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IHD Flashcards

1
Q

Acute coronary syndrome consists of

A

-unstable angina, STEMI, STEMI, LBBB

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2
Q

Pathophysiology of stable angina

A

They have a stable plaque occluding. There are collaterals that are capable of supplying blood to the myocardium in stable resting stages.

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3
Q

Blood supply to the myocardium.

A

RCA divides into right marginal artery and posterior interventicular artery. LCA divides into left circumflex artery and left anterior descending artery (anterior interventicular artery)

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4
Q

Acute coronary syndrome pathophysiology

A

Due to the lack of collaterals and the sudden narrowing of the coronary artery due to the rupture of an immature plaque which has a thin capsule, exposes the highly thrombogenic lipid core. Inflammation at the shoulder of the plaque also cause a clot formation. There is a vascular spasm due to imbalance between vasoconstriction and vasodilators

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5
Q

Diagnosing 3 main categories for acute coronary syndrome

A

Pain, ECG changes, cardiac biomarkers.

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6
Q

Pain in acute coronary syndrome.

A

Acute chest pain, tightening type lasting more than 20 min retrosternal radiating to the jaw, shoulder left arm

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7
Q

ECG changes in acute coronary syndrome STEMI

A
  • ST elevations of 2 Or more contiguous leads there should be a >= 1.0mm in limb leads or V4-6
  • V2-3 > 2.5mm in <40y , >= 2.0mm in men >40y, >=1.5mm in women
  • V7-9 >0.5mm
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8
Q

ECG changes in nstemi and unstable angina

A
  • New ST depressions
  • T inversions.
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9
Q

DDs for acute coronary syndrome.

A
  • Aortic dissection
  • acute pericarditis
  • pulmonary embolism
  • pneumothorax
  • esophageal pain
  • PUD
  • acute pancreatitis
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10
Q

Mx of ACS

A
  1. Admit
  2. Acute side bed
  3. Check A, B, C and correct as necessary. Oxygen if SpO2 < 90%
  4. Connect to cardiac monitor
  5. Blood – FBC, SE, BU, S.Cr, Lipid profile, cardiac biomarkers, blood sugar
     Troponin I – (highly specific and highly sensitive - may remain
    elevated for upto 2 weeks)
  6. Commence drug therapy
     Aspirin 300 mg
     Clopidogrel 300 mg
     Atorvastatin 40-80 mg
     IV morphine – 2.5 -5 mg as single dose/GTN – sublingual
    IV metochlopromide 10 mg
  7. Take 12 lead ECG & CXR if suspecting HF
     ECG – ST elevation – STEMI
     Non ST elevation but ST depression and T inversion – unstable angina or
    NSTEMI
     If the initial ECG is not diagnostic serial ECGs should be performed
  8. Unstable angina and NSTEMI will be treated with Heparin
    STEMI and LBBB wil be treated with streptokinase.
    The best Mx would be PCI
  9. Reperfusion
     Percutaneous coronary intervention – limited
     Thrombolytics- EgSK – 1.5 MU in 100 mL N/S over 1 hour(or fibrin specific
    fibrinolytics)
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11
Q

ACS pain interms of ChLORIDE

A

 Ch- Character –tightening type of pain
 L – Location – Retrosternal
 O – Onset – sudden onset
 R – radiation – jaw, shoulder tip, left arm
 I – Intensity – severe
 D – duration - > 20-30 min
 E – aggravating factors

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12
Q

ECG changes associated with STEMI

A

1.Hyperacute (10-20 min) -Tall peaking T waves and progressive ST
elevation
2.Acute (min to hrs)- ST elevation
3.Early (hours to days)- ST elevation disappear and Q waves appear
4.Intermediate (days to weeks)- Q waves and T inversions

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13
Q

Dosage of the thrombolytics

A

1.5 MU in 100 mL N/S over 1 hour(or fibrin specific fibrinolytics)

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14
Q

Indications of thrombolytics in ACS

A

 Within 12 hours of onset of pain
 STEMI
 New onset LBBB
 True posterior MI

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15
Q

Contraindications for thrombolysis (Absolute contraindications)

A

 Past history of haemorrhagic stroke
 PHx of ischaemic stroke within last 6 months
 Intracranial tumour
 Aortic dissection
 Active internal bleeding within last 2 weeks

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16
Q

Assessing the response to thrombolysis

A

 Relief of pain
 Restoration of haemodynamic stability
 Reduction of ST elevation by 50% in 60-90 min following administration

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17
Q

Time window for PCI as the first step

A

less than 120 minutes

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18
Q

PCI wire entry sites

A

Radial Artery
Femoral Artery

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19
Q

Q waves on the ECG means

A
  • Indicates and old infarction
  • Permanent on ECG
  • Transmural infarction
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20
Q

Transmural infarction

A

whole thickness is involved

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21
Q

How to Dx a true posterior MI from anterior leads

A

If there is an ST depression in V1.

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22
Q

Most common reperfusion arrhythmia

A

Accelerated idioventricular arrhythmia

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23
Q

the cardiac biomarker that can be done within 1-2 hours

A

highly sensitive troponin I

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24
Q

Drug therapy in ACS stat Mx

A

 Aspirin 300 mg
 Clopidogrel 300 mg
 Atorvastatin 40-80 mg
 IV morphine – 2.5 -5 mg as single dose/GTN – sublingual
IV metochlopromide 10 mg

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25
ECG changes with NSTEMI and unstable angina
Non ST elevation but ST depression and T inversion
26
Heparin is given for
* Unstable angina * NSTEMI
27
Streptokinase is given for
* STEMI * LBBB
28
ECG changes with STEMI within 10-20 min
* Tall peaking T waves * progressive ST elevation
29
ECG changes with STEMI within mins to hours
ST elevation
30
ECG changes with STEMI within hours to days
ST elevation disappears and Q waves appear
31
ECG changes with STEMI within days to weeks
* Q waves * T inversions
32
Inferior MI occurs due to a block in
Posterior interventricular artery
33
Why are heart blocks more common with inferior MI
conducting system is also supplied by RCA
34
Dressler Syndrome
Immune- mediated pericarditis
35
Ventricular ectopics after giving SK indicates
successful reperfusion
36
Assessing the response to thrombolysis
 Relief of pain  Restoration of haemodynamic stability  Reduction of ST elevation by 50% in 60-90 min following administration
37
Beta Blockers are contraindicated in
* in patients with HR<60 * SBP<100 * conduction defects
38
strategies to limit infarct size
 Β blockers  ACEI  Statin  Aspirin ( later maintenance dose)  Clopidogrel ( later maintenance dose)  (( other Gp2b/3a receptor inhibitors- abciximab, eptifibatide and tirofiban
39
Abciximab, eptifibatide, tirofiban mechanism
inhibit final common pathway for platelet adhesion and aggregation
40
Troponin I +ve - NSTEMI Mx
Enoxaparin 1mg/kg bdfor 72 hours
41
Troponin I –ve – Unstable angina Mx
Enoxaparin 1 mg/kgbd for 48-72 hours
42
Early complications for ACS
* Arrhythmia * Heart Block * HF and cardiogenic shock * Post infarction angina * Acute pericarditis * Acute MR
43
Heart block is mostly seen in
Inferior MI
44
Mx of heart block due to ACS
Use atropine, consider temporary cardiac pacing
45
Mx of cardiogenic shock in ACS
inotropes
46
Post infarction angina Mx
increase antianginal drugs, consider coronary angiography
47
Rx of Acute pericarditis in ACS
No Rx needed
48
Acute MR Mx
Surgical referral
49
Intermediate and late complications of ACS
* VSD * Dressler's syndrome
50
principles of Mx prior to discharge
* Counsel regarding lifestyle modification * Mx of stress * Arrange for ECHO and coronary angiography * Discharge with medications
51
Discharge medications
 Clopidogrel  Aspirin  Atorvastatin  B Blockers  ACEI  Nitrates
52
Mechanism of Clopidogrel
inhibit P2Y 12receptors in platelets there by block ADP dependent activation of glycoprotein 2b/3a complex
53
Mechanism of aspirin
inhibit COX 1- reduce thromboxane A2 from platelet
54
Lifestyle modification post discharge
* Aerobic exercises ( 30 min brisk walking per day at least 5 days a week) * Stop smoking, alcohol * Reduce salt, fatty food, carbs
55
Pathophysiology of stable angina
most have stable plaque occluding 70-80%, calcified mature plaques which has thick capsule
56
P/C of stable angina
chest pain on exertion. Relieved by rest or GTN
57
Grading – Canadian Cardiovascular Society
o Grade 1 – ordinary [physical activity does not cause angina, angina at strenuous or prolonged exercise o Grade 2 – slight limitation of ordinary activity o Grade 3 - marked limitation of ordinary activity o Grade 4 – angina at any level of exertion
58
Ix done for stable angina to assess the severity
Exercise ECG
59
why is a normal ECG not done in stable angina
it can be normal in 50% of patients
60
Other Ix done for stable angina
* coronary angiography * Angioplasty * CABG
61
Mx of stable angina
o Lifestyle modification o Medications – Aspirin( clopidogrel if aspirin is not tolerated) ,statin Antianginal drugs
62
mechanism of nitrates
* Relaxation of vascular smooth muscle causing venodilation * arteriolar dilation * coronary artery dilation
63
Examples of nitrates
* GTN (sublingual) * ISMN(iso sorbide mono nitrate) ,ISDN (oral)
64
ADRS of nitrates
* Headache * Flushing * tolerance * Postural hypotension
65
Beta blockers mechanism
* Reduction of heart rate * myocardial contractility
66
Examples of Beta blockers
* Atenolol * Bisoprolol
67
ADRS of beta blockers
* Conduction abnormalities * Bronchoconstriction * Worsening of PVD * Impotence * Depression * Nightmares * impaired glucose tolerance * Bradycardia
68
Calcium channel blockers mechanism
* Vasodilation * Conduction block * Reduced myocardial contractility
69
Two types of CCBs
* Dihydropyridine-**( not preferred in IHD) ** Nifedipine * Non dihydropyridine- Verapamil Diltiazem
70
ADRS of dihydropyridine
* Oedema * head ache * flushing * worsening heart failure * Tachycardia * gum hyperplasia
71
ADRS of non dihydropyridine
* Oedema * Bradycardia * heart block * constipation
72
Beta blockers are not given together with
non- dihydropyridines - worsen bradycardia
73
why is dihydropyridines not recommended in IHD
tachycardia worsens IHD
74
K channel blocker
Nicorandil
75
SA node funny current channel blocker
Ivabradine
76
Inhibiting delayed Na channel
Ranolozine
77
Enoxaparin is given as (route of administration)
Subcutaneous
78
Cardiac troponin takes ...... days to return to baseline
4-14 days sometimes
79
If a patient gets another chest pain episode 5 days after he got a STEMI. How to check if the second chest pain episode is also an MI?
Ask for a quantitative Troponin T. levels which should be reducing would suddenly increase.
80
Coronary artery vasospasm is
Prinzemetal angina
81
Prinzemetal angina is seen among
* common in females * common among smokers
82
Inferior MI can present with....
* Epigastric pain * AV block
83
If the BP reduce a little 30min after starting Streptokinase infusion. Next step?
Reduce the infusion rate and elevate the limbs
84
If the BP drops significantly 30 min after starting streptokinase infusion. Next step?
Stop SK and give IV NS bolus ( could be an allergy)
85
New risk factors for MI
* Hyperhomocystinemia * Increased CRP * Increased Fibrinogen
86
ECG leads V1- V4 look at the
anterior surface of the heart (septum)
87
aVL, V5, V6 look at the
lateral surface of the heart
88
II, III, aVF look at the
inferior surface of the heart
89
V7, V8, V9 look at the
back leads, Good to check for posterior MI
90
Can you have a STEMI in all leads in an ECG
Theoretically possible. but not possible to get acute blocks in all coronary arteries
91

Cardiology (7 decks)

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