Ischemic Heart Disease Flashcards
(74 cards)
0
Q
Unstable angina
A
- Rest
- New onset<2 mos
- Increasing angina by a class
3 kinds
1
Q
Types of angina
A
- Typical chest pain with exertion relieved at rest or ntg
- Atypical angina has only 2 of the 3
- Non cardiac chest pain
2
Q
Anginal equivalents in diabetics, woman, and elderly
A
Dyspnea
Nausea
Fatigue
Faintness
3
Q
Types of mi
A
Type 1 plaque rupture Type 2 increase ischemic burden Type3 death no enzymes Type 4 sp pci Type 4b stent thrombosis Type 5 sp MI
4
Q
> 75 years
A
MI usually NSTEMI not STEMI
More likely CHF
Increase mortality
5
Q
Mi therapy
A
No nitro if BP is low No iv betablockers Morphine OK No Norvasc Oxygen if o2 below 90 No IV acei iV lopressor only if the pain is persistent Oral acei if EF below 40
6
Q
Worst prognosis
A
St-t changes and the level of tropinin CHF PCI <6 mos DM RF
7
Q
Volume of the contrast
A
3.7x creatinine clearance
8
Q
Timacs study
A
High rusk patients benifit from early invasive therapy
9
Q
Prasugrel
A
Only in MI
Only after angio max
Donot pre load in the ER
10
Q
Dose
A
Use only 80 mg Asa with ticagrelor
11
Q
Plavix dose
A
It could be given in the ER or at PCI both class1
12
Q
Cure study
A
Asa and plavix better than asprin alone
Use plavix for 1 year
Oasis7 high dose of plavix 600 and 150 is more effective the 300 and 75 but more bleeding
13
Q
Triton study
A
Increase risk of stroke and MI in cyp2c19 carriers than non carriers
14
Q
Prasugrel
A
More effective, faster acting, and potent than pkavix.
Don’t use it before you cath and no abciximab in the ER
15
Q
Triton 38
A
Don't use in stroke patients Older Less body weight Decreased events in effient groups Decrease stent thrombosis
16
Q
Ticagrelor
A
Reversible binds to p2y12 Short acting Less stent thrombosis than pkavix Can give ticagrelor even on pkavix Side effects dyspnea asthma and heart block
17
Q
Renal failure
A
Adjust angio max dose
You can give angio max in the ER 2b
18
Q
Acuity study
A
More bleeding with UFH and 2b 3a than with angio max
Fondoperimaux can cause increase thrombosis after PCI and according to the guide lines don’t need to be stopped till CABG
19
Q
Triple anti thrombotic
A
Afib
CHF
Mechanical valve
20
Q
Post mi
A
Flu vaccine
Fish oil
Aldo blockage for low EF
21
Q
Enzymes
A
Elevated tropinin for 10 days.
If myoglobin is negative no MI it has high negative predictive value
22
Q
Thrombolysis and tx in 3-24 hours to pci facility
A
Horizon study higher TLR with drug eluding vs BMS
23
Q
Thrombolysis
A
Thrombolysis
75 yo use 75 mg pkavix
No data on effient or brillinta
24
After Thrombolysis
PCI24 need 600 plavix
All 2b 3a are class 2a indication sp mi
25
Sp tnk Thrombolysis
Enoxeparim less tan 75 bolus more than 75 no bolus
26
So mi
Eplerinone is class 1 for CHF Ephesus study
27
So mi
IABP no survival benifit
| It's 2a indication
28
Sp
| Mi
Ventricular rupture day 3-5
If they have Thrombolysis 24 hours
MR post medial pap
29
Class of indication for 2b3a in mi
No class 1 all class2
30
Highest risk of mi
Black male 65-74
31
High risk in USA
```
Tropinin
ST depression
Age>75
Hypotension
Ongoing chest pain pain at the time of the exam
Crescendo angina past 48 hours
```
32
Duke score
Intermediate score risk 10% over 5 years
33
No treadmill for
```
LBBB and WPW
STT depression >1mm
Paced rhythm
LVH
Dig
```
34
Duke score
| Exercise in min-5x max ST depression- 4x angina index 0 no cp 1 non limiting cp 2 limiting cp-
Low score more than +5 one year 1% 5 year 3%
Intermediate risk score 4to -10 one year risk 1-3% five year 9.5%
High risk greater than minus 11 one year 3% and give year 35%
35
High risk
Inability to achieve 85% HR
Heart rate recovery less than 11 beats a min
VEA VT
36
Sensitivity and specificity
Stress EKG sen 68% specific 77%
Stress echo sen 80% specific 86%
Nuclear sen 84% specific 77%
37
Adenosine
```
Binds to A2A causing increase cAMP and vaso dilatation
Myocardial ischemia is rare
A1 AV block
A3A4 bronchospasm
Hypotension 5%
No caffeine
Don't use
HR slow or carotid stenosis
```
38
Persantine
Use caution in liver failure
39
Stress test recommendation
Intermediate risk interpretable EKG standard exercise EKG
Intermediate risk un interpretable EKG do imaging
40
No stress tet
For low risk
41
CTA and MR
Low to intermediate risk
No CTA if there are no symptoms
Low risk less than 100 agaston units and less than 50% lesion
Intermediate risk 100-399 one stenosis of 70% or two 50-69%
High greater than 400 and multiple lesions
42
Swedish trial
Normal LV and stable angina
Decrease mortality and MI
Asprin only
Not nitrates
Not betablockers
Definitely not ca blockers
43
Betablockers
Sp MI all patients with normal LV and continue for 3 years
Decrease HR beta 1
Decrease after load beta 2
Decrease contractiliry beta 1 and 3
No data on metoprolol tartrate data only on metoprolol succinate
44
Acei
Clear benifit in mi CHF and HTN
Less clear in motmot endive normal LV
Hope Europa Camelot cv benifit
| Pace, transcend and navigator no benifit
45
Medical therapy vs CABG 1972-79
VA study
European study
Cases
Only sub group benefited are
3 vessel
Left main
EF<50
46
Acme study
PCI has superior angina relief compared to medical therapy
Small increase in emergency CABG
Restenosis 40%
PCI has no effect on mi or mortality
47
PTCA vs CABG
| RITA ERACI CABRI EAST GABI BARI
Overall rates or mortality same
CABG superior to pci in diabetics mortality
Benifit of CABG in Diabetics due to Lima
Fewer mi cases in CABG
Less frequent angina in CABG
48
PTCA(balloon)vs bare metal stent
No deference in death mi or emergent CABG
| Bare metal stents were helpful in angiographic restenosis and repeat pci
49
BMS vs CABG
| Erica 2 ARTS SoS
Repeat revascularization low but still higher than CABG
No mortality benifit between CABG and pci
Did not achieve complete revascularization with pci
50
BMS vs medical therapy
Courage 95% male VA study
Class 4 angina medically stable
Excluded ongoing chest pain, low EF,recent pci
```
Used asprin plavix
Betablockers amlodipiine and nitrates
Lisinopril
Simvastatin
Smoking cessation
Weight loss
```
OMT and PCI are superior to OMT alone
51
Revascularization vs OMT in type 2DM
| Bari 2D
Both are identical
| Aggressive diabetic control showed no deference
52
Bari 2 D
PCI reduces angina
PCI does not reduce mi or mortality
Type 2 DM and SIHD revascularization vs medical therapy no change in mortality
53
CABG vs DES
Syntax
Low syntax scores high strokes with surgery
More repeat procedures with stent group
Higher the syntax score( 22 )more cerebrovascukar complications with pci
Higher MACCE with pci
Overall adverse event rates are higher with pci 27% vs 37%
Neither all cause mortality nor stroke are defferent in both groups
Syntax greater than 33 much higher stroke and all cause mortality with pci
But stroke
54
Freedom study
DES and CABG
Diabetes
2-3 vessels no left main
```
Higher death and stroke
Higher mi with DES
Higher stroke with CABG
Higher repeat revascularization with pci
Low syntax scores both are same
```
55
Stitch
EF <35
No left main medical vs CABG
CABG did not reduce mortality but lower incidence of combined end points with CABG
Myocardial viability was useless
56
Exercise no more than 30 min
| 2 drinks a day
```
1200-1500 cal for woman
1500-1800 for man
69% American are over weight
Bmi over 30
All cause mortality 23%
Dash <25% cal from fat
```
57
Jnc7
No alpha blockers as they worsen CHF
58
All HAT
Chlorthalidone amlodipine and lisinopril all same
59
Older patients over 60
Start treating at BP 150
| But be aggressive in DM blacks and RF
60
Metabolic x
```
Obesity >40 for men
High tig
Low LDL
HTN
Hyperglycemia
35% people inUS
Doubles the risk
```
61
Lipid studies
TNT high and low Lipitor high is better
62
Woscoos
Low LDL
| Decrease mi and CCA by 23%
63
Lipitor is better than pravastatin
High risk LDL <70
Intermediate risk 2 risk factors
Start at 130 and get to 100
Low (0-1 risk factors) risk start at 190 and get to 160
64
Statin therapy
Do base line LFTs no need for yearly tests
Zeros no survival data
Niacin no survival data
65
Pre op high risk
```
Cad
CHF
Cva
DM
Rf
Are all high risk
No routine pre po beta blockers poise study has increase mortality
```
66
Pre op
Do not stop plavix for one year
| HTN is not a risk factor in pre op
67
You can stop Coumadin in mechanical valves
Only of it is aortic and no other issues .
| Resume in I week no bridging
68
After pci
Surgery 14 days after POBA
6 weeks after BMS
12 mos after DES
69
Intermediate risk for pre op
1-5% mi and death
70
Horizons study
Angio max
| As effective as heparin and 2b 3a but safer less bleeding and less deaths
71
Lipid therapy
2 risk factors initial LDL therapy at 160
72
Stress test
Normsl test event rate less than 2% a year
| High risk >20 per year
73
Greater than 50% patients
Will not have classic triad and atypical symptoms
