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Cardiology Exam III > Cardio 24: NSTEMI and ACS > Flashcards

Cardio 24: NSTEMI and ACS Flashcards

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1
Q

Describe the events that leak to occlusion of coronary vessels

A

Plaque formation. Plaque gets larger and becomes less stable. Fibrous cap thins leading to rupture and thrombus formation !

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2
Q

Risk factors for ACS

A 
HTN (>140/90)
Age Men >45, women >55
Diabetes
Dyslipidemia
Family hx
Smoking
Sedentary lifestyle
Chronic Kidney Disease (CKD)
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3
Q

Symptoms of ACS

A 
Chest pain (Jaw, arm, back, shoulder)
Shortness of breath
Fatigue/weakness
Nausea 
Diaphoresis
lightheadedness
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4
Q

DDx for ACS

A 
Pericarditis
Aortic dissection
   Don’t miss and give anti-coagulants/platelets to. 
Pneumothorax
Pulmonary embolism
    Often presents similar to MI
GI causes
Musculoskeletal
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5
Q

When will might you not see ST elevation with MI or UA ?

A

if collateral circulation has formed

Vasospams causing erosion

Coronary artery inflammation (youger patients )

Secondary Unstable Angina: Non-occlusive, come in with pneumonia can lead to decrease of blood supply/ oxygen leading to chest pain

Coronary artery dissection

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6
Q

What is the most common cause of UA/NSTEMI ?

A

Atherosclerotic CAD

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7
Q

What are the diagnostic tools used for ACS ?

A 
H&P
EKG
CXR
Biomarkers
Cardiac imaging
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8
Q

What is the goal for placing an EKG ?

A

get it on in 10 minutes from presentation

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9
Q

Troponins are the biomarker of choice because

A

they are sensitive and specific .
Present at 2 hours after infarction
stay elevated for 14 days post infarction

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10
Q

What increases with a greater level of troponins in blood ?

A

Greater chance of death !

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11
Q

which biomarkers are useful to detect re-infarction >

A

CPK and CPK MB

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12
Q

Earliest biomarker to rise

A

myoglobin

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13
Q

BNP is not very important except for in assessment of …

A

Risk

Higher level = worse outcome

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14
Q

What will you look for on CXR to assess cardiac health ?

A

Mediastianal widening
CHF
Cardiomegaly

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15
Q

CT scans are useful in detecting

A

Aortic dissection
PE

Not very practical due to how long it takes

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16
Q

Echocardiogram is useful in assessing

A 
LV size and systolic function
    Very useful for Circumflex occlusion diagnosis. 
Wall motion abnormalities
Mitral regurgitation
Pericardial effusion
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17
Q

Which patients are amenable to Stress testing ?

A

Low risk and stable patients

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18
Q

What is the “Gold Standard” for imaging ?

A

Cardiac catheterization

Diagnosis and treatment in same setting !

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19
Q

List the classes of Anti-platelet drugs

A

ASA
Thienopyridines
IIB/IIIA Inhibitors

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20
Q

Aspirin MOA

A

Cox-1 inhibitor (irreversible) prevents formation of thromboxane A2 (TxA2  platelet activation)

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21
Q

WIll a heart patient need to be on aspirin for life following ACS ?

A

Yes, 81-325 mg daily

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22
Q

MOA for Clopidogrel (plavix)

A

ADP receptor agonist

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23
Q

How long will a patient with a bare metal stent need to be on plavix (minimum)

A

One month

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24
Q

How long will a patient with a drug eluting stent need to be on plavix (minimum)

25
If you use ticlopidine instead of plavix what must be monitored ?
Complete blood count
26
Prasugrel has a shorter onset and can be given at the time of catheterization, making it a useful drug. What is a CI for this drug ?
Previous stroke, TIA or risk for intercranial hemorrhage.
27
What is a side effect of Ticagrelor ?
Chest tightness due to Adenosine release
28
Abciximab, Eptifibatide and Tirofiban are representative of what class of drugs ?
IIB/IIIA inhibitors abciximab is a large molecule (binds irreversibly) The other two are small molecule (bind reversibly) Useful for HIGH RISK patients
29
If you do not plan to catheterize should you use Abciximab ?
nope
30
What class of drugs should be used in all patients suspected of ACS ?
Anti-coagulants
31
UFH inhibits Factor III leading to thrombin inactivation. The downside of this drug is...
Hard to control and must monitor | May actually activate platelets
32
Enoxaparin (LMWH) is good choice because it can be dosed subq and does not need...
to be monitored like UFH
33
Bivalrudin is a direct thrombin inhibitor. It does not require monitoring and has a reduced risk of bleeding. What is a downside ?
Expensive
34
Fondaparinux inhibits
Factor Xa
35
When is Fondaparinux considered the agent of choice ?
conservative treaments of individuals with increased bleeding risks !
36
Absolute Contraindication for Thrombolytics Include
Unstable Angina NSTEMI ``` Previous Stroke Arteriovenous Malformation Cerebral malignancy Head Trauma within the past week Active bleeds ```
37
Anti-ischemics include
``` Bed rest O2 Doesn’t reduce risk unless hypoxic but still done regularly Β-blockers Nitrates Opiates Ace-I/ARB CA++ channel blockers ```
38
Advantages of Beta Blockers
Decrease HR, BP & contractility--> DECREASES MYOCARDIAL WORKLOAD (MVO2) Decrease infarct size and reinfarction Decreases Arrhythmias Decreases mortality? (short vs. lon
39
When are BB's contraindicated ?
Left sided heart failure Hypotension --> shock Severe asthma or COPD
40
How is metoprolol (a BB) administered
5mg IV q5’ X3 (HR 55-60 & BP>100) (Cautiously) | 25-50mg PO BID w/i 24°
41
MOA for Nitrates
Coronary artery and venodilator Decreases BP by decreasing preload Decreased BP means decreased O2 demand “Dilates coronary artery” actuallly just decreases demand on the heart by decreasing pre-load"
42
Should nitrate administeration preclude ACEi or BB therapy ?
NO ! NO survival benefit ever proven therefore should not preclude use of β-blocker or ACE-I 0.4mg SL q5’ X3
43
When should ACE-I be given within the first 24 hrs ?
EF <40% | Pulmonary congestion
44
ACEi should not be used if patient is....
hypotensive ! Or sensitive. In which case use an ARB
45
Non Dihydropyridine Ca+ channel blockers can be used if there is a contraindication for which class of drugs normally given to ACS patients ?
Beta Blockers Non-DHP CCB's
46
Under what conditions will you give Non-DHP CCB's and BB's together ?
Refractory ischemia
47
whens should you use caution with CCB's and BB's alike ?
Left ventricular dysfunction
48
Intra Aortic blood pump
Diastole it inflates backpush of blood leading to coronary perfusion Systole colapses  blood pumping
49
When should statins be administered to admitted ACS patients ?
as early as possible. Has pleiotropic effects
50
TIMI Risk score
Important for assessing risk in invasive treatment of ACS ``` TIMI RISK-one point for each Age >65 3 risk fx for CAD ( on the right) Diabetes Smoking Men >45 Women >55 Low HDL Fam Hx ASA use in prior 7 days Already feeling pain…. ST segment changes of ECG Prior stenosis >50% 2 or more anginal events in prior 24° + biomarkers ``` RIsk score is from 0-7 ( 4.7% - 40.9% risk of mortality)
51
PCI
``` Percutaneous coronary intervention (PCI) Balloon angioplasty Bare metal stents Drug eluting stents Other ```
52
CABG
Coronary artery bypass grafting (CABG) | Use of internal mammary artery important
53
Identify pts not considered high risk likely to benefit from invasive rx
Recurrent sx on appropriate med rx | High risk stress test
54
Long Term Treatments with Anti-platelet drugs
ASA Thienopyridines Varying length of time (maybe a month, maybe a year) Lifetime use Warfarin Not really indicated. No benefit over aspirin. Needs to be monitored and higher risk of bleeding.
55
What is the goal of anti-ischemic and antihypertensive long term treatment
Goal BP <140/90 (130/80 w/ DM or CKD)
56
What is the goal of Lipid lowering therapy long term
Goal LDL <70 in high risk pts)
57
For diabetics, what is the goal HbA1c
< 7
58
Mandatory vaccinations for patients with ACS include
Influenza Mandatory !! Pneumovax
59
Why should patients with ACS avoid NSAIDs ?
Increases risk of heart disease and death. Use nonselective only if absolutely necessary Separate dose 4° from ASA

Cardiology Exam III (12 decks)

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