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Flashcards in ASHD/ACS Deck (51)
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Who gets heart attacks?

Males, overweight, central obesity, sedentary, smoker



Arteriosclerotic heart disease (ASHD)
Acute coronary syndrome (ACS)


Risk Factors for CAD (coronary artery disease)


-Positive family history (the younger the onset in a first-degree relative, the greater the risk)
-Male sex
-Diabetes mellitus
-Physical inactivity
-Abdominal obesity
-Cigarette smoking
-Psychosocial factors
***Hypercholesterolemia is an important modifiable risk factor for coronary heart disease
**Metabolic syndrome


Metabolic Syndrome

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


Atherosclerotic plaques may rupture, what are factors that increase plaque vulnerability?

-Higher lipid content
-Higher concentration of macrophages
-Very thin fibrous cap


Precipitants to plaque rupture include:

include exercise, eating, cold weather, and emotional stress


Myocardial ischemia can be symptomatic, causing _____; others are completely silent

angina pectoris


Myocardial hibernation (describe)

-Areas of myocardium that are persistently underperfused but still viable may develop sustained contractile dysfunction
-Reversible following coronary revascularization


Myocardial stunning (describe)

-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


Circumstances that precipitate and relieve angina

rest and nitro usually relieve stable angina; exacerbated by exertion


Characteristics of the discomfort

“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)


Duration of attacks

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


Associated symptoms

nausea, diaphoresis, SOB, impending sense of doom, palpitations


Physical signs of angina pectoris

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**


Never give nitro for

posterior wall MI (decreases preload, BP drops so low you die, cardiogenic shock gets worse)



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)


EKG changes

-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


Anterior leads are



Lateral leads are

V5, V6


Inferior leads are

V2, V3, aVF (will see reciprocal depressions here)


Pretest probability factors

-History & Physical
-Laboratory and ECG
-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***


Healthy looking young person- his pretest probability is VERY low, so even if you get a positive stress, __________

it doesn’t mean anything (results won't help with treatment/diagnosis)


If pt has anginal symptoms you give nitro unless _____

posterior or inferior wall MI


If you can't give pt aspirin, instead use

Plavix or clopidogrel


TIMI risk score

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
-Recent severe angina (w/ in 24 hrs)
-Increased cardiac markers
-ST deviation of 0.5mm or more


TIMI risk score, scoring:

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)


Precautions and risks of exercise stress tests

-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


Indications to perform exercise stress test

-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


Positive stress test is

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)


Myocardial Stress Imaging helps to:

-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