disease - remember, intermittent claudication is a clinical diagnosis given for muscle pain (ache, cramp, numbness or sense of fatigue), classically in the calf muscle, which occurs during exercise, such as walking, and is relieved by a short period of rest.
a clenched fist held over the chest to describe ischemic chest pain - pressing/crushing vase-like chest pain.
levine sign
CK-MB, CK, and troponin - what’s the big diff?
CK-MB is usually ordered along with total CK in persons with chest pain to determine whether the pain is due to a heart attack. It may also be ordered in a person with a high CK to determine whether damage is to the heart or other muscles.
Increased CK-MB can usually be detected in heart attack patients about 3-4 hours after onset of chest pain. The concentration of CK-MB peaks in 18-24 hours and then returns to normal within 72 hours.
Although CK-MB is a very good test, it has been largely replaced by troponin, which is more specific for damage to the heart.
how many sets of troponin should be ordered to rule out heart attack? how many of cp-k?
1 set; 3 sets
is myoglobin a good cardiac specific marker?
no, it’s better for Rhabdomyolysis
what are the minimum initial lab tests you should run when pt comes in with possibly MI?
SMA 7, CBC, PT/PTT, troponin and CP-K (Creatine phosphokinase); plus ekg, cxr, and u/a (non blood tests)
Troponins are protein components of striated muscle. There are three different troponins: troponin C, troponin T and troponin I. Troponins T and I are only found in cardiac muscle
Again, Troponins T and I are only found in cardiac muscle
metabolic acidosis tends to be caused by what?
hyperkalemia
Troponin T or I is both more specific and sensitive.
Troponin I
elevation is useful for predicting in-hospital risk for unstable angina patients - which troponin?
I - The association of ECG changes and high troponin I identifies a population at very high risk;
T or F: no physical findings are pathognomonic for angina pectoris
True
which murmur do you send to the cardiologist immediately without echo? why? THiNK!!!
mitral regurgitation POST MI; b/c you want to know if the heart attack caused the MR; and if it did then Papillary muscle rupture has happened
how do you check for peripheral vascular disease?
check the pulses
presence of Xanthoma suggests what?
hypercholesterolemia
what is the difference between the EKG findings of pericarditis and STEMI?
PC has diffused ST elevation (meaning it appears on every lead)
what is the most common cause of pericarditis?
Group B coxsackieviruses
T or F - stress testing is not indicated in asymptotic patients as a screening test
True
what type of murmur precludes you from getting a stress test?
Aortic stenosis (esp if symptomatic)
if there is a new ST segment depression on your ekg post stress test, what does that mean?
> 1mm means they induced an MI
hypertensive or hypotensive response to exercise indicates the stress test was positive
hypo
what is the alternate stress test for elderly pt or those that live a sedentary lifestyle?
bruce protocol stress test - still treadmill just lower workload
what is the score that is used during the bruce protocol stress test? what does this score ultimately tell you?
duke treadmill score; it’s a prediction of coronary heart disease in a patient with chest pain
T or F: acute PE, myocarditis, pericarditis or aortic dissection is contraindicated to stress testing
True
pts with LBBB (specifically if it’s new) is indicative of what?
MI; if it was there previously (on an old EKG) then it’s not an MI
what are the best drugs to use in hypertensive crisis? (3)
esmolol; Sodium nitroprusside;Labetalol
what does ETT help us to do?
exercise tolerance test; helps to confirm and evaluate the severity of coronary artery disease
what are you most concerned about with pts who have chf? (from the echo)
ejection fraction decreased (below 40 indicates pt needs a new heart)
is there any pt that is contraindicated to cath?
no
in which vessel bypass is the pt prognosis the worse?
LAD - the widowmaker
sudden cardiac death typically indicates what two arrhythmias?
vfib and pulseless vtach
what are the three indications for surgical therapy with patient who have UA?
medical therapy doesn’t work; LAD involved, or 3 vessels involved in disease (esp of left ventricular function is impaired).
what is the cornerstone therapy for UA?
nitrate
T or F if the pt has atherosclerosis nitrates do no work as well to cause venous dilation
FALSE - they still work !
when is the best time to administer the nitrates?
at night time - when sleeping
nitrogen and betablockers have synergistic therapeutic effect!!
this is why nitrates plus CCB is not the preferred combo.
what does calcium do, per lau?
stabilizes the membrane
extreme generalized edema
Anasarca
renal failure or CHF? (in terms of edema)
leg edema (CHF); Anasarca (renal failure)
what is the NO. ONE side effect of taking nitrates?
HA
how many times should a UA pt take nitro? dose?
.4mg 3x (sublingual)
what is the storage procedure for nitro?
avoid sunlight b/c it deactivates it
DO NOT SWALLOW NITRO
it’s sublingual, duh!
in NG OD what is the usually outcome?
methemoglobinemia
what happens to patients who are on nitro for long periods of time? how do you prevent this?
tolerance is built - pts typically need 10-12 hours of a nitro-free period to avoid
what type of beta blocker is atenolol?
Atenolol is a selective β1 receptor antagonist
which class of drugs is known to permit unopposed alpha mediated v/c (Raynaud’s phenom)
beta blockers
NOTE: beta blockers can both increase and decrease your sugar - how ?
by masking either hypo or hyper glycemia
what drug class does Pindolol below to?
beta blocker with ISA
what is the preferred type of beta blocker to give to DM pt?
beta blockers with ISA b/c of less derangement of lipid and glucose
should beta blockers be withdrawn before coronary artery surgery?
NO
always remember alternate pain when diabetics present with MI
such as pain when chewing; sudden onset of breathlessness; sudden loc;
