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CAD Flashcards

1
Q
A
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2
Q

Stable Angina

general

A

predictable
if i excercise i get chest tightness

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3
Q

Unstable Angina

general

A

increase in durations, onset, or intensity

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4
Q

NSTEMI Angina

General

A

not showing on ECG

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5
Q

Get loading dose on all of which kind of med?

Assessed by?

A

Antiplatelet meds which can be assessed via PRU value

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6
Q

What med is preferred for DM pts with MI

A

Ticagrelor over Clopidogrel

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7
Q

Coronary Vasospasm

general

AKA, age, gender, induced by

A

AKA Prinzmetal’s or Variant Angina

Angina pain usually at rest (often b/w midnight-early morning) with no change in exercise function
More common in women < 50
May be induced by exposure to cold, emotional stress, or vasoconstricting medications
Usually involves right coronary artery (RCA)

woman watching tv or shoveling snow

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8
Q

Coronary Vasospasm

Dx

A

EKG
ST-segment elevation rather than depression

Diagnostics
Coronary angiography: no lesions with poss spasm; may give intracoronary nitroglycerine/ CCB

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9
Q

Coronary Vasospasm

Treatment
What do you avoid?

A

Calcium channel blockers (daily) and/or nitrates
Avoidance of nicotine, caffeine, cocaine, ergot’s

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10
Q

38 yo female presents in follow up after ER visit for chest pain. She had negative work up at hospital including LHC (left heart catherization) which revealed no CAD. She continues to have episodes of acute chest pressure 10-15 minutes in am while watching tv and smoking. No trigger or modifier.

A) verapamil ( calcium channel blocker)
B) aspirin 81 mg daily
C) atorvastatin 20 mg daily ( statin)
D) SL nitroglycerine prn

A

A: verapamil

resting sx..
put her on daily ca channel blocker

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11
Q

Non modifiable RF for CAD

A

Family hx
Age
Sex

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12
Q

Stable Angina Pectoris
general

A

Chest wall discomfort precipitated by stress or exertion and relieved by rest or nitrates

Occurs whenever myocardial oxygen demand exceeds oxygen supply

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13
Q

stable angina

Sx

A

Sx’s are EXERTIONAL and RELIEVED WITH REST
< 20 minutes duration

Pt’s c/o pressure, pain, squeezing, tightness, heaviness…

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14
Q

Stable angina

May present with atypical symptoms

what are they and who are affected

A

Dyspnea, indigestion, arm or jaw pain, exertional SOB, nausea, diaphoresis, fatigue, or all of the above with NO PAIN

presents in DM and females

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15
Q

Which of the following suggests ischemic etiology of chest pain?
A) exertional pain relieved with rest or nitrates
B) positional pain
C) post prandial burning relived with belching/tums
D) pain that is reproducible on physical exam
E) pain that is associated with cough or deep inspiration

A

A: describes angina
B: pericarditis, pleurisy
C: reflux
D: musculoskeletal
E: PE, pericarditis

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16
Q

Stable Angina Pectoris

labs and ECG

A

Labs
Negative troponin/CK-MB

EKG
Resting EKG is often normal
Possible Ischemic changes: ST depression, T wave flattening or inversion
During anginal episodes: horizontal or down sloping ST-segment depression that reverses after the ischemia disappears

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17
Q

Unstable Angina & NSTEMI

TX in hospital

A

MONA-BAS

Morphine
Oxygen
Nitrates
Aspirin
Beta blocker
Antiplatelet
Statin

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18
Q

STEMI

general

A

EMERGENCY!!!

Acute episode of chest discomfort that results in most cases, from an occlusive coronary thrombus at the site of a preexisting atherosclerotic plaque

Other causes: prolonged vasospasm, inadequate myocardial blood flow, emboli, coronary dissection, cocaine

COMPLETE LOSS OF FLOW

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19
Q

STEMI

Sx

A

Symptoms: depends on severity of infarct
Sudden death and early arrhythmias
50% of deaths occur before the patients arrive at the hospital
Death is presumably caused by ventricular fibrillation

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20
Q

STEMI

Dx Labs

A

Positive troponin I/T or CK-MB

each should be pos as early as 4-6 hours and abnormal by 8-12 hours

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21
Q

STEMI

Tending enzymes

A

get 3 sets every 8 hours

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22
Q

A patient presents to the ED with CP. ECG reveals ST elevation and initial troponin is normal. Which of the following is indicated?
A. administer nitrates
B. initiate MONA- B and repeat troponin in 6 hours
C. coronary revascularization
D. start heparin drip

A

C. coronary revascularization

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23
Q
A

Nitro, dont wanna bottom out their pressure

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24
Q

STEMI

Reperfusion therapy

A
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25
RF for CAD
HTN, HLP, CVA, PAD, DM, tobacco, family hx, obesity, sedentary lifestyle
26
Primary Prevention
Do not have a diagnosis of ASCVD but have risk factors Prevent the FIRST event Lifestyle interventions No smoking Daily exercise Target BMI Target risk reduction Bp goal < 130/80 LDL goal < 100 A1c goal < 7.0
27
Secondary prevention
Have a diagnosis of ASCVD or equivalent: DM PAD CVA/TIA CKD Prevent a SECOND event Target risk reduction Bp goal < 130/80 LDL goal < 55mg/dL A1c goal < 7.0
28
Medications for secondary prevention If DM? If CKD?
*Medications Antiplatelet (aspirin) Statin (moderate or high intensity) If DM: GLP-1 If CKD: ACE/ARB, SGLT2-inhibitor
29
30
# Stable angina Lab and ECG
no troponin elevation no ECG acute changes
31
# Stable angina Tx (3)
BB, ASA, Statin
32
# Unstable Angina clin presentation
Sx at rest
33
# Unstable angina Tx
cath lab, hospitalization
34
# NSTEMI Labs and ECG
+ troponin elevation ST depression or other changes
35
# NSTEMI Tx
BB,ASA, Statin +/- ischemia assessment; hosp
36
# STEMI Lab and ECG
troponin elevation ST elevation
37
# STEMI Tx
Cath lab (90 min door: balloon time)/reperfusion BB, ASA, Statin ACE; hosp
38
# Stable Angina most commonly caused by? other causes?
Most commonly caused by atherosclerotic obstruction of one or more coronary arteries Other causes: Coronary artery vasospasm, congenital anomalies, emboli, arteritis, LVH, cocaine, and dissection
39
# Stable Angina Tests to Evaluate Perfusion
Stress test w or w/o imaging ( myocardial perfusion scan or stress echo) Cardiac CTA
40
# Stable angina First line Tx To reduce risk
reduce risk of further attacks Beta blocker Aspirin or clopidogrel
41
# stable angina Secondary Tx (3)
long lasting nitrates Ranolazine Calcium channel blockers
42
# Angina non pharm ways to reduce risk
**risk reduction: stop smoking, BP control, lipid control, DM control, weight reduction etc
43
Which of the following medications has been shown to improve cardiac outcomes in patient w/CAD? A) beta blockers B) calcium channel blockers C) nitrates D) ranolazine
A- beta blockers
44
# stable angina the most common noninvasive testing in evaluating for inducible ischemia stable patient
Exercise ECG Contraindicated if unstable angina, active ECG changes, aortic stenosis
45
# stable angina If patient has a negative stress test and resolution of symptoms on Rx therapy ( asa/statin/bb) then..?
continue monitoring and consider other etiology
46
# stable angina If patient has a negative stress test and ongoing symptoms refractory to medical therapy, consider
cath
47
# stable angina If patient has a positive stress test proceed with
cath
48
# stable angina is stable a part of ACS?
NO
49
# stable angina typically lasts
2-15 minutes
50
Which treatment for stable angina is INCORRECT? A) sl ntg prn B) diltiazem 120 mg po daily ( CCB) C) metoprolol 25 mg daily D) asa 81 mg daily
B- you want beta blocker not calcium channel blocker
51
differece in troponin with Unstable angina and NSTEMI?
angina= negative troponin NSTEMI= positive troponin
52
Fibrinolytic therapy has been found to be harmful for
NON STEMI
53
If hypertensive what is BP BB of choice?
labetalol IV- most BP reduction
54
A patient presents to ED for CP and is diagnosed with NSTEMI. Which therapy is contraindicated? A) Aspirin B) Morphine C) Nitroglycerine D) Beta blocker E) fibrolytics
E) fibrolytics
55
# Unstable angina and NSTEMI Risk-Stratification Tools HEART Score
predicts 6 week risk adverse event Low risk (0-3), Moderate risk (4-6), High risk (7-10)
56
# Unstable angina and NSTEMI Risk-Stratification Tools used to evaluate patients long term risk post ACS
GRACE risk score and TIMI risk score
57
# Unstable angina and NSTEMI Tx when discharged
Beta Blocker Aspirin +/- antiplatelet ( 1 year) Statin Cardiac rehab
58
# Unstable angina and NSTEMI hosptal admission Tx
Medical Therapy (for all) MONA-BAS Antiplatelet agents & Anticoagulants +/- cath
59
68 y/o WF presents in office as work in new patient. No previous PMHx. +fam hx CAD. + tobacco use. She states she just returned from vacation during which she was hospitalized w “heart attack”, she had heart cath and “stents” put in. She took the last of her pills today and needs urgent refill. She can’t remember what she was taking. -What rx should she be on post MI?
beta blocker, Ace-I/ ARB, DAPT, statin DAPT= dual antiplatelet therapy
60
61
# STEMI Diagnostic ST elevation according to ACC or AHA
Diagnostic ST elevation at the J point in at least 2 contiguous leads of ≥ 2 mm in men or ≥ 1.5 mm in women in leads V2-V3 and/or of ≥ 1 mm in other contiguous chest leads or the limb leads
62
# STEMI
63
# STEMI 12 lead ST elevation | anterior, lateral, inferior wall
V2-V4: anterior wall Left Anterior Descending Artery Prone ventricular arrythmias/ shock I, avL, V5, V6: lateral wall Circumflex Artery II, III, aVF: inferior wall Right Coronary Artery Give IV fluids!!! Pre-load dependent so caution with nitroglycerine and morphine Transient AV blocks
64
Anterior wall MI
V2-V4: anterior wall Left Anterior Descending Artery Prone ventricular arrythmias/ shock (VF/VT) think about septum and L ventricle
65
inferior wall MI Avoid?
II,III,aVF Right Coronary Artery Prone blocks and RV failure think about R ventricle and SA/AV node **Give IV fluids!!! Pre load dependent so caution with nitroglycerine and morphine or fibrinolytics** Transient av blocks
66
Inferior wall MI
67
lateral wall MI
68
lateral wall MI
I, aVL, V5, V6 Left Circumflex Artery
69
# STEMI Tx
70
# STEMI Fibrinolytic therapy
71
# STEMI Fibrinolytic Contraindications Absolute
Previous hemorrhagic stroke, or strokes or cerebrovascular events within 1 year Known intracranial neoplasm Recent head trauma Active internal bleeding (excluding menstruation) Suspected aortic dissection
72
# STEMI Fibrinolytic Contraindications Relative
BP > 180/110 CVA > 3 months ago Bleeding / surgery within 2-4 weeks Intracranial tumor (benign) Pregnancy Traumatic/prolonged CPR Current OAC tx Dementia
73
Which patient is a good candidate for fibrinolytics? A) CP with positive enzymes, flattened t waves on ECG B) tearing CP in scapula/ PMH of aortic aneurysm and marfan’s C) CP started 18 hours ago, + enzymes, ST elevation on ECG D) CP in patient with history of CVA 2 months ago E) CP hx of CAD, + enzymes, new LBBB
A is considered NSTEMI- no lytics B do not have ecg to determine if STEMI- presentation most like aortic dissection C stemi- > 18 hours- prefer cath due to > 3 hour D – do not have ECG , don’t know if stemi; recent stroke- not candidate **E- new LBBB is equivalent – if > 2 hours to lab via transfer then lytics**
74
# STEMI Post fibrinolytic management
Continue with aspirin and anticoagulation until revascularization or for the duration of the hospital stay (up to 8 days) Myocardial reperfusion can be recognized clinically by the early cessation of pain and the resolution of ST-segment elevation. Although at least 50% resolution of ST-segment elevation by 90 minutes may occur without coronary reperfusion, ST resolution is a strong predictor of better outcome. GI bleeding prophylaxis Some PPIs may decrease the effect of clopidogrel
75
# STEMI After reperfusion therapy EF < 45
76
# STEMI AFTER Reperfusion Therapy NO NO’S
**Calcium Channel Blockers** No role in nearly all patients with acute myocardial infarction (may exacerbate ischemia) **NSAIDs** Other than aspirin, should be avoided around the time of STEMI due to increased risk of mortality, myocardial rupture, hypertension, and heart failure
77
Which of the following rx should not be prescribed post ACS? A) aspirin B) metoprolol C) clopidogrel D) ibuprofen E) rosuvastatin
D) ibuprofen (No NSAIDS)
78
is indicated for all ACS pts for 1 year
Acute Coronary Syndrome Dual antiplatelet therapy is indicated for 1 year in all patients
79
Post MI complications
ACT RAPID Arrhythmia Congestive Heart Failure Tamponade/Thromboembolic Rupture (ventricular, septum, papillary muscle) Aneurysm Pericarditis Infection Death/Dresslers
80
# Complications of MI Arrythmias
Sinus bradycardia – inferior infarctions SVT – correct electrolyte abnormalities, hypoxia A.Fib – BB, Amiodarone, Cardioversion Ventricular arrhythmias – common in 1st few hours Antiarrhythmics (IV lidocaine, IV amiodarone) Electrical cardioversion AV block 1st degree > 2nd degree, 3rd degree
81
Which of the following is NOT a sign of cardiogenic shock? A) decreased urine output B) hypotension C) cool extremities D) bradycardia
D- usually tachycardic in shock
82
Patient with anterior wall MI post PCI to LAD EF 30%. transferred to ICU. In last 12 hours they are becoming hypotensive , rales BLL, decreasing O2 sat. No murmur What is the most likely cause of shock? A) RV failure B) LV failure C) chordae rupture D) free wall rupture
B) LV failure
83
Patient with anterior wall MI post PCI to LAD EF 30%. transferred to ICU. In last 12 hours they are becoming hypotensive , rales BLL, decreasing O2 sat. No murmur What treatment is NOT indicated? A) IV fluids B) IV diuresis C) Inotropes D) IABP
A) IV fluids
84
# STEMI complications RV Infarction
85
Post MI Complications Mechanical
Acute ventricular septal defect Acute mitral regurgitation Left ventricular free wall rupture * All would present with new loud/harsh murmur
86
87
# STEMI complications LV Aneurysm
88
# STEMI complications Pericarditis
Audible friction rub with positional chest discomfort Treatment: High-dose aspirin and colchicine
89
# STEMI complication Dressler syndrome (post-myocardial infarction syndrome) and Tx
1-12 weeks after infarction Autoimmune phenomenon with **pericarditis** fever, leukocytosis, and occasionally, pericardial or pleural effusions Treatment: High-dose aspirin and colchicine
90
# STEMI complications Mural Thrombus
Common in large anterior infarctions Emboli occur in ~2% of patients with known infarction, usually within 6 weeks Anticoagulation- Initially with heparin Followed with warfarin or NOAC/DOAC therapy
91
# STEMI Post-infarction Management
## Footnote IF they had impaired EF will need to recheck with Echo as outpatient
92
CABG
Multivessel disease Significant Left main coronary blockage Surgical correction of MI complications VSD, ventricular aneurysm, etc. LV dysfunction NSTEMI and high-risk features
93
Which of the following pre-operative physical exam findings may alter CABG plan? A) poor dentition, dental caries B) history of vein stripping C) history or radiation to chest D) abnormal Allen’s test
If poor dentition increased risk infection- consider treatment Vein stripping you need to make sure they have conduit Chest radiation need to consider LIMA/RIMA may be damaged Allen’s test abn need to access if can use radial artery

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