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Cardio final > Silverstein Ischemia stuff > Flashcards

Silverstein Ischemia stuff Flashcards

1
Q

What does ischemia look like on an ECG?

A

T wave inversions that are >1mm and are symmetric

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2
Q

What does strain look like on an ECG?

A

asymmetric inverted T waves

HTN, BBB, etc

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3
Q

Which leads will show ST elevation in an inferior infarct? What vessel is likely infarcted?

A

II, III, aVF

RCA

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4
Q

Which leads will show ST elevation in an anteroseptal infarct? What vessel is likely infarcted?

A

V1-V4

LAD

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5
Q

Which leads will show ST elevation in an lateral infarct? What vessel is likely infarcted?

A

I, aVL, V5, V6

varies*

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6
Q

What is an important consideration in treating pts with right ventricular infarctions? What will this look like on an ECG?

A

these pts are preload dependent

giving nitro will cause their BP to drop

inferior MI with V1 ST elevation >V2 or with a depressed V2

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7
Q

What is a Q wave due to?

A

necrotic tissue will not produce electrical current (not viable)

Q wave reflects current from tissue opposite the infarct

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8
Q

what are the differences in a normal vs abnormal Q wave?

A

Normal Q wave:

  • left to right depolarization of the septum
  • small normal in I, aVL, V5, V6

Abnormal Q wave:
>1 box wide and 2 boxes deep
>25% of depth of QRS complex
-seen in V1-3

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9
Q

What will Pericarditis present with?

A

diffuse ST elevation

PR depression

TP segment is most isoelectric

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10
Q

What will early depolarization look like on an ECG?

A

Smiley face, concave shape from J point to apex with ST elevation <0.5 mm in limb leads

no reciprocal changes

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11
Q

Which walls of the heart are related to each precordial lead?

A

V1-2=septal

V3-4 =anterior

V5-6=lateral

NONE for posterior!!

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12
Q

What are the risk factors for CAD?

A 
History of known CAD
Age (Men 60+; Women 70+)
HTN
Hypercholesterolemia
Tobacco
Diabetes
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13
Q

How does hypertension increase risk of CAD?

A

Endothelial injury –> inc permeability to lipoproteins

increase in scavenger receptors on macrophages–> inc foam cells

increased production of proteoglycans which retain LDL

Angiotensin II stimulates NADPH oxidases–> increases oxidative stress + proinflammation

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14
Q

How does diabetes increase risk for CAD?

A

Glycation of lipoproteins–> increase cholesterol uptake by scavenger macrophages

Prothrombotic; antifibrinolytic

Reduced NO

Increased leukocyte adhesion

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15
Q

What are the 4 major characteristics of stable angina?

A
  1. quality: pressure, heaviness squeezing or burning (NOT sharp)
    - -> Levine’s sign (arm over chest)
  2. exacerbation by increase O2 demand (exercise or emotional stress and sometimes cold weather or large meals)
  3. relief with rest or sublingual nitroglycerin
  4. accompanying symptoms of SOB (due to increased LVEDP–> inc. pulm P), nausea (vagal stimulation), diaphoresis (sympathetic stimulation
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16
Q

How long does the pain from stable angina typically last?

A

2-10 minutes

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17
Q

Where is angina pain normally felt?

A

Retrosternal
Diffuse
(Patient points to location with 1 finger-> probably NOT angina)

Can radiate to shoulder, jaw, neck, arm

  • Especially left
  • Sometimes epigastric
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18
Q

What is the difference between stable and unstable angina (onset and duration)?

A

stable=triggered by exercise and only lasts about 2-10 minutes with rest

unstable=brought on by light exertion or at rest and lasts up to 20 minutes

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19
Q

How does exercise increase myocardial O2 demand?

A

increase HR and contractility

increase wall stress

20
Q

What percentage of the vessel is narrowed in stable angina? Unstable?

A

stable=70-90%
unstable = > 90%

asymptomatic= <60%

21
Q

What test should be ordered for suspected CAD?

If this is does not confirm your diagnosis, what should be ordered next? Why?

A

Exercise Tolerance Test (stress test) (only 65-70% sensitive)

> 1mm horizontal or downsloping ST depression –> angina

if inconclusive, order imaging (nuclear stress test and ECHO) –> more sensitive than stress test

22
Q

If the pt cannot exercise, what medication should be given during stress tests? What do these medications do?

A

adenosine–> vasodilation

ECHO: Dobutamine (beta agonist) –> increase the O2 demand by inc. HR and contractility

23
Q

What is the first line of treatment for chronic stable angina? What does this medication do?

A

beta-blocker

decrease contractility and HR and increase the time spent in diastole

also improve mortality in post-MI pts

24
Q

When is revascularization the first line treatment for angina? (3 conditions)

A

(refractory symptoms or increased risk)

left main

3 vessel diseases with reduced ejection fraction

multi-vessel disease with diabetes

25
Q

What additional pharm treatments should be given in chronic stable angina?

A

aspririn –> decrease likelihood of thrombus

high dose statin==> decrease lipid content and decrease inflammation

26
Q

What are the characteristics of a “vulnerable” plaque?

A

larger lipid pool

thin fibrous cap

many inflammatory cells

often rupture with plaque formation leading to MI

27
Q

What are the 4 classes of the grading of angina?

A

I: angina with strenuous/prolonged exercise

II: angina w/exercise

III: angina w/ everyday activity

IV: angina w/ any activity or rest

28
Q

Pt that are _____ likelihood of CAD by history should undergo a stress test.

A

intermediate

29
Q

What heart sounds are commonly heard during episodes of ischemia?

A

S4 (atrial contraction against a non-compliant ventricle)

S3 due to systolic dysfunction

Mitral regurgitation murmur

30
Q

What EKG changes indicate a high likelihood of CAD?

A

STEMI or ST depression > 1mm

marked symmetric T wave inversions

dynamic EKG changes with pain

intermediate:
T-wave inversion > 1mm, ST depression .5-1 mm

31
Q

What is Wellen’s sign?

A

deep symmetric T wave inversions in V 2-4

32
Q

What is the main mechanism by which nitroglycerin helps ischemia?

A. Reduced preload

B. Reduced afterload

C. Coronary vasodilation

A

A. reduced preload (by increasing systemic venodilation)

33
Q

What will help you determine between unstable angina and NSTEMI?

A

Troponin!!

unstable angina will NOT have + troponins

34
Q

How do you distinguish between stable and unstable angina?

A

clinical presentation

35
Q

How do you distinguish between a NSTEMI and a STEMI?

A

EKG findings

STEMI=ST elevation–> Q waves

NSTEMI=ST depression and/or T wave inversion

36
Q

What lab results are necessary to rule out an NSTEMI?

A

2 negative serial troponins at least 6 hours apart

37
Q

What is the early treatment for ACS?

A

Aspirin

Nitrates IF ongoing pain

Beta-blockers (latest guidelines oral preferred)

Platelet receptor inhibitors (clopidogrel/ticagrelor; prasugrel if intervention)

Anticoagulant (enoxaparin, fondaparinux, heparin; bivalirudin if intervention)

High dose statin (atorvastatin 80 based on PROVE-IT trial)

38
Q

When is an aldosterone antagonist indicated in ACS?

A

if the ejection fraction is LOW

39
Q

What is the TIMI Score used for?

What is it comprised of?

A

Used to determine angiogram (high risk) vs. stress test (low risk)

AMERICA pneumonic

Age >65

elevated bioMarker (troponin/CKMB)

ST segment deviations on Ekg

> or 3 Risk factors

2+ anginal episodes (Ischemia) in the last 24 hours

known Cad >50%

use of Aspirin in prior 7 days

40
Q

When is early invasive strategy recommended?

A

TIMI 3+

elevated biomarkers

new ST depression

heart failure, new/worse MR, LVEF ≤ 40

Shock

VT
recurrent severe angina despite aggressive therapy*

Prior MI, stent or bypass surgery, heart failure

If none of above: can do stress test pre-discharge

41
Q

What is the discharge treatment for unstable angina or an NSTEMI?

A

Dual Anti-platelet (aspirin + plavix) x 12mo

Statin

Beta-blocker

Lifestyle modification

ACE inhibitor

42
Q

What type of coronary lesion causes ST elevation?

A

plaque with occlusive thrombus

43
Q

What medication should immediately be given to any patient with chest pain?

A

Aspirin (unless the pt has an allergy)

44
Q

What is the major treatment for STEMI? How can this be achieved (2)?

A

re-open the vessel

fibrinolysis (alteplase, reteplase, tenecteplast, streptokinase) or a stent placement

45
Q

What are the complications of an RCA injury? (4)

A

Sinus bradycardia

Atrioventricular block

Right ventricular infarction

Posteromedial papillary muscle rupture

(RCA supplies the right ventricle)

46
Q

What are the complications of an LAD injury?

A

Bundle branch blocks

Left ventricular free wall rupture

Ventricular septal rupture

Ventricular aneurysm
Stroke

47
Q

What are the complications of BOTH an RCA and LAD injury?

A

V fibrillation

CHF/cardiogenic shock/pericarditis/dressler

Cardio final (15 decks)

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