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CAD Flashcards

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1
Q

Coronary artery calcium scoring

A

detects subclinical atherosclerosis with MESA score
>400= silent ischemia, high risk of events
Good for asymptomatic, intermediate risk stratification

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2
Q

Don’t give nitro in ACS if

A

Recent use of PDE4 inhibitor

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3
Q

Bradycardia immediately after relief of occluded RCA

Treatment

A

Bezold-Jarisch reflex
Stimulation of vagal fibers in inferior LV wall
Atropine, fluids-> isoprotenerol-> pacing

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4
Q

Papillary muscle rupture

Treatment

A

Posteromedial-only supplied by pda (inferior MI)

Surgery, can temporize with Afterload reduction and IABP

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5
Q

Micro vascular angina diagnosis

Treatment

A

coronary flow reserve by positron emission tomography or Doppler flow wire during angiography.

aggressive risk-factor modification, alpha-BETA-BLOCKERS and calcium channel blockers, and novel therapies (including potassium channel openers, metabolic agents, rho-kinase inhibitors, angiotensin-converting enzyme inhibitors, late sodium channel modifiers, ivabradine, phosphodiesterase-5 inhibitors, and statins).

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6
Q

No exercise stress test if

A

Risk stratification for suspected ACS (elevated troponin, recent chest pain)
Do pharmacological instead

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7
Q

P2Y12 inhibitor mechanism of action
Aspirin
GpIIa/ IIIb

A

Inhibits ADP induced platelet activation
and aggregation

Inhibits COX1 and production of thromboxane A2( which causes platelet aggregation)

block the cross-linking of platelets by inhibiting platelet binding to the dimeric fibrinogen molecule. (Figure 1)

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8
Q

Antiplatelets for stable angina itself

A

One (aspirin or P2Y12) to prevent MI and death

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9
Q

Duke treadmill score calculation

A

exercise duration (minutes) - (4 x angina index) - (5 x maximum ST deviation). The angina index is 0, 1, or 2 (no angina, non exercise limiting angina, exercise limiting angina)

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10
Q

Duke treadmill score interpretation

A

A low-risk DTS is >5 and indicates a 5-year survival of >97%.
An intermediate-risk DTS of -10 to +4 is associated with a 5-year survival of 90%.
A high-risk DTS score of -11 or lower is associated with a 5-year survival of 65%.

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11
Q

Concave ST elevations with PR depression 1-8 weeks post MI

A

Dressler syndrome

Aspirin high dose (750 TID), can consider addition of PPI

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12
Q

No thrombolysis in NSTEMI, only STEMI

Anticoagulation choices

A

1) enoxaparin for hospitalization or until (PCI)
2) bivalirudin, only in patients managed with an early invasive strategy, continued until diagnostic angiography or PCI;
3) fondaparinux for hospitalization or until PCI (with unfractionated heparin or bivalirudin administered during PCI because of the risk of catheter thrombosis);
4) unfractionated heparin for 48 hours or until PCI

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13
Q

Myocardial injury due to ischemia vs not

A

rise and/or fall of cardiac troponin +
at least one of the following:
symptoms of acute myocardialischemia, new ischemic ECG changes,
pathological Q waves,
imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology.

For a type I myocardial infarction, coronary thrombus must also be identified (acute atherothrombosis)

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14
Q

Plaque vulnerability to rupture

A

Inflammation : increased macrophage infiltration, larger necrotic lipid cores, thinner fibrous caps, fewer smooth muscle cells, neoangiogenesis, and intraplaque hemorrhage

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15
Q

LBBB stress test

Agent
Image: echo or perfusion imaging or ECG

A

No ECG testing/ exercise radionuclide myocardial perfusion imaging (increased false positives)

Vasodilator myocardial perfusion imaging is ok
Dobutamine would be ok but increases risk of arrhythmias

CT coronary can also be used to assess ischemia

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16
Q

Late reperfusion

A

In asymptomatic patients, do not if after 12 hours

Do in cardiogenic shock or acute severe heart failure, intermediate- or high-risk findings on predischarge noninvasive imaging, or myocardial ischemia that is spontaneous or provoked by minimal exertion.

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17
Q

Cardiac PET for

A

Viability

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18
Q

Stress testing in known CAD

A

Imaging, not treadmill ECG

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19
Q

Predictors of mortality in ACS

Biggest predictors

A

TIMI
>75 yo, SBP <100

a score of 0 to >8 is associated with a 30-day mortality of 0.8-36%, whereas the 1-year mortality among those surviving the first 30 days ranges from 1% to 17%.

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20
Q

Risk discussion

CAC scores

A

40-75 years of age without diabetes who are at a 10-year ASCVD risk of 7.5-19.9%

1-99 favors statin therapy
>=100 Agatston units or ≥75th percentile, statin therapy

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21
Q

ST elevations with q waves

A

LV aneurysm

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22
Q

Inferior STEMI (1/3 will have RV infarct)

A

Avoid nitro and diuretics

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23
Q

Inferior ST elevation + ST elevation in V1

greater ST-segment elevation in lead III than lead II

A

RV infarct, get right sided EKG (STE in V4R)

RCA, not lcx

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24
Q

LV aneurysm vs pseudoaneurysm

increased risk of

A

broad neck, anticoagulate vs narrow,contained rupture-> surgery
ventricular arrhythmias, heart failure, and thromboembolism

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25
restricted motion of the posterior mitral valve leaflet MI
inferior- ischemic mitral regurg
26
ACS mechanisms
SCAD, plaque rupture with overlying thrombosis, vasospasm, coronary embolus, myocardial bridging
27
myxoma
vascular mass
28
takotsubo CM
REGIONAL (mid-apex) motion abnormality, can form thrombus in 2 days neuro disorders and pheo can be triggers
29
aldosterone antagonist
STEMI, already on ACEI/ARB+BB, EF less than or equal to 40% and either symptomatic heart failure (HF) or diabetes mellitus (Class I)
30
intermediate- high coronary artery calcium score (>100)
CAD, treat medically if asymptomatic, high intensity statin
31
prior to revascularization in SIHD
should be on GDMT
32
women with angina, normal cath mechanism diagnosis
microvascular dysfunction endothelial or nonendothelial dysfunction coronary flow reserve with adenosine (<2.5)/ diameter decrease with nitro- nonendo decreased diameter with acetylcholine-endo
33
microvascular dysfunction increases risk of
progression to epicardial coronary disease, major adverse cardiovascular events, and hospitalization.
34
Apical variant of takotsubo Treatment
LV outflow tract obstruction Avoid dobutamine/norepinephrine Use beta blockers to decrease HR Decrease after load with things like phenylephrine if possible
35
Chest pain in the setting of an argument and strong smoking history
``` Coronary vasospasm (smooth muscle hyperreactivity) Disappearing EKG changes ```
36
TIMI risk score
>65 years of age; three or more risk factors for coronary artery disease; prior coronary stenosis ≥50%; ST deviation on electrocardiography; two or more anginal events in the prior 24 hours; use of aspirin in the prior 7 days; and elevated cardiac biomarkers.
37
Localizing MI AVL elevation
ST depressions do not localize - reciprocal Elevations do High lateral (Ostial OM)
38
NSTEMI cath strategy Immediate invasive (within 2 hours ) Early invasive (within 24 hours) Delayed invasive (after)
Sick Not sick, but high risk score
39
patients with MI. ST-segment depressions of ≥2 mm AVR elevation Inferior MI, III>II
Posterior MI subtotal occlusion of the left main or proximal left anterior descending artery. RCA
40
Suspected RV infarct Hypotension caused by
Inferior STEMI + (hypotension, JVD, clear lungs)-> get right sided ECG-> ST elevation in lead V4R (RV involvement). Decreased preload Increased RVEDP-> septal bowing-> decreased LV filling RV dilation-> increased pericardial pressure-> restricts LV filling
41
Beta blocker duration post MI
At least 3 years | Indefinitely if EF <40%
42
Strongest predictor of survival post MI
EF
43
Hibernating myocardium Predictor of recovery
resting LV) dysfunction due to reduced coronary blood flow that improves with revascularization. Extent of fibrosis
44
Hibernating myocardium dobutamine stress echo
Hypokinetic at rest, improves with low dose dobutamine, akinetic at peak
45
ACS diagnosis
Clinical, can be made without EKG changes or trop elevation or typical symptoms
46
No reflow phenomenon Due to
Slow flow after revasc Microvascular obstruction
47
Intervening on stenosis <40% 40-70%
No FFR <0.8/ iFr < 0.89/ intravascular ultrasound area <6 *anything >50% in left main is considered significant*
48
Sgarbossa criteria
1) concordant ST elevation >1mm in leads with a positive QRS complex (score 5); 2) concordant ST depression >1 mm in leads V1-V3 (score 3); and 3) excessively discordant ST elevation >5 mm in leads with a negative QRS complex (score 2).
49
Negative ECG+ high suspicion for ACS
get posterior EKG (V7-V9) | Prominent R waves with ST depression in V1-V3
50
Cardiac rehab timing Phase I Phase II/III Phase IV
while hospitalized: patient assessment, education; a follow-up plan 2 weeks post MI, supervised exercise, 1 year Self-motivated maintenance
51
Biggest prognosticator in ETT
exercise duration
52
NSTEMI peak troponin
12-24 hours after onset
53
Evolucumab
PCSK9 inhibitor intolerant to statin therapy or does not achieve adequate LDL lowering with statin therapy
54
Rise and fall of troponin w/o positive EKG/symptoms
myocardial injury, type II NSTEMI | Stress test before discharge
55
Strongest risk factor for death in ACS
Age
56
Reduce myocardial oxygen requirements (ischemia) w/o affecting hemodynamics
Ranexa
57
Post MI TTE timing
2-3 days | Then 40 days after
58
Recurrent angina after thrombolytics for STEMI
Cath
59
Post MI bradycardia | Permanent pacing if
Due to increased vagal tone, self-limited | persistent sinus node dysfunction or high-degree AV block after a waiting period
60
Prinzmetal angina Diagnosis Treatment
At rest in the early morning hours, cigarettes. transient STE with no epicardial CAD Narrowing that resolves with nitro -> Provocative testing with ergonovine or acetylcholine. smoking cessation and CCB, nitrates
61
Killip class
Spectrum of HF in acute MI, increased mortality if higher, strongest predictor of mortality at 90 days
62
Killip I II III IV
No clinical signs of heart failure Rales (crackles), an S3, and JVD Acute pulmonary edema Cardiogenic shock or hypotension (systolic blood pressure <90 mm Hg) and evidence of peripheral vasoconstriction.
63
Typical angina Atypical angina Noncardiac chest pain Unstable angina Stable
Exertional/emotional substernal chest discomfort relieved by rest/relaxation/nitroglycerin meets two of the above characteristics meets one of the above characteristics, no further testing new in onset (within 2 months), increasing, or occurring at rest (doesn’t have to be persistent, just worsening qualifies) Occurs predictably and reproducibly at a certain level of exertion and relieved with rest
64
What portends the highest risk of future CV events in stable angina?
patients with a history of prior ischemic event (such as MI or stroke)
65
Cocaine effects
Platelet activation-> thrombosis Htn Thin vascular walls due to smooth muscle apoptosis and cystic medial necrosis-> coronary or aortic dissection Increased Myocardial oxygen demand-> ischemia Coronary vasospasm Myocarditis Arrhythmia Bradycardia, prolonged qtc-> torsades
66
Aspiration thrombectomy before PCI in STEMI
Increases risk of stroke, don’t do
67
Post anterior STEMI LVOT complication Treatment
LVOT obstruction and SAM due to increased contractility of the preserved myocardial segments to decrease inotropy, increase preload, and increase afterload.
68
Hydra/dinitrate
Fourth line for heart failure in blacks after BB, ACEI, MRA
69
Coronary microvasc disease provocative tests
Acetylcholine for impaired endothelial-dependent reactivity nitroglycerin, papaverine, adenosine, or dipyridamole for vascular smooth muscle mediated disease
70
Symptoms and EKG changes in likely multi vessel disease with normal perfusion
Balanced ischemia | If pretest prob is high, ignore perfusion findings, go straight to cath
71
GDMT for stable CAD
aspirin, statin, BP control | Cath is not indicated unless meds fail
72
Post MI ventricular arrhythmias
Bb or nondihydro CCB If sustained VT/VF-> amio -> lidocaine. ICD before d/c
73
Takotsubo mot consistent if
There is pheochromocytoma or myocarditis.
74
Reversible P2Y12 inhibitor
Cangrelor , function returns within an hour
75
PAD with or without stenting
Plavix period (or aspirin)
76
Ticagrelor to plavix
SOB
77
STEMI fibrinolytic therapy, other meds
anticoagulant therapy for entire hospitalization, up to 8 days, or until revascularization if performed. Heparin/lovenox/fonda
78
Prasugrel CI
Prior TIA/ stroke
79
High risk findings on perfusion imaging
large (>12% of myocardium) or severe reversible defects abnormal EF increased lung uptake of tracer, and/or transient ischemic dilation (TID) (>1.2) -> subendocardial ischemia
80
SCA due to coronary spasm in ppl who can’t tolerate meds
ICD
81
AIVR vs VT
slow (60-100) bpm
82
Iatrogenic coronary occlusion during MV repair/replacement
direct injury/distortion from suturing and/or coronary embolization (bone, suture material, silicone, thrombus, and air embolism).
83
most likely mechanism of chronic stable angina
stable coronary plaque that limits augmentation of blood flow
84
RCA vs lcx lesion
STE in III more than II
85
SCAD screening
Extracoronary vascular disease | CTA/MRA of carotids and renal arteries
86
Post MI recurrent chest pain with rapid progression to hemodynamic collapse
LV free wall rupture
87
Empiric echo
Suspected CHF or valvular disease
88
ACS + LV thrombus
DAPT + AC (DOAC/heparin ok) | Triple therapy is ok
89
Absolute CI to fibrinolysis
H/o intracranial hemorrhage
90
Highest negative predictive value for MI
Troponin
91
Full dose alteplase
15 mg
92
SCAD mechanism
intimal tear with blood subsequently entering a false lumen or spontaneous hemorrhage of the vaso vasorum causing intramural hematoma within coronary artery
93
Takotsubo mechanism
Catecholamine-induced myocardial stunning
94
Most common NSTEMI mechanism
disruption of the fibrous cap (plaque rupture or erosion), which stimulates thrombogenesis
95
Late reperfusion (>12 hours) increases risk of
Mechanical complications
96
Intermediate risk statin decision Get
40-75 years without DM and with LDL between 70-189 mg/dL and a 10-year ASCVD risk between 7.5-19.9% CAC 0- no statin...except in smokers, and those with a strong family history of premature ASCVD.
97
Cocaine intoxication Cocaine ACS treatment
hypertension, tachycardia, and altered mental status | Benzos, nitro
98
Coronary spasm caused by
alcohol, hyperventilation, epinephrine, norepinephrine, ephedrine, cocaine, and/or methamphetamines.
99
NSTEMI patients with refractory angina, signs/symptoms of HF or new/worsening mitral regurgitation, hemodynamic instability, recurrent angina at rest, or ventricular tachycardia/fibrillation
Cath w/in 2 hours
100
Post medically managed ACS stress test indicated if
Low and intermediate risk NSTEMI, free of ischemia for 12-24 hours Medically managed STEMI without high risk features For prognosis, eval residual ischemia
101
Takotsubo pathophysiology MRI
catecholamine excess, derangement of myocardial glucose and fatty acid metabolism, microcirculatory dysfunction, coronary vasospasm, and estrogen deficiency. No late gadolinium enhancement.
102
Bio markers for intermediate risk stratification
An elevated hs-CRP >/= 2 mg/L serum triglycerides >/= 175 mg/L, lipoprotein(a) > 50 mg/dl or > 125 nmol/L, apolipoprotein B >/=130 mg/dl, and ankle brachial index <0.9
103
Fragmented QRS complexes=
Pathological qs
104
EKGs in ACS eval
repeated every 15-30 minutes for the first hour
105
EKG segment
TP interval

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