Ischemia Flashcards
(88 cards)
1
Q
What is ischemic heart disease (IHD)?
A
Inadequate supply of blood/oxygen to a portion of the myocardium
2
Q
What is CAD?
A
Coronary arteries are fucked up (atherosclerosis)
3
Q
What is CHD?
A
Things caused by CAD:
Angina pectoris
MI
Death etc
4
Q
What is CVD?
A
All of your arteries are fucked up (atherosclerosis)
vs CAD where just your coronary arteries are bad
5
Q
Is it common for patients to drop dead from CHD when they didn’t even know they had it?
A
Yes in 15% of CHD patients, Sudden Cardaic Death is the first event they have
6
Q
Nitric oxide is produced by _______
A
Endothelial cells
7
Q
If your endothelial cells get damaged, and they can’t produce nitric oxide, what can happen?
A
Atherosclerosis
8
Q
In addition to vasodilation, what other 2 things does nitric oxide do?
A
- inhibits plaque formation
- has anti-inflammatory properties
9
Q
True or False:
HDL plays an atheroprotective role, due to it’s anti-inflammatory and antioxidant properties?
A
True
10
Q
What is the first step of athersclerosis?
A
Endothelial dysfunction
11
Q
What populations have atypical ischemic heart disease symptoms?
A
Women
Elderly
Diabetic
12
Q
Atherosclerotic plaques usually form in sites of:
A
Increased blood turbulence
Branching
13
Q
The main coronary arteries are located in the _________
A
Epicardium
14
Q
What is another term for angina pectoris?
A
Stable angina
15
Q
Transient~ ischemia may result in _________
A
Angina pectoris aka stable angina
16
Q
Prolonged~ ischemia may result in _________
A
MI
17
Q
Is stable angina considered part of Acute Coronary Syndrome?
A
No
ACS is unstable angina and MI (both STEMI and NSTEMI)
18
Q
How long does stable angina pain last?
A
2-10 minutes
Typically a crescendo-decrescendo
19
Q
What makes stable angina pain go away?
A
Rest
Nitro
20
Q
When someone has stable angina pain, how will they describe the pain?
A
Heaviness
Pressure
Squeezing/tightness
21
Q
Will people with stable angina pain demonstrate Levine’s sign?
A
Yes
22
Q
Can stable angina pain radiate beyond the sub sternal region?
A
Yes.
Shoulders, arms, neck, jaw, teeth, epigastrum, mid back
23
Q
What are some atypical presentations of angina, and which one is very common in women?
A
Shortness of breath- common in women
Nausea
Fatigue
Faintness
(All of these more common in elderly, diabetic and women)
24
Q
If your female patient says she feels “breathless,” should you be concerned for angina?
A
Yes, dyspnea is a common presentation in women
25
Are sharp stabs of chest pain, or a prolonged dull ache likely to be ischemic in nature?
No, but you cant rule out based on this
26
What is stable angina?
Exertional related chest/arm discomfort that resolves with rest or nitro and usually doesnt last more than 5-10 minutes***
27
Will you see ECG changes in a patient with stable angina?
You might see some ST and T wave changes during their episodes, but they’ll go away when the patient’s pain goes away
(Basically, they ARE having ischemia, but its not lasting long enough to cause damage that would last on an EKG)
28
Why do we do exercise stress testing?
We are attempting to reproduce cardiac ischemia through defined exertion
29
What is the Bruce protocol?
On the treadmill, you increase speed and incline every 3 MINUTES*** until their heart rate is at 85% of the max HR for their age
30
What things are we looking for when we get the patient on the treadmill?>
ECG Changes
Decreased heart perfusion seen on nuclear imaging
Drop in systolic BP more than 10mm
Any other symptoms 🤷🏻♂️
(this was in red)
31
In what situations would we skip the treadmill and go right to pharmacologic stres testinf?
- pt unable to exercise (old, legs don’t work, breathing problems, neurological deficits)
- can’t get to target HR through exercise becasue they’re on beta blockers
- high likelihood of false-positive since they have poor exercise tolerance
32
What will we see on a stress echocardiogram in a patient with ischemia?
Wall motion abnormality with stress/exercise
**in red
33
What are you looking for on nuclear medicine imaging before and after the patient’s heart is stressed?
Perfusion defect (when you compare resting to stressed)
***in red
34
What is the Gold Standard for diagnosing CAD?
Coronary angiography **
35
Will coronary angiography show the presence of vulnerable plaques?
No
36
Is coronary angiography without risk?
No, there’s definitely risks.....
Bleeding, arrhythmias, vessel injury, emboli and renal failure (from the contrast dye)
37
Is the current treatment for ischemic heart disease based on prevention?
No 🤑 it 🤑 is 🤑 based 🤑 on 🤑 treating 🤑 symptoms 🤑 so 🤑 that 🤑 BIG 🤑 PHARMA🤑 gets 🤑 richer🤑
38
Do we see a lot of CAD in cultures that primarily eat plant based diets? 🐇
No almost zero
39
How do we treat stable angina?
Risk factor modification- statins, stop smoking, lose weight etc
Meds- nitrates, beta blockers, CCB, statins, antiplatelets
Revascularization
40
What 3 classes of meds DECREASE oxygen demand?
Nitrates- preload reduction
Beta blockers-afterload reduction
Calcium channel blockers- afterload reduction for patients who don’t respond to nitrates and beta blockers
41
What is the first line medication for chronic angina?
Beta blockers
42
What 2 meds INCREASE oxygen supply?
Nitrates-dilate coronary arteries
Calcium channel blockers- coronary vasodilators
(YES both of these also Decreased oxygen demand)
43
What is the typical dose of nitroglycerin?
0.3-0.6 mg sublingual/buccal spray
Take at onset of pain and every 5 minutes for up to 3 doses
If still no relief, call 911
44
What are the antiplatelet medications we can give for stable angina?
Aspirin (75-325mg) - basically every patient
Plavix- if they cant take aspirin
Combination of the 2
45
Patients who have had an MI are at a _____x higher risk of death from CHD than those who don’t have CVD
20x more likely to die from CHD
| This was in red
46
What role do statins have in treating stable angina?
They STABILIZE PLAQUES***
-slow progression and even reverse coronary atherosclerosis
47
Do we care what the pateints’ baseline LDL is when we put them on high dose statins for angina
No
48
When would we do CABG instead of PCI for revasculartizaon ?
Left main coronary stenosis
Triple vessel disease
49
Which vessels do we use for CABG?
Saphenous vein
Internal mammary arteries
50
What 3 things fall under the umbrella of Acute Coronary Syndromes?
Unstable Angina
NSTEMI
STEMI
51
“Sudden breathlessness” and a sense of impending doom......
| Should you be worried?
Lol yeah your patient probably has unstable angina, STEMI, or NSTEMI
52
What are the 5 diagnoses that should be on your differential for chest pain that you need to rule out?
THIS SLIDE HAD A STAR ON IT
Aortic dissection
PE
Pneumothorax
Perforated viscous (?)
Cocaine abuse 🦄
53
What is unstable angina?
Ischemic pain AND at least one of the following:
- occurs at rest, usually lasts more than 10 min
- new onset and severe
- occurs with a crescendo pattern
54
What is prinzmetals angina?
Ischemic symptoms caused by vasospam!
This will be chest pain at rest
55
What ECG findings will you see with prinzmetals angina/
Transient ST elevations
56
Who usually gets prinzmetals angina?
Younger people with few risk factors
57
How do you diagnose Prinzmetals angina?
Coronary angiography
| Stress testing unhelpful
58
How do you treat Prinzmetals Angina?
Nitrates
Calcium channel blockers
59
Should we give beta blockers to our patient with prinzmetals angina?
NO
Might make it worse
60
What are the 4 ways you can end up with unstable angina or NSTEMI?
1. Plaque rupture with a nonocclusive thrombus (not completely~ occluded) MOST COMMON
2. Obstruction due to vasospasm (prinzmetals)
3. Progressive mechanical obstruction- following Percutaneous coronary intervention
4. Increased oxygen demand/decreased supply like from tachycardia or anemia
61
What is the most common cause of unstable angina and NSTEMI?
Plaque rupture with a nonocclusive thrombus ***
62
If we think someone is having unstable angina or an NSTEMI, should we do stress testing?
No, its not safe if they are actually having an event. BUT if their enzymes are normal and there is no evidence of infarction and we don’t know what’s going on you can do it
63
Will your cardiac enzymes be elevated in unstable angina?
NO NO NO NO NO NO NO!!!
64
Will your cardiac enzymes be elevated in NSTEMI>?
YES YES YES
| There has been an actual MI!!!!
65
What kind of ECG changes are you likely to see with unstable angina or NSTEMI?
ST depression
T wave inversion
66
How do you treat unstable angina/NSTEMI?
Bedrest with cardaic monitoraing and oxygen
MONA
Beta blockers
Antiplatelets (plavix)
Heparin
Statins
Revascularization if needed
67
What is MONA?
Morphine, oxygen, nitro, aspirin/antiplatelet
| Not done in this order
68
What are the TIMI variables for calculating the risk of progression of unstable angina or NSTEMI?
65 or older
3+ risk factors for CHD
Prior coronary stenosis of 50%+
ST segment deviation on admission ECG
2+ anginal episodes in 24hrs
Increased cardaic enzymes
Aspirin use in last 7 days
(Basically the more of these you have, the more likely you are to die or have a serious ischemic event in the next 2 weeks)
69
What time of day is STEMI more likely?
Within a few hours of waking up in the morning
70
What 3 things are known to precede STEMIs in 50% of cases?
Vigorous exercise
Extreme emotional stress
Illness
71
What 2 things can cause a STEMI?
Rupture of a vulnerable plaque that causes 100% occlusion of a coronary artery (MUCH more common)
Slowly developing stenosis of an artery (rare, because collateral vessels usually develop as stenosis increases)
72
what is it:
ST elevation
No cardiac enzymes
unstable angina
73
What is it:
ST elevation
Increased cardaic enzymes
STEMI
74
What is it:
No ST elevations
Increased cardaic enzymes
NSTEMI
75
What is it:
no ST elevation
No cardaic enzymes
Unstable angina
76
When is the onset of increased cardaic enzymes? (Both CK and troponin)
3-12 hours
77
When do cardiac enzymes peak? (Both CK and troponin)
18-24 hours
78
How long do CK enzymes stay elecvated ?
36-48 hours
79
How long do troponins stay elevated ?
Up to 10 days
80
What should you do if patient has STEMI?
MONA
IV access
Beta blockers (CCB too if nitro and B-blockers not relieving pain)
Antiplatelet (plavix)
Heparin
Anti-arrhythmics
ACE-inhibitors
Statins
REVASCULARIZATION
81
In what order do we do MONA?
O N M A
82
What are the ABSOLUTE contraindications to thrombolytic/fibrinolytic therapy?
Hx of intracranial hemorrhage
Stroke in past year
Poorly controlled HTN (180/110+)
Suspected aortic dissection
Active internal bleeding lol
83
What are the 2 ways we can achieve revascularization?
Percutaneous coronary intervention
Thrombolytic drugs
(In experienced hands, PCI is more effective)
84
Do we give thrombolytics for unstable angina or NSTEMI?
No
85
Both UA/NSTEMI and STEMI will get PCI or CABG, but what is the difference?
STEMI will get it as soon as possible
NSTEMI/UA will get it later
86
What is “Dressler’s Syndrome”?
Pericarditis after MI, CABG, or heart trauma
87
What are the complications after an MI?
Recurrent ischemia
Depression!***
Pump failure-leading cause of death
Arrhythmias
Pericarditis/Dresslers syndrome
Mural thrombus
Cardiac rupture/LV aneurysm
88
How do we manage a patient after an MI?
Risk stratification-consider stress test
Treat risk factors- diet, smoking, BP
Medications- Bblockers, aspirin, and ACE or ARB if LV is messed up
