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Cardiology > Coronary Artery Disease > Flashcards

Coronary Artery Disease Flashcards

1
Q

What is arteriosclerosis?

A
  • overtime (age) there accumulation of phospholipid and cholesterol –> symmetric thickening and hardening of the arterial wall (lumen) –> narrowed –> vessel walls are weakened*
  • there is not “plaque” involved, it is only the WALLS that are getting big that narrows the lumen
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2
Q

What happens when the vessel walls are weakened?

Arteriosclerosis

A

there is a loss of elasticity leading to dilation, rupture, occlusion

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3
Q

What happens to diastolic and systolic in arteriosclerosis?

A

diastolic increases; systolic decreases

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4
Q

What is atherosclerosis?

A
  • inflammatory process that results in patchy, nodular, lipid laden lesions in large and medium arteries
  • major cause of death
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5
Q

What is the inflammation process of atherosclerosis?

A

lesion occurs –> thin fibrous cap covering lipid rich core ruptures –> release of cytokines –> stimulates platelets –> thrombus occurs –> vasoconstriction of vessel

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6
Q

What can atherosclerosis lead to in coronary arteries?

A
  • unstable angina myocardial ischemia

- myocardial infarction/myocardial cell death

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7
Q

What terminologies are associated with atherosclerosis?

A
  • fatty streaks (early)
  • fibrous plaques
  • complicated lesions
  • “soft” lesions
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8
Q

Where does atherosclerosis commonly occur?

A

abdominal aorta

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9
Q

Who is affected w/ CAD?

A
  • probably all older adults have some degrees of CAD

- asymptomatic until it ruptures and there is a thrombosis occurring

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10
Q

What is a marker for CAD?

A

-LDH

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11
Q

What is myocardial infarction?

A

RESULT of:
plaque from atherosclerotic lesion causes a break in the coronary artery –> thrombus forms –> stopping blood flow –> MYOCARDIAL CELL DEATH!

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12
Q

What is angina?

A

the RESULT of the narrowing of the coronary artery d/t plaque in coronary artery –> decrease of radius –> COULD stop blood flow and ischemia when oxygen delivery is needed (exercise) –> PAIN occurs –> NOT MYOCARDIAL CELL DEATH

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13
Q

What is unstable angina?

A

blood flow is greatly obstructed cxing pain at rest & exercise

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14
Q

What is acute coronary syndrome (ACS)?

A
  • unstable angina is the primary syndrome for ACS

- a broad descriptor that is used for the range of myocardial ischemia from unstable angina to myocardial infarction

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15
Q

What are the risk factors for CAD?

A
  • males (women are “protected” during menstruation; become equal after menopause)
  • -hypoestrogenemia
  • -elevated C protein/homocysteine
  • old age
  • family hx (dad/brother < 55yo; mom/sister <65 yo)
  • DM
  • HTN
  • lipid elevation
  • smoking
  • not active
  • abdominal visceral obesity (apple vs pear-apple)
  • hypercoagulability
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16
Q

How can you REDUCE RISK of CAD?

A

-control glucose
-tx HTN
-incr lipid
–diet
–drugs/meds
-STOP smoking
-wt loss
-exercise regime
LIFE STYLE CHANGES

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17
Q

What is % mortality and survivors of MI?

A
  • 30% mortality

- even if you survive there is increased risk of death w/in 1st yr of survival

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18
Q

What ECG changes are w/MI?

A 
STEMI (ST elevation Myocardial Infarction)
non STEMI (non ST elevation myocardial infarction)
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19
Q

What is STEMI?

A
  • indicates there’s tissue dying

- MI is happening now

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20
Q

What is non STEMI?

A
  • lower amounts of tissue dying

- POSITIVE troponin is required for non STEMI (or else it’s ischemia)

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21
Q

What is inferior MI age indeterminent?

A

MI is happened in the past or happening now

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22
Q

PE of MI?

A

-pain (see classic)
-asymptomatic common in DIABETIC, OLDER WOMEN
(“mom can’t get over cold”)
– sudden breathlessness
– dyspnea
– fatigue
– weakness
– “brain freeze” headache
-early morning presentation
-triggers (physical/emotional, surgery (intubated: pt can’t tell you where they’re hurting - THINK)
-denial in men (delay’s help)
-xanthoma/tuberous xanthomas (fluid fat building up in the eye/body)
-AV nicking (d/t HTN)
-papilledema
-diabetic retinopathy/cotton wool
-copper wire (d/t reflection of lipid to make it look “silver”)
-erectile dysfunction

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23
Q

Classic PE of MI?

A

elephant crushing my chest (substernal chest pain) running down (radiation) to left elbow and jaw)

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24
Q

DDx for MI?

A
  • acute aortic dissection
  • acute pericarditis
  • GI pain (cholecystitis, esophageal spasm)
  • pulmonary pain (pleurisy, PE)
  • musculoskeletal related pain (costchondritis)
25
Q

Initial impression of MI?

A
  • acute MI: anxious
  • large area is involved: listless, weak, confused, comatose (d/t poor CO)
  • pallor, sweat, nausea, vomiting (diaphoretic)
26
Q

Vita signs of MI?

A
  • low BP (than normal)
  • -lower BP = larger myocardial infarction
  • pulses: weak, thready, irregular
  • “anterior MI”: tachycardia, HTN
27
Q

Cardiac exam of MI?

A
  • abnormal systolic pulsation
  • -part of heart bulges out (dyskinetic bulge)
  • rate and rhythm assessment
  • heart sounds may be normal OR:
    • S2
    • S3 (HEART FAILURE)
    • murmur
    • jugular cannon wave vein (d/t papillary m. dysfunction; papillary m. is ischemic –> AV valve doesn’t close very well aka acute ventricular failure = MURMUR
    • pericardial friction rubs d/t transmural infarction (STEMI: pericardium gets irritated and rubs like sandpaper instead of smooth glass)
28
Q

Pulm exam of MI?

A

-rales = HF
d/t blood being pulled to lower lung than higher –> if more prominent signs on upper lobe –> tissue gets boggy –> RALES!

29
Q

Labs for MI?

A
  • routine labs (CBC/CHEM 20)
    • high WBC
    • high myoglobin
    • increase AST
    • high LDH1 (norm: low LDH1/ LDH2; MI: high LDH1/LDH2)
    • high CK: MB band (heart), MM (heart), BB (brain)
  • HIGH TROPONIN (gold standard)
    • 1-3 days is high and remains high 5-7 days
  • SERIAL TESTS of cardiac enzymes (4-6 hrs)
  • total quantity of cardiac enzymes released = size of infarct
30
Q

ECG for MI? - infarction

A

-ST elevation/depression
-Q waves
-abnormal T waves
-decreased R wave
CLASSIC PATTERN:
normal ECG > peaked T waves > ST elevation > Q wave > T wave inversion/flat

31
Q

ECG for MI? - ischemia

A
  • ST depression (same as infarction)
  • TALL POSITIVE T WAVES
  • inversion/flat T waves (same as infarction)
32
Q

ECG for MI? - rhythm abnromalities

A
  • PVC
  • VT
  • VF
  • PAC
  • A flutter and A fib
  • heart blocks
33
Q

ECG for MI? -serial EKG

A
  • you need SERIAL EKGs to dx (NOT ONE)

- COMPARISON IS VERY HELPFUL

34
Q

CXR for MI?

A
  • LVH/RVH
  • HF
  • mediastinal widening (d/t acute aortic dissection)
  • tumor, infiltration, fracture, suspicion of pericardial effusion
35
Q

Echocardiography for MI?

A
  • VERY SENSITIVE but NOT specific (can’t tell if MI is happening NOW or happened years ago: scar)
  • abnormal wall motion
  • can asses for ventricular aneurysm, pericardial effusion, valvular dysfunction, ejection fraction
36
Q

Imaging for MI?

A

Radionuclide imaging

  • Thallium 201: reveals “cold” spot by concentrating at VIABLE myocardium –> NOT GOOD FOR ACUTE MI (cannot distinguish between old and new MI)
  • Tc99: reveals “hot” spot by localizing MI and sizing –> GOOD FOR ACUTE MI
  • SPECT: 3D image for ‘stressed’ myocardium and ‘resting’ myocardium
37
Q

MI management?

A 
ACUTE:
-Nitrate (NOT in hypotensive or right ventricular infarction)
-O2
-Beta blockers
-Anti platelet and thrombo
-ACE
-Analgesia 
-Aspirin
IV access for easy access (D5)
Cardiac Catherization
before Cath lab if pt stable:
-Beta blockers
ACE inhibitors (NOT IN HYPOTENSIVE)
lipid lowering (aggressive)
pump failure mangement
Reperfusion
38
Q

MI management w/ ST segment elevation?

A 
tPA 
NON STEMI= NO tPA; ONLY IF NEW
best w/in 3-12 hrs
-limits infarct size and mortality
-AltePLASE, retePLASE, tenectePLASE
-streptokinase (only give ONCE d/t allergic rxn risk is high)
-anticoagulation w/ hep after tPA
39
Q

What is the goal of getting patient into cath lab?

A

90 min upon arrival of the ER

40
Q

What is cardiac catherization?

A
  • PTCA

- Coronary Stent placement

41
Q

What is pump failure management in MI?

A

-monitoring
-inotropes
(excitatory and inhibitory actions on the heart and vascular smooth muscle)
-IABC (intra aortic balloon counter pulsation)

42
Q

What is reperfusion in MI management?

A
  • tPA
  • -Streptokinase (only once d/t allergic rxn)
  • -heparin
  • PTCA (percutaneous transluminal coronary angioplasty)
  • CABG (coronary artery bypass graft)
43
Q

Post MI management?

A
  • modify risk factors
  • medication
  • Reperusion
44
Q

Post MI management? - modify risk factors

A

LIFESTYLE MANAGEMENT

  • stop smoking
  • control lipids
  • control diabetes
  • wt loss
  • start cardiac rehab exercise (more for support in case pts are scared to start walking again)
45
Q

Post MI management? -meds

A

-antiplatelet medication
-ACE inhibitors
-lipid lowering meds
-Beta blockers
ADJUNCTIVE meds:
-digoxin (inotrope)
-nitrates (for angina symptoms)
-CCB
AVOID NSAIDS –> RECURRENT/MORTALITY RISK INCR

46
Q

Post MI management? -reperfusion

A
  • CABG

- PTCA

47
Q

What is stable angina?

A
  • when sx of pain decrease w/ rest after exertion

- NO myocardial cell death

48
Q

What is unstable angina?

A

-rest does not relieve pain and sx

49
Q

Stable angina: Hx?

A
  • provokers: physical activity, stress, LARGE MEALS
  • relievers: REST (goes away in 3-5 min)
    • tightness, radiating
  • -dyspnea
50
Q

Stable angina: PE?

A

usually normal OR:

  • nicotine stained fingers
  • HTN
  • AV nicking/copper wire
  • arterial bruit
  • OTHER EVIDENCE OF ATHEROSCLEROSIS
51
Q

Stable angina: work up?

A
  • routine labs: diabetes, renal dz, lipid abnormalities, glucose, thyroid fxn
  • CXR: LVH/ CHF
  • EKG: MI, LVH
  • CARDIAC STRESS TEST
    1) Exercise stress test 2) echo: wall motion abnormality 3) coronary angiogram: gold standard
52
Q

Stable angina: Tx?

A 
LIFESTYLE CHANGES:
-reduce risk factors for CAD
-physical conditioning
Meds (not everyone can get surgery)
-- Antiplatelet
-- Nitrates (if they know what triggers angina, take it before)
-- Beta blockers (decrease contractility = decrease myocardial O2)
-- CCB
Revascularization:
- PTCA 
- CABG
53
Q

How to Dx unstable angina?

A

1) NEW onset (less than 2 mo)
2) had stable but develops more FREQUENT, SEVERE, PROLONGED angina or angina happens w/ LESS exertion aka Accelerate angina
3) ANGINA AT REST

54
Q

Tx for unstable angina?

A
  • asprin
  • coronary care unit ASAP / cath lab
  • RULE OUT MI via EKG, serial cardiac enzymes
  • Cardaic Cath/Revascularzation URGENT for:
    1) persistant chest pain AND EKG changes w/in 1hr
    2) recurring ischemia w/ AGGRESSIVE THERAPY
    3) responds to meds but has ischemia w/ min activity
55
Q

What are TMI scores?

A
  • 65 yo+
    -prior coronary stenosis
  • ST segment deviation
    -2+ angina/day
    -3 risk factors for CAD
    (family hx, male, HTN, high lipids, DM, smoking, obesity)
    -incr serum cardia markers
56
Q

How to group TMI scores?

A
  • low (0-2%)
  • int (3-4%)
  • high (5-7%)
57
Q

What is Prinzmetal Angina?

A
  • ischemic pain at rest WITH transient ST elevation
  • d/t transient coronary vasospasm
  • YOUNGER and FEW coronary risks (but they smoke)
  • area of spasm is ADJACENT to plaque
58
Q

Tx Prinzmetal Angina?

A
  • nitrates

- CCB

Cardiology (10 decks)

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