CHD and ACS Flashcards
(65 cards)
1
Q
Differential dx for Chest Pain?
A
- Non-ischemic cardiovascular CP: aortic dissection, expanding aortic aneurysm, pericarditis, PE
- Non-cardiovascular causes: Pulmonary (PNA, pleuritis, pneumothorax), GI (GERD, esophageal spasm/ or perforation, PUD, pancreatitis, biliary dz), Musculoskeletal (costochondritis, cervical radiculopathy, rib fx), other (anxiety/panic attack, Munchausen, sickle cell crisis, Zoster)
2
Q
What is the classic ACS initial therapy?
A
MONA:
- Morphine: pain, anxiety, & pulmonary edema
- Oxygen: for pt’s with SpO2 <90%, heart failure, or dyspnea
- Nitroglycerin: for pts w/ ongoing CP, HTN, or HF
- ASA: all pts w/out hypersensitivity, chewable or PR
+/- antiemetics
3
Q
What percentage of people in the US who experience ACS will be NSTE-ACS?
A
- 70%
- M>F over 40 y/o
- women and elderly w/ atypical sxs such as GI, lung, and fatigue
4
Q
What is angina?
A
clinical syndrome characterized by jaw, shoulder, or arm discomfort attributable to coronary ischemia
5
Q
What is typical angina?
A
- substernal chest discomfort w/ characteristic quality and duration
- provoked by exertion or emotional stress
- relieved by rest or nitroglycerin
6
Q
What is atypical angina?
A
- having only 2 of the typical characteristics
- may be pleuritic, reproducible pain w/palpation or movement, constant and lasting days, fleeting pain lasting seconds
7
Q
What is stable angina?
A
- develops w/predictable amount of exertion
- similar to typical angina
- short duration (<5 mins)
- resolves w/rest or antianginal med
8
Q
What is unstable angina?
A
- develops at rest or w/minimal exertion
- change in typical pattern of angina
- more severe, longer lasting up to 30 mins
- may not resolve w/rest or antianginal medication
- due to insufficient coronary blood flow, w/out evidence of myocardial necrosis
9
Q
What is NSTE-ACS?
A
- any condition compatible w/acute myocardial ischemia and/or infarction usually due to an abrupt reduction in coronary blood flow
- imbalance of myocardial oxygen consumption and demand that may lead to ischemia/infarct
10
Q
What is NSTEMI & STEMI
A
- angina w/elevated cardiac biomarkers indicating MI w/ or w/out ST segment deviation
11
Q
What is a myocardial infarction?
A
rise or fall of cardiac biomarker values (preferably Troponin) w/ at least one value above the 99% of upper reference limit + one of the following:
- sxs of ischemia, new ST-segment-T wave changes or new LBBB, pathological Q waves, new loss of viable myocardium or new RWMAs, intra-coronary thrombus by angiography or autopsy
12
Q
What are pain descriptors that are characteristic of angina?
A
- radiation to R arm or shoulder, both arms or shoulders, radiation to left arm, exertional, diaphoresis, N/V, pressure
13
Q
Describe the coronary dz spectrum.
A
Ischemia: stable and unstable angina
infarction: NSTEMI, STEMI
ACS: unstable angina, NSTEMI, STEMI
stable > unstable angina > NSTEMI, STEMI (worst)
14
Q
When would you do ischemia-guided (conservative) strategy vs. early invasive?
A
- ischemia guided: low risk score (TIMI 0-1/2), pt/md preference, extensive comorbidities (hepatic, renal, pulmonary failure, CA)
- early invasive: new ST depression, elevated Trop, recurrent angina at rest despite therapy, CHF sxs or low LV function, hemodynamic instability, arrhythmia, prior PCI/CABG w/in 6 mo’s
15
Q
Etiology of NSTE-ACS?
A
- Coronary a. obstruction (atherosclerosis –> plaque rupture and thrombosis)
- vasospasm (Prinzmetal’s “pressure” angina, drugs)
- coronary embolism (DVT w/ PFO, LV thrombus, endocarditis)
- dissection (aortic or coronary)
- non-obstructive (hyper/hypotension, anemia, hyperthyroid, arrhythmias)
16
Q
What are some initial steps in evaluation for a pt with ACS?
A
- Hx
- PE: possible findings incl Levine’s sign (bring hand up to chest saying “tight”), new S4, splitting of s2, pericardial friction fub, 3 P’s (Palpable, positional, pleuritic)
17
Q
What is pt’s baseline risk for ACS? aka what are the CAD risk factors?
A
- M > F, age, prior hx CAD, kidney dz, DM, HLD, HTN, PAD, smoking
18
Q
What should every patient undergo w/in 10 mins of arrival to ED for evaluation of ACS?
A
- an ECG along w/ obtaining hx
- may repeat q15-30 mins for 1st hour as sxs change
- a normal ECG does not exclude ACS
- ECG changes: peaked T waves, Q wave formation, T wave inversion
19
Q
what changes would you see on ECG for NSTE- ACS?
A
- ST-segment depression by 5mm in 2 contiguous leads and T-wave inversion of at least 1mm (0.1mV)
20
Q
what are some ECG pitfalls?
A
False positives: pre-excitation, J-point elevation (Brugada syndrome), CNS dz, metabolic disturbance, drug-induced (digoxin)
False negatives: RV pacing, LBBB, prior MI w/ Q waves or persistent ST elevation
21
Q
What diagnostic studies should you order when doing initial evaluation for ACS?
A
- Serum biomarkers: CK, CK-MB, Trop
- CBC, BMP, coagulation panel, cholesterol levels
- B-type natriuretic peptide (BNP)
- CXR
22
Q
What are diagnostic studies you could order in addition to the initial diagnostic studies for ACS?
A
- exercise stress testing
- stress echocardiography
- pharmacologic stress testing
- Myocardial perfusion imaging
- cardiac CT angiography
23
Q
IF you do an ECG and ST is elevated =
A
STEMI
24
Q
IF you do an ECG and ST is depressed or there are T-wave inversions =
A
NSTE-ACS
25
NSTE-ACS Troponin: when should you order? which pt's?
- all pt's who p/w sxs c/w ACS to identify rising and/or falling pattern
- at presentation and 3-6 hrs after sxs onset
- obtain beyond 6 hrs for pt's w/ normal Trop but ECG or clinical presentation confer intermediate/high index suspicion for ACS
26
Cardiac biomarkers: Troponins are elevated as early as ___, but may not be elevated for up to ____, and may persist _____ or longer.
- 2-4 hrs
- 12 hrs
- 14 days
Note: normal levels does not mean there is no ischemia
27
How long does Troponin stay elevated after onset of AMI?
- about 1 week
28
False positive cardiac biomarkers
- sepsis, burns, respiratory failure, drug toxicity, HTN, acute PE, CKD
29
Causes of elevated troponin: injury related to supply/demand imbalance of myocardial ischemia?
- tachy/brady arrhythmias
- cardiogenic, hypovolemic, or septic shock
- Hypertension w/ or w/out LVH
30
Causes of elevated troponin: multifactorial or indeterminate myocardial injury?
- heart failure
- severe pulmonary embolism or pulmonary hypertension
- sepsis and critically ill pt's
- renal failure
31
Cardiac enzymes: CK-MB can be used for the dx of ___ and to ___. What is the difference between the enzyme CK-MB and Troponin?
- reinfarction
- assess reperfusion
- Trop normalizes in 7-14 days while CK-MB normalizes in 1-3 days
32
What are the 3 most common risk-stratification modules useful in management of NSTE-ACS?
- TIMI risk score
- GRACE risk model
- HEART score for MACE
33
Describe the TIMI UA/NSTEMI risk score.
```
generates score up to 7 w/ yes answers.
1) age 65 y/o or greater
2) 3 or more risk factors for CAD
( fam hx, HTN, HLD, DM, current smoker)
3) known CAD (stenosis >50%)
4) ASA in past 7 days
5) severe angina >2 or + episodes w/in 24hrs 6) ST changes > 0.5mm (ST depression)
7) positive cardiac biomarker
- 0-2 = low risk
- 3-4 = intermediate risk
- 5-7 = high risk
```
34
Who should be admitted to the hospital for initial inpatient management?
- pt's w/ recurrent sxs, ischemic changes on ECG, elevated Trop, intermediate to high risk pt's (TIMI 3)
35
NSTE-ACS standard medical therapies
- supplemental O2
- anti-platelet
- Statin: high intensity (i.e. Atorvastatin 80mg)
- obtain fasting lipid panel w/in 24 hrs
- Nitroglycerin: for persistent angina, CHF, or HTN
- Analgesics: IV morphine, NSAIDs contraindicated
36
NSTE-ACS standard medical therapies: describe anti-platelet therapy
- ASA (non-enteric coated, chewable) continue indefinitely
- P2Y12 inhibitor in addition for up to 12 mo's (i.e. plavix): Clopidogrel (300-600mg) then 75mg daily, Ticagrelor 180mg then 90mg daily
- All pt's should receive DAPT (dual antiplatelet therapy)
- GP IIb/IIIa inhibitors (Abciximab, Eptifibatide, Tirofiban)
37
How long should you continue anti-platelet therapy after NSTE-ACS?
- ASA 81mg daily for life
| - P2Y12 inhibitor for STEMI for 1 year
38
All pt's w/ NSTE-ACS w/out contraindications should receive a P2Y12 inhibitor. What 2 should you choose from?
- Clopidogrel or Ticagrelor
39
____ is recommended in addition to DAPT in pt's with NSTE-ACS irrespective of initial treatment strategy?
Anticoagulation:
- indirect thrombin inhibitors --> UFH, Enoxaparin,
Fondaparinux
* increase ATIII activity but do not lyse existing clots
- direct thrombin inhibitors --> Bivalirudin, Argatroban
40
For a NSTE-ACS which medication should you give w/in the 1st 24 hrs? When should you hold giving this medication? What med could you give instead if the previous med was contraindicated?
- Betablockers: oral metoprolol, carbedilol, bisoprolol
- if pt has acute CHF, hypotension, heart block or airway dz
- Calcium Channel blockers
41
When would you consider giving a NSTE-ACS an Angiotensin Converting Enzyme Inhibitor (ACE-I)? What would you use if pt has an intolerance to ACE-I?
- all pt's w/ a LV-EF <40%, HTN, DM, or stable CKD
| - ARB (i.e. Losartan)
42
When is an aldosterone antagonist recommended for NSTE-ACS?
- for pts post-MI w/ no renal dysfunction (Cr) or hyperkalemia, who are on therapeutic ACE-I and BB & have... an LVEF <40%, DM, or CHF
43
What are the steps to risk stratification?
- clinical features: angina pattern, ECG, trop, CHF
- consider risk factors: HTN, HLD, DM, FH, gender, tobacco use
- combination: Diamond-Forrester angina scale, TIMI risk score, GRACE,etc)
- is there coronary ischemia or not? Order noninvasive stress test
44
When is it recommended to order a noninvasive stress test for evaluation of coronary ischemia?
- if pt has had 2 negative Trop's
| - low or intermediate risk who are free of ischemia at rest for minimum of 12hrs
45
What are the advantages and disadvantages to an exercise ECG?
- A's: simple, low cost, available
| - D's: doesn't quantify ischemia, low sensitivity, prone to false positives in women
46
Which pt's need to undergo stress imaging?
- abnormal baseline ECG (i.e. baseline ST abnormalitis, BBB's, digoxin, etc)
47
Advantages and disadvantages to a stress echocardiography?
D: subjective and not standardized
A: good specificity and sensitivity, localizes ischemia, fast results
48
What are the advantages and disadvantages to a stress nuclear myocardial perfusion imaging test?
- A: good sensitivity and specificity, if pt has CAD, info about viability of myocardium, quantity of involved myocardium
- D: expensive, takes more time, radiation exposure
49
Post-hospital care for pt's that rule in and have an MI should be referred for...
cardiac rehab bc it decreases cardiac and overall mortality
50
What TLC's and medications should the patient receive post-hospital visit after having an MI?
- ASA 75 - 162mg daily
- ACE-I/ARB on discharge if LV systolic dysfunction
- Beta blockers
51
Provide a short summary of the management of NSTE-ACS.
- pt p/w angina
- EKG w/in 10 mins
- H&P + biomarker (risk stratify)
- if low risk then d/c home and consider outpt stress test
52
Acute coronary syndromes w/ ST segment elevation =
STEMI, which results from a thrombus developing from a ruptured atherosclerotic plaque
- depicted by irreversible ischemia leading to death of the myocardium (infarction)
53
Special considerations for Acute coronary syndromes w/ST segment elevation.
- consider cocaine in young adults
- Vasospasms (less common)
- R-sided ECG if inferior AMI suspected
- sxs are more severe
- painless MI seen in 1/3 pt's, esp. women, elderly, DM, and alcoholics
54
What changes on ECG would you expect to see for a STEMI?
- new ST-segment elevation (>1mm) in 2 contiguous leads
- in leads V2-V3, 2mm or more in men and 1.5mm or more in women
- in other leads 1mm or more
55
If pt has a STEMI on ECG...
- if FMC to device is 90 mins or less...do PCI if capable --> guideline-directed medical therapy
- if greater than 120mins--> fibrinolytic therapy in 30 mins or less --> guideline-directed medical therapy
56
What is a percutaneous coronary intervention?
- coronary angiography: catheter inserted leg and up the aorta --> tip stops at left coronary a. --> contrast agent inject into aa. --> xray imaging shows stenosis in left coronary a.
57
When do you do a CABG?
- unsuccessful angioplasty or persistent ischemia
- stent thrombosis
- fibrinolysis and PCI contraindicated
- Class I: signif L main stenosis over 70%
58
STEMI Anti-platelet therapy: ASA, when & which dosages?
- ASA 162-325mg at presentation then 81mg for life
59
STEMI Anti-platelet therapy: P2Y12 inhibitor, when & which dosages?
- P2Y12 inhibitor at presentation or time of PCI: Clopidgorel 600mg, Prasugrel 60mg (No if hx of TIA/CVA), Ticagrelor 90mg BID;
- maintenance doses go down to Clopidgorel 75mg, Prasugrel 10mg, Tacagrelor 90mg for 1 year or until bleeding risk outweighs benefit
60
STEMI Anti-platelet therapy: Fibrinolytic therapy & antiplatelet, when & which dosages?
- Fibrinolytic therapy and anti-platelet therapy: load w/ ASA 162-325mg &... Clopidgorel 300mg for patients 75 y/o or younger or Clopidgorel 75mg for pt's 75 y/o +
- continue ASA for life; Clopidgorel at least 2 weeks
61
STEMI Anti-platelet therapy: IIb/IIIa inhibitor, when & which dosages?
- IIb/IIIa inhibitor at time of PCI: Abciximab, Tirofiban, Eptifibatide
62
STEMI management- anticoagulation: PCI therapy
- initiate ASAP
| - UFH (unfractionated Heparin) w/ or w/out GP IIb/IIIa inhibitor
63
STEMI management- anticoagulation:
| Fribrinolytic therapy
- iniate ASP
- UFH (unfractionated Heparin)
- Enoxaparin - if beyond 48 hrs
- Fondaparinux
64
Fibrinolytics/Thrombolytics
- streptokinase, urokinase, and rtPA
- earlier it is initiated more benefits
- major contraindications: brain bleed
65
STEMI management - routine medical therapy
MONS
