17 and 18. Acute Coronary Syndrome and chronic coronary artery diseaes

Question 1

UA, NSTEMI, STEMI are result of:

Answer 1

acute atheromatous plaque rupture with variable degree of coronary lumen obstruction

Question 2

Tx recommendation for ACS

Answer 2

Best rest, analgesics, Oxygen, Statins, Beta blockers and nitrates

Question 3

With ACS, you IG will form a thrombus as a result of

Answer 3

Plaque rupture which causes: Platelet activation/adhesion/aggregation Activation of Coag factors

Question 4

What tx would you want to give someone right away with Thrombus formation during ACS?

Answer 4

Antiplatelets: aspririn/Clopidigrel/Prasurgrel/Ticagrelor OR Antithrombics: heparin/LMWH/Direct thrombin inhbitors

Question 5

Once we know patient has ACS… what is our goal?

Answer 5

Reperfusion: #1 immediate PCI and use Thrombolytics (in UA and NSTEMI, still have some flow, so give drugs and hold off on PCI>> reevaluate in few weeks) Do cardiac Catheterization: PCI or CABG

Question 6

What ECG and lab findings do we expect to see in STEMI?

Answer 6

ST elevation (but not always) and elevated CK and CK-MB pt will have chest pain, diaphoresis, and perhaps hitsory of DM, HTN, smoking

Question 7

Recommend reperfusion of infarct related to STEMI?

Answer 7

IV throbmolytic therapy Emergency coronary interevention

Question 8

How would you get acute left to right intracardiac shunt?

Answer 8

IV septum rupture

Question 9

What would you expect to see in pt with NSTEMI on ECG and in labs

Answer 9

will have elevated enZ but will NOT have elevated ST; will be DEPRESSED!

Question 10

Partial thrombotic occlusion of the vessel lumen results in

Answer 10

NSTEMI

Question 11

Role of thrombolytic agents in NSTEMI

Answer 11

NONE… we don’t use them

Question 12

General on IHD

Answer 12

leading cause of death worldwide –>after 40; risk of devo CAD is 49% men and 32% women

Question 13

MOst common cause of IHD

Answer 13

obstruction of coronary arteries by atheromatous plaque also congenital issues, vasculitis or radiation

Question 14

How are ACS and IHD similar?

Answer 14

Both are caused by restrictive blood flow to myocardium d/t flow restrictions in coronary arteries Supply/demand mismatch

Question 15

Chronic stable angina on ECG and labs?

Answer 15

only ST depression during episode.. goes away and CK and MB-CK are normal

Question 16

How will a pt with IHD present at clinic?

Answer 16

chronic chest discomfort (stable angina), have heart fail, cardiac arrythmias or have sudden death. (very similar to acute MI but more chronic in nature)

Question 17

What can we give to someone with Angina pectoris?

Answer 17

Nitroglycerin or rest

Question 18

Diagnosis of CAD: Early finding on ECG Late findings on ECG

Answer 18

Early we see ST elevation; shows that we’ve had injury Later we will see development of Q waves

Question 19

In a timeline of MI: Immidately before MI starts: Within hours after MI: Weeks later:

Answer 19

T wave inversion ST elevation Significant Q wave only

Question 20

Leads to look at for LATERAL wall damage

Answer 20

V5, V6

I, aVL

Question 21

Inferior wall leads

Answer 21

II, III, aVF

Question 22

Anterior wall leads

Answer 22

V2-V4

Question 23

Damage to LAD is likely to show up on which leads

Answer 23

V1-V6

I

aVL

(anterior leads)

Question 24

Damage to RCA likely to show up on which leads?

Answer 24

Inferior ones:

II, III, aVF

Question 25

Damage to CIRC likely to show up on which leads

Answer 25

I, aVL, V5-V6

(Lateral leads)

Question 26

What type of data do we collect during stress testing?

Answer 26

look for ECG changes (twave inversions, ST depression or elevation)

Do imaging for wall mostion abnormalities or defect

Question 27

Whats an option for stress testing in those that can’t exercise?

Answer 27

Dobutamine; will increase HR and contractility

Adenosine: cause arterial dilation for normal arteries, abnormal ones will not dilate

Question 28

What is the Gold Standard for Diagnosis of obstructed coronary blood flow?

Answer 28

Angiography

lesions of >70% are considered significant

Question 29

What medical tx can we give to pts with decreased cornary blood flow?

Answer 29

Antiplats: apsirin or ADP-R inhibitors

Beta blocks

Ca+ blockers

ACEI

Nitrates

STatins

Question 30

Aspirin therapy in pts with exsisting CAD will reduce future events by:

Answer 30

25%

Question 31

Whats all the cool shit that Beta blockers do?

Answer 31

Decrease O2 demand via decrease HR, BP, and contractility

Decrease V fib risk

Decrease automaticity; increased electrophysiologic threshold

Bradycardia wil prolong diastole thus improves diastolic perfusion

REDUCTION IN REMODELING and improves LV hemodynamics to reduce infarct

reduce risk of mortality after MI by 23%

Question 32

Metoprolol and Carvelilol are examples of what kind of drugs?

Answer 32

Beta blockers

selective for beta 1

Question 33

Overall effect of Ca+ Channel Blockers

Answer 33

reduce myocardial O2 demand and increase O2 supply

Helpful in pts with Prinzmetal

No mortality benefit, just symptom relief

Question 34

When are ACE I really beneficial

Answer 34

For pt with low LV ejection fraction after MI… can help up to 26%

(still helpful after MI by reducing mortality by 22%)

Question 35

Action of Nitrates

Answer 35

relax vascular smooth muscle

Mostly in the VENOUS system which reduces PRELOAD==> thus reduces myocardial wall tension and oxygen requirements

Question 36

Would we do revascularization for crhonic CAD?

Answer 36

we can do it electivly for symtomatic lesions:

PCI such as balloon or stent or a surgical bypass

** do this AFTER we’ve tried medical therapy and antianginal therapy as well as lifestyle changes

Question 37

What situations would CABG be preferred over PCI?

Answer 37

Left main

Triple vessel

Double vessel with proximal LAD and LVEF <50%

Diabetics

Question 38

Sequela of Chronic CAD

Answer 38

Cardiomyopathy (heart fail)

LV aneurysms

Ventricular Arrhthmias/Sudden Death

Question 39

Cardiac Arrest risk is higher post MI especially if:

Answer 39

Left ventricular ejection fraction is depressed

*put in implantable cardiac defribilatory if you have LVEF