How do P2Y12 inhibitors work?

Inhibit ADP receptor P2Y12 and thus inhibit platelet aggregation.

Ischemic Heart Disease (Exam II) Flashcards by Alex McKenna

What chemical mediators are released from ischemia that activate cardiac nociceptors?

Adenosine and Bradykinin

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What is the path for cardiac pain signals to reach the spinal cord?

Cardiac nociceptors → Afferent Neurons → T1 - T5 SNS ganglia.

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What is the CNS response to cardiac ischemia?

↓ AV conduction and thus ↓HR
↓ Contractility

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3 physical inducers of angina

exertion
emotional tension
cold weather

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Differentiate stable vs unstable angina.

Stable - No change in chest pain severity or frequency in 2-mo period.
Unstable - Increasing frequency and severity of chest pain.

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Are cardiac biomarkers (troponin) present with unstable angina?

NO. If they were, that would be an MI.

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What EKG abnormality is associated with old MI’s and/or current ischemia?

T-wave inversion

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What is nuclear stress testing utilized for?

Coronary Perfusion assessment

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What is the relationship between ST-segment depression and CAD.

The greater the degree of ST-segment depression, the greater the likelihood of significant artery disease

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What determines the significance of CAD during a nuclear stress test?

Size of the perfusion abnormality

Arrows point to arrows of lesser perfusion.

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What test can differentiate a new vs and old perfusion abnormality?

Nuclear Stress Testing

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What nuclear stress test tracers are used with exercise?

Thallium and Technetium

less tracer, less blood flow

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What nuclear stress test drugs are used without exercise?

Atropine
Dobutamine
Pacing

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What test determines location of occlusive disease, diagnoses prinzmetal angina, and assess results of angioplasty/stenting?

Coronary angiography

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When are adenosine and dipyridamole used with nuclear stress testing? Why?

Used after test to dilate normal, non-ischemic areas of the heart.

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What test would be useful for imaging wall motion abnormalities or valvular function?

Echocardiography

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What is Prinzmetal Angina?

Coronary Spasm

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Differentiate old vs. new plaque

Old - lots of collateral blood flow
New - not a lot of collateral blood flow

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How do you measure the stability of plaques?

You can’t

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Non-pharmacologic tx for IHD

Cessation of smoking
Ideal body weight
Low-fat/low-cholesterol diet
Statins (LDL > 160 mg/dL)
Aerobic exercise
Tx for hypertension

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What is the mechanism of action for aspirin?

COX-1 Inhibition → TXA2 inhibition → Plt aggregation inhibition.

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Drug therapy for CAD?

ASA (75-325 mg/day)
…unless allergic, then: PY12 inhibitor (clopidogrel, prasugrel, or ticagrelor)

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How can aspirin be reversed?

Trick question. It can’t be, platelets are damaged until they die and are replaced.

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What is the mechanism of action of abciximab, eptifibatide, and tirofiban?

Platelet glycoprotein IIb/IIIa receptor antagonists

Inhibit platelet activation, adhesion, and aggregation.

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What drugs (discussed in lecture) are P2Y₁₂ inhibitors?

Clopidogrel and Prasugrel

What common drug class will antagonize P2Y₁₂ inhibitors?

PPIs

How does Prasugrel compare to Clopidogrel?

More predictable pharmacokinetics but greater bleeding risk.

How do P2Y₁₂ inhibitors work?

Inhibit ADP receptor P2Y₁₂ and thus inhibit platelet aggregation.

What drug classes are synergistic with nitrates?

- β-blockers - CCBs

When are nitrates contraindicated?

- Aortic Stenosis - Hypertrophic Cardiomyopathy

What drug class is the only one proven to prolong life in CAD patients?

β-blockers

What properties do β-blockers have?

- Anti-ischemia - Anti-HTN - Anti-dysrhythmic

Which β blockers are cardioselective?

- Atenolol - Metoprolol - Acebutolol - Bisoprolol

Which β blockers are non-selective?

- Propanolol - Nadolol

What risk is associated with non-selective β blockers in asthma patients?

↑ risk of bronchospasm in reactive airway disease patients.

What drug class is uniquely effective is decreasing the severity/frequency of coronary vasospasm?

CCBs

What drug prevents ventricular remodeling, stablizes electrical activity of re-profused heart, and prevents the occurrence of reprofusion arrhythmias?

ACE Inhibitors | also treats hypertension, HF, and cardioprotective

Angiotensin II will increase what four things?

- Myocardial hypertrophy - Interstitial myocardial fibrosis - Coronary vasoconstriction - Inflammatory responses

Is troponin or CK-MB more specific for myocardial injury?

Troponin

How soon with troponin start to increase after myocardial injury?

3 hours | lasts for 7-10 days

What are the 3 categories of acute coronary syndrome?

STEMI non STEMI Unstable angina

What diagnostic studies might indicate a myocardial infarction?

- EKG: abnormality (ex. LBBB) - US: Regional wall motion abnormalities

What are indications for PCI treatment of an MI?

- Contraindicated tPa therapy - Severe HF and/or pulm edema - S/S for 2-3 hours - Mature clot

When is CABG >>> PCI

- Significant left main coronary artery disease - Three-vessel coronary artery disease - Pt's with DM who have 2 or 3 vessel CAD

What risks are associated with PCI (percutaneous coronary intervention) ?

- Endothelial destruction - Bleeding* - Thrombosis*

What is Dual Antiplatelet Therapy (DAPT) ?

- ASA w/ P2Y₁₂

How long would one want to wait for elective surgery post angioplasty **with no stenting**?

2 - 4 weeks

How long would one want to wait for elective surgery post angioplasty **with bare-metal stent placement**?

At least 30 days (12 weeks preferable)

What is responsible for *acute* thrombus formation?

Vulnerable plaques | more prone to rupture w/rich lipid cores and thin fibrous caps

How long would you wait for elective surgery post angioplasty **with drug-eluting stent placement**?

At least 6 months (12 months if post ACS)

How long would you wait for elective surgery **post-CABG**?

At least 6 weeks (12 weeks preferable)

How long would you wait for elective surgery **post angioplasty w/o stenting**?

2-4 weeks

How long would you wait for elective surgery **post bare metal stent placement**?

At least 30 days, 12 weeks prefered

Is glycopyrrolate or atropine preferred for treatment of bradycardia?

Glycopyrrolate

Are β blockers or ACE-inhibitors continued peri-operatively?

β-blockers

Are β blockers or ACE-inhibitors discontinued 24 hours prior to surgery?

ACE inhibitors

Are statins or ACE-inhibtors discontinued 24hrs prior to surgery?

ACE-inhibtors

What components are worth 1 point on the Revised Cardiac Risk Index (RCRI) ?

What % risk of major cardiac events would be conferred by a RCRI score of 0 ?

0.4%

What % risk of major cardiac events would be conferred by a RCRI score of 1 ?

1.0%

What % risk of major cardiac events would be conferred by a RCRI score of 2 ?

2.4%

What % risk of major cardiac events would be conferred by a RCRI score of ≥3 ?

5.4%

What does 1 MET equal?

3.5mLO₂/kg/min

What drug is the preferred treatment for tachycardia?

Esmolol

What anticholinergic is the better option for treatment of bradycardia in CAD patients?

**Glycopyrrolate** > Atropine

What coronary artery would you expect to be effected from abnormalities noted on II, III, and aVF?

RCA

What coronary artery would you expect to be effected from abnormalities noted on I and aVL?

Circumflex artery

What coronary artery would you expect to be effected from abnormalities noted on V3 - V5?

LAD

Two biggest risk factors for developing atherosclerosis in the coronary arteries

Male gender Increasing age

% of surgical patients w/IHD

30%

What diagnostic data is indicative of a myocardial infarction, select 2

- Detection of rise and/or fall of cardiac biomarkers - Evidence of myocardial ischemia indicated by one of the following... Q waves, symptoms of ischemia, ST changes, etc.

What is pseudonormalization of the T wave?

Return of T-waves to an upright position after having chronically inverted T waves resulting from a previous MI

What is the primary goal for management of STEMI?

Reestablish blood flow in the obstructed coronary artery ASAP *time is tissue*

Drug therapy for MI

MONA (Fentanyl better than Morphine) P2Y12 inhibitors IIb/IIa inhibitors Unfractionated heparin B blockers RAAS | *ASA

In what time frame should tPA be initiated?

Within 30-60 min of hospital arrival Within 12hrs of symptom onset

Presentation of unstable angina/STEMI

Angina at rest, lasting >10min Chronic angina pectoris - a crescendo pattern of occurance New-onset angina that is severe, prolonged, or disabling

What therapy is not indicated in unstable angina/NSTEMI?

Thrombolytic therapy - increases mortality *Treatment includes: bed rest, oxygen, analgesia, B-blockers, nitro, CCB, ASA, clopidogrel, prasugrel, ticagrelor, and heparin*

# Reendothelialization times.... Ballon angioplasty: Bare-metal stent: Drug-eluting stent:

Ballon angioplasty: 2-3 weeks Bare-metal stent: 12 weeks Drug-eluting stent: 1 year + | *drug-eluting has the longest reendothelialization time ## Footnote thrombosis is major concern

What is the most significant independent predictor of stent thrombosis?

P2Y12 inhibitor discontinuation

Perioperative glucose goal

< 180 mg/dL

What are neuroendocrine stress responses that will cause increased cardiac oxygen demand in surgery?

↑HR ↑BP Metabolic changes (↑ blood sugar) ....also postoperative shivering

What inflammatory responses caused by surgery might result in a perioperative MI?

Hypercoaguable state Plaque rupture

What are examples of high-risk surgery?

- Abdominal aortic aneurysm - Peripheral vascular operation - Thoracotomy - Major abdominal operation

What is a good pre-op MET score?

= or > 4 METS | raking leaves, gardening

What is a MET?

Metabolic Equivalent of Task

Emergent vs. Urgent vs. Time-Sensitive

Emergency - ☠️ or 🦵🏻 threatened if surgery doesn't proceed within 6hrs Urgent - ☠️ or 🦵🏻 threatened if surgery doesn't proceed withing 6-24hrs Time-sensitive - delays exceeding 1 to 6 weeks would adversely affect patient outcomes

In what kind of case would you need to skip a pre-op cardiac assessment?

Emergency case

How many days should elapse after a recent MI before noncardiac procedure?

60 days | in the absence of coronary intervention

What are examples of **active** cardiac conditions?

- Unstable coronary syndrome - Unstable or severe MI - Decompensated HF - Severe valvular disease (aortic/mitral stenosis) - Significant dysrhymias - Age???

Maintain BP/HR within _______ % of normal awake baseline

Why should you avoid hyperventilation when trying to meet myocardial O2 needs?

Hypocapnia may cause coronary artery vasoconstriction

True/False - The use of nitrogen is contrindicated in patients with CAD

FALSE

Ischemic Heart Disease (Exam II) Flashcards

(92 cards)