Ischemic Heart Disease

Question 1

What is the typical in a patient history for stable angina?

Answer 1

Symptoms precipitated by stress or exertion. Relieved by rest or nitrates. Long standing >1-2 months

Question 2

What is the typical in a patient history for unstable angina?

Answer 2

Chest pain at rest or with minimal exertion. New onset angina. Worsening angina (crescendo)

Question 3

How is ischemic heart disease classified?

Answer 3

class I: asymptomatic. class II: mild limitation of excercise tolerance and sx w/ordinary exertion. class III: moderate limitation of excercise tolerance and sx w/minimal exertion. class IV: severe limitation of activities and sx at rest

Question 4

What labs should be done for unstable angina?

Answer 4

troponin I, CK-MB, CBC, TSH, update lipids, CMP, DM

Question 5

What EKG changes are suggestive of ischemia?

Answer 5

New bundle branch block, T wave inversion, depression or flattening, ST depression or elevation, Q waves

Question 6

When is cardiac catheterization/coronary angiography indicated for chronic stable angina?

Answer 6

Persistent limiting angina despite maximal medical therapy. Stress test suggestive of high risk disease.
History of aortic valve disease. Worsening symptoms

Question 7

How are short acting nitrates used for immediate relief of anginal sx?

Answer 7

0.4mg sublingual nitroglycerin tablets or spray. Repeat in 3-5 min if needed until pain is gone. Pain lasting > 20 min call EMS

Question 8

How do nitrates decrease the O2 demand on the heart?

Answer 8

causes vasodilation that decreases arteriolar and venous tone, preload, afterload, and BP.

Question 9

What are most common side effects of nitroglycerin?

Answer 9

HA, dizziness, hypotension, flushing

Question 10

What are contraindications to nitrates?

Answer 10

hypotension, aortic stenosis, volume depletion, acute RV infarction, hypertrophic cardiomyopathy, ED meds

Question 11

Describe the use of long acting nitrates for ischemic heart disease

Answer 11

Used to prevent sx. added to beta blockers or calcium channel blockers. Need a nitrate free interval of 8-10 hours a day to help prevent development of tolerance

Question 12

What are the three long acting nitrates?

Answer 12

Isosorbide dinitrate (Isordil), Isosorbide mononitrate (Imdur), Transdermal patch (NitroDur)

Question 13

What is the first line therapy for treatment of angina?

Answer 13

beta blockers: decrease HR, contractility, rate of AV conduction therefore decreasing myocardial O2 consumption

Question 14

What are contraindications to beta blockers?

Answer 14

Severe bronchospasm, Bradyarrhythmias, Decompensated heart failure, May worsen Prinzmetal’s angina

Question 15

What is the only approved calcium channel blocker for use with CHF?

Answer 15

Amlodipine (Norvasc). Belongs to class of dihyropyridines which don’t decrease HR or contractility

Question 16

Name the calcium channel blockers

Answer 16

Dihydropyridines: Amlodipine (Norvasc) and Nifedipine (Adalat, Procardia). Nondihydropyridines: Diltiazem (Cardizem) and Verapamil (decrease HR and contractility)

Question 17

What are the common side effects of calcium channel blockers?

Answer 17

edema*, HA, constipation, hypotension, dizziness, bradycardia (nondihyropyridines-Cardizem/Verapamil)

Question 18

What are contraindications to nondihyropyridines (Diltiazem/Verapamil)?

Answer 18

Systolic CHF, AV block or bradycardia

Question 19

What are the common antiplatelet agents used for ischemic heart disease?

Answer 19

Aspirin 81-325 mg daily or Clopidogrel (Plavix) 75 mg

Question 20

What diagnostic results characterize vasospastic/Prinzmetal’s/Variant angina?

Answer 20

EKG evidence of ischemia during pain (ST elevation), Normal exercise tolerance, Normal coronary angiogram

Question 21

What is vasospastic/Prinzmetal’s/variant angina?

Answer 21

chest pain w/o usual precipitating factors that may awaken pt from sleep, be associated with arrhythmias or conduction defects, and presents in a cyclical pattern over months

Question 22

What are vasospasm triggers?

Answer 22

Exposure to cold, Emotional stress, Vasoconstricting meds, Cocaine, Tobacco, Beta blockers

Question 23

What disorders are associated with coronary vasospasm?

Answer 23

concomitant coronary artery disease, Migraine headaches, or Raynaud’s phenomenon

Question 24

How is a coronary vasospasm treated?

Answer 24

Rule out obstructive disease with cardiac catheterization. SL nitro for acute relief. Calcium channel blockers and long acting nitrates for prevention. NO beta blockers

Question 25

What three medical conditions are classifed as acute coronary syndromes?

Answer 25

NSTEMI, unstable angina, STEMI

Question 26

What is the EKG criteria for diagnosis of NSTEMI?

Answer 26

New horizontal or down sloping ST depression > .05 mV in 2 contiguous leads and/or T wave inversions

Question 27

What is the EKG criteria for diagnosis of STEMI?

Answer 27

ST elevation at the J point in 2 contiguous leads of ≥ .1mV. ST elevation ≥ .2mV in men or ≥ .15mV in women in leads V2, V3

Question 28

What is the medical therapy for unstable angina and NSTEMI?

Answer 28

Oxygen, Nitroglycerin, Morphine, Beta blockers, Antiplatelet therapy, Anticoagulation

Question 29

What should be added to the antiplatelet therapy for NSTEMI after checking with a cardiologist?

Answer 29

a P2Y12 receptor blocker (platelet inhibitor): Clopidogrel (Plavix), Prasugrel (Effient), Ticagrelor (Brilinta). Often wait until after angiogram because they irreversible inhibit platelets

Question 30

What is recommended for anticoagulation in unstable angina instead of heparin?

Answer 30

Enoxaparin (Lovenox): 1mg/kg subcutaneous Q 12 h

Question 31

What should be added to anticoagulation therapy for patient's with NSTEMI who are high risk and have early invasive surgery in addition to heparin?

Answer 31

GP IIb/IIIa inhibitor: Abciximab (Reo Pro), Eptifibatide (Integrilin), Tirofiban (Aggrastat)

Question 32

What should be provided to all ischemic heart disease before discharge?

Answer 32

Statins: Atorvastatin (Lipitor) 80 mg daily

Question 33

What % of risk of all cause mortality for MI are associated with each TIMI score?

Answer 33

``` 0-1: 4.7%. 2: 8.3%. 3: 13.2% 4: 19.9% 5: 26.2% 6-7: at least 40.9% ```

Question 34

How is a cocaine associated MI treated?

Answer 34

similar to other ACS patients except give benzodiazepines early and do not use beta blockers

Question 35

What is a STEMI?

Answer 35

MI due to complete obstruction of the coronary artery

Question 36

What is medical therapy for STEMI?

Answer 36

same as for NSTEMI plus fibrinolytic therapy or PCI

Question 37

What is the first line therapy for STEMI?

Answer 37

primary percutaneous coronary intervention (PCI) unless not available within 90-120 minutes otherwise administration of fibrinolytics

Question 38

What is the mechanism of action of fibrinolytics?

Answer 38

Initiation of local fibrinolysis by binding to fibrin in the thrombus and converts entrapped plasminogen to plasmin

Question 39

What are contraindications to fibrinolytics?

Answer 39

intracranial hemorrhage, ischemic stroke, cerebral vascular malformation, metastatic intracranial malignancy, aortic dissection, bleeding disorder, closed head injury

Question 40

Why is there a greater mortality in NSTEMI vs STEMI?

Answer 40

may be related to the fact that over half of patients with NSTEMI have multivessel disease and a greater likelihood of residual ischemia