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Flashcards in ASHD/ACS Deck (51)
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1
Q
Who gets heart attacks?
A
Males, overweight, central obesity, sedentary, smoker
2
Q
ASHD
ACS
A
Arteriosclerotic heart disease (ASHD)
Acute coronary syndrome (ACS)
3
Q
Risk Factors for CAD (coronary artery disease)

EXAM
A
-Positive family history (the younger the onset in a first-degree relative, the greater the risk)
-Male sex
-Diabetes mellitus
-Hypertension
-Physical inactivity
-Abdominal obesity
-Cigarette smoking
-Psychosocial factors
-Diet
***Hypercholesterolemia is an important modifiable risk factor for coronary heart disease
**Metabolic syndrome
4
Q
Metabolic Syndrome
A
Constellation of three or more of the following: abdominal obesity, triglycerides 150 mg/dL or higher, HDL cholesterol less than 40 mg/dL for men and less than 50 mg/dL for women, fasting glucose 110 mg/dL or higher, and hypertension
5
Q
Atherosclerotic plaques may rupture, what are factors that increase plaque vulnerability?
A
-Higher lipid content
-Higher concentration of macrophages
-Very thin fibrous cap
6
Q
Precipitants to plaque rupture include:
A
include exercise, eating, cold weather, and emotional stress
7
Q
Myocardial ischemia can be symptomatic, causing _____; others are completely silent
A
angina pectoris
8
Q
Myocardial hibernation (describe)
A
-Chronic
-Areas of myocardium that are persistently underperfused but still viable may develop sustained contractile dysfunction
-Reversible following coronary revascularization
9
Q
Myocardial stunning (describe)
A
-Acute
-Persistent contractile dysfunction following prolonged or repetitive episodes of myocardial ischemia
-Often seen after reperfusion of acute myocardial infarction and is defined with improvement following revascularization
-Sends blood to other parts of heart to keep you alive- reversible
10
Q
Circumstances that precipitate and relieve angina
A
rest and nitro usually relieve stable angina; exacerbated by exertion
11
Q
Characteristics of the discomfort
A
“true” chest pain presents as substernal pain, crushing, tightness, squeezing, epigastric pain (inferior wall MI, posterior wall), may radiate to jaw or left arm or back (may never radiate)
12
Q
Duration of attacks
A
if lasting for 30 seconds and goes away, probably not angina; if it last between 5-30 mins, probably angina chest pain; if lasting about 4 months- not angina
13
Q
Associated symptoms
A
nausea, diaphoresis, SOB, impending sense of doom, palpitations
14
Q
Physical signs of angina pectoris
A
1. Significant elevation in systolic and diastolic BP
2. Hypotension may also occur, and may reflect more severe ischemia or inferior ischemia (especially with bradycardia) due to a Bezold-Jarisch reflex
3. Gallop rhythm and an apical systolic murmur due to transient mitral regurgitation from papillary muscle dysfunction are present during pain only
4. **Supraventricular or ventricular arrhythmias may be present**
15
Q
Never give nitro for
A
posterior wall MI (decreases preload, BP drops so low you die, cardiogenic shock gets worse)
16
Q
Labs
A
Standard laboratory tests to evaluate for acute coronary syndrome (troponin and CK-MB)

If you catch MI in first few hours, Troponin wont be elevated
EKG may even be normal

Use MYOGLOBIN for acute phase (will be greater than 900 with acute MI)
17
Q
EKG changes
A
-Often normal in pts w/ angina
-Old myocardial infarction, nonspecific ST–T changes, and changes of LVH
-Horizontal or downsloping ST-segment depression that reverses after the ischemia disappears, T wave flattening or inversion
-Transient ST-segment elevation
18
Q
Anterior leads are
A
V1-V4
19
Q
Lateral leads are
A
V5, V6
20
Q
Inferior leads are
A
V2, V3, aVF (will see reciprocal depressions here)
21
Q
Pretest probability factors
A
-History & Physical
-Laboratory and ECG
-Age
-Sex
-Patients with low to intermediate pretest probability for CAD should undergo noninvasive stress testing whereas patients with high pretest probability are generally referred for cardiac catheterization***
22
Q
Healthy looking young person- his pretest probability is VERY low, so even if you get a positive stress, __________
A
it doesn’t mean anything (results won't help with treatment/diagnosis)
23
Q
If pt has anginal symptoms you give nitro unless _____
A
posterior or inferior wall MI
24
Q
If you can't give pt aspirin, instead use
A
Plavix or clopidogrel
25
Q
TIMI risk score
A
Each is worth 1 point:
-Age of 60 or older
-3 or more risk factors (HTN, family hx, DM, high cholesterol, smoker)
-Known CAD (stenosis of 50% or more)
-Aspirin use in past 7 days
(presentation:)
-Recent severe angina (w/ in 24 hrs)
-Increased cardiac markers
-ST deviation of 0.5mm or more
26
Q
TIMI risk score, scoring:
A
Total 0-7 points
TIMI of 7: go to cath lab
TIMI of 0: go home
TIMI in between: not sure if pt is high or low risk, STRESS TEST (point of this is to risk stratify people)
27
Q
Precautions and risks of exercise stress tests
A
-Risk of exercise testing is about one infarction or death per 1000 tests
-Individuals who have pain at rest or minimal activity are at higher risk and should not be tested
-Patient must be stable and ambulatory
28
Q
Indications to perform exercise stress test
A
-To confirm the diagnosis of angina
-To determine the severity of limitation of activity due to angina
-To assess prognosis in patients with known coronary disease
-To evaluate responses to therapy
29
Q
Positive stress test is
A
1 mm (0.1 mV) horizontal or downsloping ST-segment depression (beyond baseline) measured 80 msec after the J point
(examples of abnormal EKGs on slides 18 & 19)
30
Q
Myocardial Stress Imaging helps to:
A
-confirm the results of the EKG (if they are different than clinical s/s)
-to localize the region of ischemia
-determine ischemia from infarction
-assess amount of revascularization after bypass or angioplasty
-Prognostic indicator in patients with known CAD
31
Q
Myocardial perfusion scintigraphy (radionuclide imaging)
A
-Scintigraphic defects indicate a zone of hypoperfusion that may represent either ischemia or scar
-If the myocardium is viable, as relative blood flow equalizes over time or during a scintigram performed under resting conditions, these defects tend to "fill in" or reverse, indicating reversible ischemia
32
Q
To get coronaries to stress, agent used is ________
A
Adenosine at lower doses
(regadenosine is isomer that is usually used; vasodilates coronary vessels)
33
Q
During Myocardial perfusion scintigraphy, if rest and stress are same; both missing, this indicates

If rest is fills in and stress it doesn’t fill in, this indicates
A
irreversible damage

REVERSIBLE ISCHEMIA
34
Q
Radionuclide angiography (Multi Gated Acquisition Scan, or MUGA scan) U\uses radionuclide tracers to image _________
A
the LV and measures its EF and wall motion

The test is also used for monitoring patients exposed to cardiotoxic therapies (such as chemotherapeutic agents)
35
Q
During MUGA scan- In coronary disease, resting abnormalities usually represent _______, and those that occur only with exercise usually indicate ______
A
infarction

stress-induced ischemia
36
Q
Stress echocardiography:
Echocardiograms performed during supine exercise or immediately following upright exercise may demonstrate
A
exercise-induced segmental wall motion abnormalities as an indicator of ischemia
(High-dose dobutamine can be used as an alternative)
37
Q
Positron emission tomography Can accurately distinguish
A
transiently dysfunctional (“stunned”) myocardium from scar tissue
38
Q
CT scanning has high sensitivity for excluding
A
significant CAD
-good for quantifying coronary artery calcification
39
Q
Cardiac MRI is excellent for assessing
A
pericardial disease, neoplastic disease of the heart, myocardial thickness, chamber size, and many congenital heart defects
40
Q
Who gets coronary angiogram in cath lab?
A
-Patients with life-limiting stable angina despite an adequate medical regime
-Clinical S/S of unstable angina, postinfarction angina, or high risk disease
-Concomitant aortic valve disease and angina pectoris
-Asymptomatic older patients undergoing valve surgery
-Recurrence of symptoms after coronary revascularization to determine if there are occlusions
-more on slide 30
41
Q
_____ can induce myocardial ischemia and infarction by causing coronary artery vasoconstriction or by increasing myocardial energy requirements and contribute to accelerated atherosclerosis and thrombosis
A
Cocaine
42
Q
Ischemia in Prinzmetal (variant) angina usually results from _______
A
coronary vasoconstriction
43
Q
Patients with chest pain associated with ST-segment elevation should undergo __________
A
coronary arteriography
44
Q
If significant lesions are not seen and coronary vasospasm is suspected, avoid ______
A
precipitants, such as cigarette smoking and cocaine

-Treat with nitrates and calcium channel blockers
45
Q
People on cocaine don't get beta blockers because of
A
unopposed alphas, very dangerous
46
Q
Unstable angina (UA) S/S:
A
Change in nature of pain
Change in response to meds

-give aspirin
47
Q
NSTEMI
A
-Cardiac enzyme elevation
-Can have EKG changes, however not ST segment elevation
-give aspirin
48
Q
STEMI S/S
A
Sudden but not instantaneous development of prolonged (more than 30 minutes) anterior chest discomfort (sometimes felt as “gas” or pressure).
Sometimes painless, masquerading as acute heart failure, syncope, stroke, or shock.
49
Q
STEMI on EKG
A
ST-segment elevation or left bundle branch block
-must be NEW LBBB (MUST compare to old EKG)
50
Q
If you’re within (less than) _____ of a hospital (NEED to get to cath lab), if nothing is around can go to nearest hospital to get _____
A
45 mins

TPA (fibrinolytic therapy)
51
Q
Complications of MI
A
Postinfarction ischemia
Arrhythmias
Acute LV failure
RV infarction
Mechanical defects
Myocardial rupture