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Internal Medicine > JH IM Board Review - Coronary Artery Disease II > Flashcards

JH IM Board Review - Coronary Artery Disease II Flashcards

1
Q

ACS includes (3):

A
  1. UA.
  2. NSTEMI.
  3. STEMI.
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2
Q

All 3 syndromes occur when …

A

A VULNERABLE PLAQUE RUPTURES.

==> PLT activation and aggregation ==> Intracoronary thrombus.

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3
Q

Definition of UA:

A
  1. Angina at rest (>20min).
  2. New-onset exertional angina of at least class III in severity (ie w/ mild exertion).
  3. Preexisting angina that has increased in frequency or duration or that is now brought on w/ less exertion than before.
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4
Q

Definition of NSTEMI:

A

Clinically similar to UA, but distinguished by evidence of myocardial necrosis (ie elevation in serum cardiac enzymes).

ECG does not show ST elevation.

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5
Q

Definition of STEMI:

A

Elevated cardiac enzymes and ECG criteria that include >1mm ST segment elevation in two or more contiguous limb leads.

Or >2mm ST segment elevation in 2 or more contiguous PRECORDIAL leads.

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6
Q

Of note, a new or presumed new LBBB is …

A

NO LONGER considered a STEMI equivalent. (2013 ACC/AHA)

==> Must employ other ECG criteria to diagnose MI in these cases.

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7
Q

NSTEMI vs STEMI - ECG:

A

NSTEMI ==> ST depressions, T inversions, nonspecific ST-T changes.

STEMI ==> ST elevation.

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8
Q

NSTEMI vs STEMI - Vessel at time of catheterization:

A

NSTEMI ==> 30-40% occluded.

STEMI ==> >80%.

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9
Q

NSTEMI vs STEMI - Type of clot?

A

NSTEMI ==> Rich in PLTs (white).

STEMI ==> Rich in fibrin (red).

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10
Q

NSTEMI vs STEMI - Extent of disease?

A

NSTEMI ==> More likely collateral formation and multivessel disease.

STEMI ==> More commonly single vessel.

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11
Q

NSTEMI vs STEMI - Tx:

A

NSTEMI ==> Thrombolysis NOT recommended — GP IIb/IIIa inhibitors can be useful.

STEMI ==> Thrombolysis beneficial — GP IIb/IIIa inhibitors usually not indicated (unless PCI performed).

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12
Q

NSTEMI vs STEMI - Hospital mortality?

A

NSTEMI ==> Lower.

STEMI ==> Higher.

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13
Q

NSTEMI vs STEMI - Reinfarction rate?

A

NSTEMI ==> Higher after d/c.

STEMI ==> Lower after d/c.

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14
Q

NSTEMI vs STEMI - Long-term prognosis?

A

NSTEMI ==> Higher 1y mortality rate after d/c.

STEMI ==> Lower 1y mortality rate after d/c.

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15
Q

Of note, …-…% of ACSs are clinically silent.

A

20-30%.

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16
Q

TIMI (thrombolysis in MI) risk score for UA/NSTEMI - RFs:

7

A
  1. > 65y.
  2. 3 or more coronary artery RFs.
  3. Prior coronary stenosis >50%.
  4. > 2 anginal events in past 24h.
  5. Aspirin use in past 7 days.
  6. ST-segment changes.
  7. Positive cardiac markers.
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17
Q

Risk of adverse cardiac event by TIMI score:

A

0-1 ==> 4.7% (Low risk).

2 ==> 8.3% (Low risk).

3 ==> 13.2% (Intermediate risk).

4 ==> 19.9% (Intermediate risk).

5 ==> 26.2% (High risk).

6-7 ==> 41% (High risk).

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18
Q

Calculate GRACE (Global Registry of Acute Coronary Events) 2.0 risk score.

Incorporates (7):

A
  1. Age.
  2. HR.
  3. SBP.
  4. Killip class.
  5. Presence of cardiac arrest.
  6. ST-segment change.
  7. Troponins.
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19
Q

The GRACE 2.0 score estimates …

A

6mo mortality.

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20
Q

Always consider other diagnoses that can mimic ACS (3):

A
  1. AD.
  2. Acute pericarditis.
  3. PE.
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21
Q

AD - ECG can reveal ST elevations if the …

A

Dissection involves one or more of the coronary arteries.

typically affect the RCA first

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22
Q

Management of UA/NSTEMI - Medical therapy consists of (6):

A
  1. Antiplatelet therapy.
  2. Antithrombotic therapy.
  3. Beta blockers.
  4. Nitrates.
  5. CCBs.
  6. Statins.
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23
Q

UA/NSTEMI - Antiplatelet therapy consists of …

A
  1. Aspirin.
  2. Thienopyridines.
  3. GpIIb/IIIa inhibitors.
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24
Q

UA/NSTEMI - Aspirin leads to more than …% relative reduction in risk of MI and death.

A

50%.

Should be continued INDEFINITELY.

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25
Q

UA/NSTEMI - Thienopyridines - Clopidogrel:

A

Reduces adverse cardiac events in pts with UA/NSTEMI when given in addition to aspirin.

==> Continue for at least 12mo if PCI with DES.

==> 1 month if PCI with BMS.

==> 9 mo if NO PCI.

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26
Q

UA/NSTEMI - Prasugrel should be avoided in pts who may be potential candidates for …

A

CABG.

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27
Q

UA/NSTEMI - Role of GpIIb/IIIa:

A

Clear benefit demonstrated in both UA and NSTEMI.

==> The greatest benefit is seen in pts who have positive troponins and are treated with PCI.

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28
Q

Abciximab has clear benefit in …

A

UA/NSTEMI undergoing PCI.

NO BENEFIT in pts with UA/NSTEMI who do NOT require PCI.

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29
Q

Antithrombotic therapy is a/w …

A

Lower rates of MI and death in pts with ACS.

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30
Q

Enoxaparin compared to UFH in UA/NSTEMI?

A

Superior to UFH in reducing death, MI, and recurrent ischemic events in pts who are treated CONSERVATIVELY.

==> No difference in pts treated invasively, and also a/w higher rate of bleeding.

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31
Q

Fondaparinux can be used …

A

Both with conservative strategy and as an invasive strategy in pts with UA/NSTEMI.

==> Preferable to UFH or enoxaparin in pts with increased risk of bleeding.

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32
Q

Direct thrombin inhibitor - Bivalirudin is an option only in pts in whom …

A

An early invasive approach is planned.

==> If high risk of bleeding exists, then bivalirudin monotherapy can be considered instead of heparin/GpIIb/IIIa inhibition combination.

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33
Q

Beta blockers in UA?

A

Reduce ischemia + shown to reduce subsequent infarction.

34
Q

Beta blockers in NSTEMI?

A
  1. Reduce ischemia + infarct size.
  2. Help prevent reinfarction.
  3. Decr mortality.
35
Q

Administer beta blockers orally if there is no evidence of …

A

Acute heart failure.

36
Q

Do not give diltiazem, verapamil, or nifedipine in pt with LVEF

A

40%.

37
Q

Statins in UA/NSTEMI?

A

They have been shown to have antiplatelet and antioxidant properties as well.

38
Q

Thrombolytics in UA/NSTEMI?

A

NOT indicated.

39
Q

Cardiac catheterization in UA/NSTEMI - Emergent indications:

3

A
  1. Persistent ischemia despite medical tx.
  2. Hemodynamic instability.
  3. V-tach, v-fib, SCD.
40
Q

Catheterization in UA/NSTEMI - Indications in pts stabilized w/ medication tx:

A
  1. Stress test — positive high-risk results.
  2. ECG: ST depression suggesting ischemia in a large territory.
  3. ST depression on ECG + elevated enzymes.
  4. DM.
  5. CKD.
  6. Low EF.
  7. TIMI risk score: High or intermediate risk.
  8. GRACE score >140.
41
Q

Thrombolytic tx in STEMI is successful in …%

A

60%.

42
Q

Thrombolytics for STEMI are most effective when given in the first …, but can be given up to … after onset of pain.

A

6h

12h

43
Q

Between …-…, only consider thrombolytics if there is no available PCI, and the STEMI pt has hemodynamic compromise or a large myocardial area at risk.

A

12-24h

44
Q

Thrombolytic tx in STEMI — Indication?

A

Duration of sx <12h.

45
Q

Thrombolytic tx in STEMI — Absolute contra:

7

A
  1. Hx of ICH.
  2. Known cerebral vascular lesion (eg AVM).
  3. Known malignant intracranial neoplasm.
  4. Ischemic stroke within 3mo.
  5. Suspected AD.
  6. Active bleeding or bleeding diathesis.
  7. Closed-head or facial trauma within 3mo.
46
Q

Thrombolytic tx in STEMI — Relative contra:

8

A
  1. SBP >180 or DBP >110 AT PRESENTATION.
  2. Hx of ischemic stroke >3mo.
  3. Prolonged CPR (>10min).
  4. Major surgery within <3wks.
  5. Recent internal bleeding (within 2-4wks).
  6. Pregnancy.
  7. Active PUD.
  8. For strepto/anistreplase ==> Prior exposure >5 days ago or prior allergic reaction.
47
Q

Thrombolytics a/w hemorrhagic stroke — Which groups are more prone to?

(5)

A
  1. Elderly.
  2. Women.
  3. HTN.
  4. DM.
  5. Pts w/ previous stroke or treated w/ warfarin.
48
Q

PCI — Major advantages over thrombolytics:

A
  1. Higher reperfusion rates (>90% success rate).
  2. Decreased incidence of stroke.
  3. More effective than thrombolytics in pts w/ acute decompensated HF, cardiogenic shock, and prior bypass surgery.
49
Q

PCI — Major disadvantages over thrombolytics:

A

Not available in all hospitals.

50
Q

Terminology — Primary PCI:

A

Pt w/ STEMI is taken directly to the catheterization lab for PCI instead of receiving thrombolytics.

51
Q

Terminology — Rescue PCI:

A

Urgent PCI after failure to reperfuse w/ thrombolytics.

52
Q

Terminology — Pharmacoinvasive PCI:

A

PCI after reperfusion w/ thrombolytics.

53
Q

Approx. …-…% of pts receiving thrombolytics fail to reperfuse and have high mortality rates.

They have better outcomes if they then undergo rescue PCI.

A

20-30%.

54
Q

Of note, … suggests successful reperfusion after thrombolytic administration.

A

Accelerated idioventricular rhythm.

55
Q

Medications NOT recommended for STEMI tx?

A
  1. Empirical antiarrhythmics ==> Proph antiarrhythmic use can actually increase mortality in the peri-MI setting.
  2. GpIIb/IIIa inhibitors ==> Only useful if undergoing PCI. Not useful in conjunction w/ thrombolytics.
56
Q

12 complications of MI:

A
  1. Bradyarrhythmias.
  2. Mobitz I.
  3. Mobitz II.
  4. 3o AV block.
  5. BBB.
  6. Premature ventricular contractions.
  7. V-tach or V-fib.
  8. Papillary muscle rupture.
  9. Ventricular septal rupture.
  10. Ventricular free wall rupture.
  11. RV infarct.
  12. Pericarditis.
57
Q

Bradyarrhythmias are usually seen in the first …-… for all types.

A

24-48h.

58
Q

Mobitz I is usually seen w/ …

A

IMI ==> Ischemia or increased vagal tone.

Conduction block usually in AV node.

59
Q

Mobitz I may cause …

A

Asx hypotension.

60
Q

Mobitz I responds to …

A

Atropine and usually resolves in 2-3 days.

61
Q

Mobitz II is caused usually by …

A

Anterior MI.

Block typically INFRANODAL.

62
Q

Mobitz II may cause …

A

Asx hypotension.

63
Q

Mobitz II needs …

A

Temporary pacer b/c high risk for progression to complete block.

==> Many require permanent pacer.

64
Q

3o degree block is caused by either …

A

Anterior MI or IMI.

65
Q

3o degree AV block is treated w/ …

A

Permanent pacer usually required w/ AMI.

Often resolves spontaneously w/ IMI.

66
Q

BBB is usually caused by …

A

Anterior MI.

67
Q

BBB is usually seen during the first …-… .

A

24-48h.

68
Q

BBB - Tx?

A

Temporary pacer indicated for:

  1. Alternating LBBB and RBBB.
  2. RBBB w/ alternating Left Anterior Fascicular Block (LAFB) + LPFB.
  3. LBBB or RBBB w/ 1o AV block.

***BBB a/w higher mortality.

69
Q

Premature ventricular contractions are usually caused by …

A

Any MI.

70
Q

Premature ventricular contractions are usually caused during the first …-… .

A

24-72h.

Usually asx.

71
Q

Tx for premature ventricular contractions:

A
  1. Usually not required.
  2. Avoid lidocaine (can incr. mortality).
  3. Can use beta blockers.
72
Q

V-tachy/V-fib are caused by …

A

MI of any territoery, but commonly AMI.

73
Q

V-tachy/V-fib are usually seen when?

A

VT in first 24h ==> Usually transient and benign.

Late VT ==> Consider recurrent ischemia.

Most VF occurs in first 48h.

74
Q

Beta blockers … the incidence of lethal VFs.

A

Decrease.

75
Q

Papillary muscle rupture - Tx:

A

Intra-aortic balloon pump (IABP) ==> To help stabilize.

Urgent surgery is required.

76
Q

Ventricular septal rupture - Usually caused by which type of MI?

A

Both AMI and IMI.

77
Q

Ventricular septal rupture may occur …-… after MI.

A

1-20 days.

78
Q

Ventricular free wall rupture may occur …-… after STEMI.

A

2-14 days.

79
Q

Which group is at highest risk for ventricular free wall rupture?

A

Elderly women.

80
Q

Implantable defibrillators — Improve survival in pts w/ …

A

Ischemic cardiomyopathy and low EF (even in the absence of V-arrhythmias).

81
Q

Implantable defibrillators — Measure EF at least … after MI in pts who are being treated w/ goal-directed medical HF tx.

ICD indicated if EF

A

40 days.

30%

35%

Internal Medicine (107 decks)

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