week 1 content Flashcards
__________ angina: coronary artery spasms
Caused by -
endothelial dysfunction = spasms of the coronary arteries = decreased blood flow to heart = leading to intermittent chest pain even at rest
Prinzmetal/variant/vasospastic
Prinzmetal/variant/vasospastic angina
T/F
- Issue = Supply ischemia
- r/t to atherosclerotic plaque build up
- CAD (atherosclerotic plaque) may or may not be present
- onset can be both at rest or with minimal exertion
- onset is not at night
- EKG changes – elevated ST segment (during spasm)
- treatment – nitrates to relax spasms
- can range from benign or cause serious dysrhythmias
- T
- F - NOT r/t atherscletosis. is r/t spasms
- T
- T
- F - can be
- T
- T
- T
Issue = type of chest pain that occurs when the heart muscle does not receive enough blood and oxygen.
cause = (Fixed stenosis) a narrowing of the coronary arteries, which supply blood to the heart. This narrowing is often due to atherosclerosis, a buildup of plaque in the arteries (demand ischemia)
Chronic Stable angina
Issue= thrombus can form in a coronary artery, which supplies blood to the heart muscle. This can block blood flow and lead to ischemia. (Supply ischemia)
often associated with the rupture of a vulnerable/unstable atherosclerotic plaque and results in formation of a thrombus.
Unstable angina:
type of chest pain that:
- occurs at rest or with minimal exertion
- may be more severe or frequent than usual
- is occurring for the first time (myocardial ischemia occurring)
- different in any way (new regions of the heart are undergoing myocardial ischemia)
Unstable angina:
- Does Myocardial infarction (blood flow to a section of the heart muscle is blocked) occur with unstable angina? why?
- The thrombus occlusion/blockage is ___________
- Thrombus ________ - EKG changes show:
- Ischemia or infarction changes?
- Transient, temporary, or both abnormalities - are troponin or other cardiac enzymes elevated? why?
- NO b/c
- The thrombus occlusion/blockage is only partial (so some blood flow is getting through)
- Thrombus dissolves - ischemia, both
- No – troponin is and indicator of heart muscle damage, and that doesn’t happen with UA
An umbrella term that includes a range of conditions that occur when blood flow to the heart muscle is suddenly reduced or blocked.
- similar patho
-similar presentation and early management rules
- _______ would require eval for acute reperfusion intervention
Acute coronary syndrome
STEMI
s/s of MI or ACS?
- chest pain lasts a long time
- no relief with nitrates
- tightness
- elephant on chest
- diaphoresis
- SOA
-n/v
- anxiety
- discomfort or tingling in arms, back, neck, shoulder, jaw
- remember men and women can present different
- GI symptoms (heartburn, n/v) – women
- suddenly dizzy – women
- cold sweat – women
- unusual tiredness – women
ACS
when stable angina changes or gets worse that’s when we consider ______
ACS
ACS s/s
remember men and women can present different. what are (4) unique women s/s?
- GI symptoms (heartburn, n/v) – women
- suddenly dizzy – women
- cold sweat – women
- unusual tiredness – women
_______ plaque: This type of plaque is less likely to rupture or break off. It often has a fibrous cap that helps to stabilize it.
________ plaque: This type of plaque is more likely to rupture, leading to a blood clot that can block blood flow to the heart or brain. It often has a thinner, more fragile cap.
Stable
Unstable
Chest pain that:
- occurs at rest or with minimal exertion
- often indicating a more severe underlying condition.
- plaque disruption and platelet aggregation
- Unstable plaque
- clot is small
- blood supply is maintained
- New or changing chest pain caused by ischemia (insufficient blood flow to an organ or tissue,)
unstable angina
unstable angina
- _______ disruption and _______ aggregation
- Unstable or stable plaque?
- clot is big or small?
- blood supply is maintained or blocked?
- New or changing chest pain caused by ischemia or infarction?
- plaque disruption and platelet aggregation
- Unstable plaque
- clot is small
- blood supply is maintained
- New or changing chest pain caused by ischemia
A type of acute Myocardial Infarction
-thrombus is present
- vessel is more narrowed (b/c of unstable plaque and plaque disruption and platelet aggregation that turned into a thrombus)
- some blood is still able to get through
NSTEMI
A type of acute Myocardial Infarction
- thrombus is present
- vessel is completed occluded (b/c of the thrombus)
- blood flow is completely blocked
STEMI
s/s of MI or unstable angina?
- diaphoresis
- dyspnea
- extreme anxiety
- levine’s sign – fist to chest
- pallor
- retrosternal crushing chest pain that radiates to shoulder, arm, jaw, back
- weak pulses
MI
- ST segment = depression or normal
ST segment = elevation “tombstone” - QRS complex = wide, develops over hours
QRS complex = normal “narrow” - T wave = peaked, then inverted
T wave = inverted - Troponin = elevated, goes back to normal
Troponin = sudden elevation, continues - Size of infarct/necrosis = smaller area
Size of infarct/necrosis = larger area
6.
Outcomes = poorer
Outcomes = better
- NSTEMI
STEMI - STEMI
NSTEMI - STEMI
NSTEMI - NSTEMI
STEMI - NSTEMI
STEMI - STEMI
NSTEMI
stable vs unstable plaque:
- Size of lipid core
- ______ plaque = small lipid core
- ______ plaque = large lipid core - Size of fibrous cap
- _______ plaque = large
- _______ plaque = small - Inflammation (CRP levels)
- ________ plaque = not as active
- ________ plaque = active
- stable - small core is good
unstable - large core is bad (if the core is big it means the fibrous cap is small, the cap is what stabilizes it, so plaque is unstable and could break off) - cap stabilizes lipid core
stable = large cap is good
unstable = small cap is bad - stable
unstable
stable vs unstable plaque
- Smooth muscle cell
-_______ plaque = more smooth muscle
- ______ plaque = fewer smooth muscle cells - Proliferation of smooth muscle cells
- _______ plaque = less proliferation of smooth muscle cells
- ______ plaque = Smooth muscle cells often proliferate - Intima - innermost layer of a blood vessel
- ______ plaque = intima is often covered by a thick, fibrous cap
- _______ plaque = intima may be thinner
- stable plaque = smooth muscle cells often migrate to the surface and form a thick, fibrous cap. This fibrous cap helps to stabilize the plaque and reduce the risk of rupture.
- unstable plaque = fewer smooth muscle cells, This can lead to a thinner, more fragile fibrous cap, making the plaque more likely to rupture.
- unstable plaque = less proliferation of smooth muscle cells or the proliferating cells may be dysfunctional. This can lead to a thinner, more fragile fibrous cap and increase the risk of plaque rupture.
- stable plaque = Smooth muscle cells often proliferate in stable plaque, contributing to the formation of a thick, fibrous cap that helps to stabilize the plaque.
- stable plaque = intima is often covered by a thick, fibrous cap that helps to stabilize the plaque. This fibrous cap is formed by the proliferation of smooth muscle cells and the deposition of extracellular matrix proteins.
- unstable plaque = intima may be thinner and more vulnerable to rupture.
Theory of plaque rupture
- Factors such as
- ________ stress
- _______
- _________
Cause - ___CREASED SNS ACTIVITY =
- ___creased BP, HR and force of contraction =
- ___creased force of coronary artery blood flow =
- ___creased force exerted against injured endothelium =
- _________ RUPTURE =
- _________ adhere to ruptured plaque
- substances are released that:
- attract more _________
- contribute to vaso______ - __________ FORMATION
Theory of plaque rupture
- Factors such as
- psychological stress
- exercise
- circadian rhythms
Cause - INCREASED SNS ACTIVITY =
- increased BP, HR and force of contraction =
- increased force of coronary artery blood flow =
- increased force exerted against injured endothelium =
- PLAQUE RUPTURE =
- platelets adhere to ruptured plaque
- substances are released that:
- attract more platelets
- contribute to vasospasm - THROMBUS FORMATION
ACS vs stable angina
- which lasts longer?
- which one is relieved by Nitrates?
- which one has additional pain descriptors that include tightness, elephant on chest?
- Which one has Accompanying symptoms that include diaphoresis, SOA, n/v, anxiety?
- ACS
- SA
- ACS
- ACS
Acute myocardial infarctions (STEMI and NSTEMI)
- AMI is associated with the rupture of a _____________ and results in formation of a ___________
- The thrombus can cause ______ or _________ disruption in blood flow
- We classify AMI as STEMI or NSTEMI based on _____________
- myocardial cells suffer irreversible ischemic _________
AMI is ACS with:
- temporary or prolonged ischemia?
- without recovery or with recovery?
- AMI is associated with the rupture of a vulnerable/unstable atherosclerotic plaque and results in formation of a thrombus.
- The thrombus can cause partial or total disruption in blood flow
- We classify AMI as STEMI or NSTEMI based on EKG findings
- myocardial cells suffer irreversible ischemic necrosis
- AMI is ACS with:
prolonged ischemia
without recovery (permanent)
AMI
- does Myocardial infarction (blood flow to a section of the heart muscle is blocked) occur with AMI? why?
- The thrombus occlusion/blockage is causing _______ or ________ to blood flow - EKG changes:
______ – normal or depressed ST segment
______ – elevated ST segment - troponin or other cardiac enzymes elevated?
- yes
- The thrombus occlusion/blockage is causing prolonged disruption in blood flow (none or very little blood flow is getting through for a prolonged time)
OR
- The thrombus occlusion/blockage is causing total blood flow disruption in blood flow (no blood flow is getting through) - NSTEMI
STEMI - Yes – troponin is and indicator of heart muscle damage, heart damage occurs with both STEMI and NSTEMI acute MI. - Should be back to normal after occlusion is fixed
The extend of damage occurred during AMI depends on 3 factors
- location or level of occlusion in the coronary artery – small or large artery occluded, total or partial occlusion?
- length of time that the coronary artery has been occluded – time is tissue!
- hearts availability of
collateral circulation - body naturally builds other vessels around the occlusion to keep blood flow, like a compensatory mechanism, can be a good thing
ischemia vs infarction
insufficient blood flow to an organ or tissue, leading to a lack of oxygen and nutrients.
- This can cause tissue damage, but the tissue may still be viable if blood flow is restored quickly (reversible)
ischemia
insufficient blood flow to an organ or tissue, leading to a lack of oxygen and nutrients, is prolonged and severe, leading to tissue death.
- it cannot be revived (irreversible)
- this can occur within 30 min – 4 hour
infarction
Infarction - ischemia is prolonged and severe, leading to tissue death.
- Once tissue has infarcted, it cannot be ___________
- this can occur within ___ min – ___ hours
- at 4 hours – tissue _______ begins
- in 1-2 weeks – ____ tissue is cleared away
- in 6 weeks – _________ tissue replaces the necrotic tissue
- Once tissue has infarcted, it cannot be revived (irreversible)
- this can occur within 30 min – 4 hour
- at 4 hours – tissue necrosis begins
- in 1-2 weeks – necrotic tissue is cleared away
- in 6 weeks – tough fibrous scar tissue replaces the necrotic tissue
AMI
3 zones of damage
1st – __________ zone (reversible)
- full recovery is possible
2nd – ________ (reversible)
- not dead yet
- some recovery is possible – so we can perfuse it and restore it to become viable
3rd – _________ = necrosis (irreversible)
- MI
- dead cells
- cant recover dead cells
- can stop it from increasing
- Increase oxygen
- Decrease the demand on the heart
ischemic
injury
infarction
infarction
1. can we recover dead cells?
2. can we stop necrosis from increasing?
- ___crease oxygen
- ___crease the demand on the heart
- no
- yes
- Increase oxygen
- Decrease the demand on the heart
____________ artery
- supplies the left ventricle (worst one to occlude b/c without LV heart can’t pump blood out to body)
- most commonly involved in MI
- “widomaker”
Left anterior descending (LAD) artery
AMI treatment
(6)
morphine
oxygen
nitroglycerin
ASA
beta blockers
thrombolytic agent - maybe
AMI pharm
Acute MI/STEMI treatment
__________
- Increases o2 delivery to ischemic myocardium
___________
- Suppresses platelet aggregation
- Decreases mortality
- Chew first dose
___________
- Decrease pain
- Reduce preload and afterload
- Helps preserve ischemic tissue
__________ (if no contraindications)
- Reduce HR and contractility = reduces oxygen demand
- Reduces pain, infarct size, and mortality
___________
- Reduces preload and afterload
- Limits infarct size
- Doesn’t reduce mortality
_________ (if pt is eligible)
- ideally used within 4-6 hours of onset of MI
oxygen
ASA
morphine
beta blockers
nitroglycerin
thrombolytic agent
fibrinolytic therapy/thrombolytic agent
MOA
Dissolves existing clot by converting plasminogen into plasma
Adv - Most effective
Disadv – works best within ___-___ mins, ideally used within ___-___ hours of onset of MI
s/e
________
contraindicated with hx of brain bleed
always give with heparin and antiplatelet therapy (prevents new clot from forming)
alteplase (tPa)
30-70 min
4-6 hours
bleeding
s/e
hypotension
h/a
flushing
severe hypotension especially when given with nitrates
do not give with sildenafil (Viagra) – risk of severe hypotension
nitroglycerine
__________ - medical procedures aimed at restoring blood flow to an organ or tissue that has been deprived of oxygen due to ischemia
ex: balloon catheter or stent
_____________ - rapid restoration (surge) of blood flow to the myocardium also contributes to injury b/c of myocardial stunning
reperfusion
reperfusion injury
reperfusion injury
caused by
- oxidized free radicals generated by _______
- ________ response to restored blood flow
Monitor for
- reperfusion ________ - esp. _____ and _____
caused by
- oxidized free radicals generated by WBCs
- cellular response to restored blood flow
Monitor for
- reperfusion dysrhythmias
– esp. VTACH and VFIB
Long term drug therapy after MI:
_______
– inhibit platelet aggregation
________
– reduce HR and BP
- lowers risk of death when continued long-term after MI
________
– stimulate dilation of blood vessels by inhibiting angiotensin II
- improves ventricular remodeling after MI
________
– addresses the CV disease
Aspirin
Beta blockers
ACE inhibitors
statin
localized dilation or outpouching of a vessel wall
- cause turbulent blood flow
- are susceptible to rupture
- bruits may be heard over it
aneurysms
aneurysms
localized dilation or outpouching of a vessel wall
- cause ________ blood flow
- are susceptible to _______
- _______ may be heard over aneurysm
aneurysms
localized dilation or outpouching of a vessel wall
- cause turbulent blood flow
- are susceptible to rupture
- bruits may be heard over aneurysm
aneurysms patho
1. ______ weakens the artery walls
2. increases development of ______ in artery walls “aneurysms”
- HTN weakens the artery walls
- increases development of bulges in artery walls “aneurysms”
Risk factors for _______ are Anything that causes damage to blood vessels:
- atherosclerosis
- HTN
- disease of blood vessels
- trauma
- tobacco use
- age >65 years
- hereditary
s/s
- depend on location
- may be asymptomatic
aneurysms
most common aneurysms:
1. veins or arteries?
2. which 3 arteries?
3. whats the “triple A”
4. variation: ______ ________
- aortic
- aortic, thoracic, and cerebral
- abdominal aortic aneurysm
- aortic dissection
- auscultation of a bruit over the abdominal aorta suggests the presence of an ___________
- if a pulsatile mass is evident in the abdomen during inspection or light palpation: ________ should not be performed until the possibility of AAA is ruled out
- complications of AAA: __________ – will bleed out quickly
- abdominal aortic aneurysms (AAA)
- deep palpation
- rupture
bulging in all 3 layers of the vessel wall =
tear in the artery wall that causes separation of the vessle, and blood is getting in between vessel layers, only single outside layer is still intact =
localized tear in 1-2 layers of the artery wall =
aneurysm
dissecting aneurysm
pseudo aneurysm
variation: aortic dissection/dissecting aneurysm:
1. ______ of the artery wall are separated and blood enters the region
2. having an ________ can increase your risk of having an aortic dissection
3. dx with a ____ or ______
4. surgical emergency – minutes counts (most important intervention is _______)
5. emergency pharm – ______ (lower HR and BP) and _______
- layers of the artery wall are separated and blood enters the region
- having an aneurysm can increase your risk of having an aortic dissection
- dx with a CT scan or MRA (Magnetic Resonance Angiography - type of MRI scan that specifically looks at blood vessels and blood flow)
- surgical emergency – minutes counts (most important intervention)
- emergency pharm – beta blockers (lower HR and BP) and nitrates
high vs very high risk for rupture:
- Aneurysm: A bulging of the aorta.
- Dissection aneurysm: A tear in the inner layers of the aorta. only outer layer is still intact.
- Aneurysm: A bulging of the aorta. High rupture risk!
- Dissection: A tear in the inner layer of the aorta. outer layer is still intact… but for how long? Very high rupture risk!!
which type of aneurysm?
s/s
- sudden severe, tearing pain in chest, neck, back, jaw or abdomen
early sign
- BP rises
late sign
- BP is so low it may be unobtainable
- syncope
- hemiplegia – paralysis/weakness on one side of the body
- paralysis of LE
- CV collapse = shock = death
variation: aortic dissection/dissecting aneurysm
- sudden severe, tearing pain in chest, neck, back, jaw or abdomen (indicates dissection)
Types of aneurysms:
___________
- Balloon shaped
- Involves only one part of circumference of vessel
- wide neck
saccular
Types of aneurysms:
_________
- entire circumference of vessel
- gradual/progressive dilation
- potentially extensive involvement
- usually r/t diffuse anterior sclerotic changes
- treatment - may be monitored for growth, intervention not required until it gets to a certain size
fusiform
__________ aneurysm
- localized dissection/tear in 1-2 layers of inner artery wall
- type of hematoma
- complication of vascular interventional procedures
- treatment – may heal on own or require intervention
pseudo/false
Pericardial disease
any condition that affects the __________, the sac-like membrane that encases the heart
pericardium
pericardial layers listed superficial to deep
1. __________ - thin, fibrous sac that surrounds the heart.
Contains 2 layers:
- _________ pericardium: The outer layer, which is tough and inelastic.
- ________ pericardium: The inner layer, which is divided into two parts: the parietal pericardium and the visceral pericardium.
__________ : This is the thickest layer of the heart and is made up of cardiac muscle tissue. It is responsible for the heart’s pumping action.
____________ : This is the innermost layer of the heart, lining the chambers and valves. It is composed of endothelial cells, which help to prevent blood clots from forming.
pericardium
- Fibrous
- Serous
Myocardium
Endocardium
pericardium is inflamed and fluid (pericardial effusion) accumulates in the pericardial space surrounding the heart
pericarditis
- some fluid in the pericardial space surrounding the heart is =
- if fluid accumulates to >200 mL = __________ the heart = “_________ _________”
- cardiac tamponade – ______ ______ are restricted by the surrounding pericardial fluid so they can’t stretch and fill with blood
- medical emergency
- drain fluid STAT or pt will die
ok, it serves as lubrication
compresses
cardiac tamponade
heart chambers
s/s of acute _________
- chest pain – sharp and worsens with deep breathing
- fever – inflammatory response
- dyspnea
- pericardial friction rub – scratching sounds
- EKG findings – ST segment can be elevated or depressed
- pulsus paradoxus – decrease of 10 or more systolic blood pressure during inspiration
- “Beck triad”:
- hypotension
- jugular vein distension
- muffled heart sounds
which (2) are associated with cardiac tamponade?
pericarditis
- pulsus paradoxus
- “Beck triad”:
- hypotension
- jugular vein distension
- muffled heart sounds
treatment for _______
- NSAIDS
- ASA
- corticosteroids – pros and cons
- colchicine – indicated when not responding to ________
pericarditis
NSAIDS
Inflammatory disease of the myocardium (muscle layer of heart) with degeneration and necrosis of cardiac myocytes (muscle cells)
- can range from a mild disorder (pain) to a lethal condition (HF, needs transplant to survive)
- dysrhythmias/conduction disruption is common
myocarditis
Etiology
- virus most common – coxsackie viruses A and B
myocarditis
________ aneurysm
- subtype of saccular
- small neck
- dx by angiography
- get hx of clinical manifestations
- located at bifurcation of arteries
- common location – circle of Willis (at base of brain - provides connection between the anterior and posterior circulation systems, arteries that stem off from the COW supply a lot of blood to the brain)
- treatment – medical control of HTN and vasospasms OR surgical drain, clipping, coiling
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