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Cardio > Ischemic Heart Disease II - Exam 2 > Flashcards

Ischemic Heart Disease II - Exam 2 Flashcards

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1
Q

What is the first diagnostic test ordered when working a pt up for Ischemic Heart Disease? How soon after arrival?

A

EKG!! always first

anyone with symptoms of ACS within the first 10 minutes of the pt’s arrival

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2
Q

What do you do if the EKG is not diagnostic but the patient remains symptomatic?

A

serial EKGs (e.g., 15- to 30-min intervals during the for the first 1-2 hrs) should be performed to detect ischemic changes.

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3
Q

What is the earliest presentation of an MI? What do they need to be distinguished from? How long are they present?

A

hyperacute T waves

Must be distinguished from the peaked T waves associated with hyperkalemia.

exist for only 20-30 minutes and are rarely seen in the real world

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4
Q

What is the difference between STEMI peaked T waves and hyperkalemia peaked T waves?

A
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5
Q

What is the dx test for MI?

A

cath is dx for MI NOT EKG

EKG is NOT diagnostic for MI

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6
Q

What is ST segment depression or T wave inversion in more than 2 contiguous leads make you think?

A

suspicious for NSTEMI or unstable angina

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7
Q

What does ST segment elevation or new LBBB make you think?

A

suspicious for STEMI

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8
Q

What are the 4 stages of EKG changes when talking about the evolution of a STEMI? How long does it take for each change to appear?

A
  1. ST elevation (minutes to hours)
  2. Pathological Q wave and Inverted T waves (1-2 days)
  3. ST flattening with pathological Q wave (7-10 days)
  4. normalization with persistent Q wave (months)
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9
Q

After a STEMI, when will a Q wave tend to appear? Does it always have to appear?

A

Q waves in leads that previous had the infarction but does NOT always have to appear

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10
Q

What is the second test when working a pt up for a IHD presentation?

A

labs!! aka cardiac enzymes

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11
Q

What are the 3 cardiac enzymes? Which one shows up the earliest?

A

Myoglobin- shows up the earliest but is the least helpful

CK-MB

Troponin I, T

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12
Q

T/F: Myoglobin is found in cardiac and skeletal muscle

A

TRUE!! aka it is not strictly a heart enzyme

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13
Q

What is important to note about myoglobin? What timeframe?

A

High sensitivity, poor specificity and is released more rapidly from infarcted myocardium but is only good for EARLY detection of MI

1-4 hours after an MI

myoglobin: think very early detection of MI and that is basically it

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14
Q

T/F: Troponin is naturally found in the serum in very small amounts and becomes elevated during a MI

A

FALSE! troponin is normally NOT found in the serum and is only released when myocardial necrosis occurs

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15
Q

What is the preferred marker for myocardial injury? Why?

A

troponin

highly sensitive and specific for even small amounts of cardiac damage

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16
Q

**What is the nature elevation and depression of troponin levels with regards to a MI?

A

Serum levels increase within 3-12 hrs

peak at 24-48 hrs

return to baseline over 5-14 days.

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17
Q

**When should you measure troponin? _____ troponin is worthless

A

at presentation

at 90 minutes

Every 6-8 hrs after symptom onset x 3 or until trending down

one isolated value is worthless!!!! and you must determine the trend to diagnose an MI

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18
Q

What is the normal value for troponin? Give both new and old school versions

A

normal is between 12-13 for newer versions

normal is less than .001 for old troponin levels

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19
Q

What does troponin tell you? What does it NOT tell you?

A

elevation indicates the presence of myocardial injury but does NOT tell you the reason why the heart is angry

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20
Q

What effect does blood loss have on troponin?

A

blood loss will elevate troponin levels

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21
Q

How good of a cardiac test is CK-MB when compared to troponin? How long does it take for CK-MB to become elevated?

A

Less sensitive and specific than troponins

Serum levels ↑ 3-12 hrs after injury, peaks around 24 hrs, remains elevated 36-48 hrs

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22
Q

What is considered a positive CK-MB? What can make it appear falsely positive?

A

Positive if CK-MB >5% or total CK and 2 x normal

False positives with exercise, trauma, muscle disease, DM, PE

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23
Q

**Where is Lactate Dehydrogenase (LDH) commonly found? What is the timeframe?

A

Found in many tissues (kidney, skeletal muscle, brain, blood cells, lungs) so not specific for heart disease.

Level rises within 24 - 72 hours after a heart attack, peaks in 3 - 4 days, and returns to normal in about 14 days

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24
Q

What cardiac enzyme will stay elevated longer than troponin? Which cardiac enzyme becomes elevated first?

A

total CK stays elevated longer than troponin

myoglobin will become elevated first

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25
Which cardiac enzyme would be most beneficial for a pt with chest pain for 2 hours? for 6 hours? for recurrent chest pain 36 hours after having PCI for an MI?
2 hours- myoglobin 6 hours- troponin recurrent chest pain 36 hours after having PCI for an MI: CK-MB
26
What are 3 elevated lab findings that are possible with an MI?
leukocytosis elevated CRP ESR
27
What are the 1st, 2nd, and 3rd line testing for a pt with chest pain?
1st: EKG 2nd: labs 3rd: stress tests
28
The _____ is the most commonly used and recommended initial noninvasive procedure for evaluating inducible ischemia in the patient with angina. What are the 2 different versions? Which version is more accurate?
stress test exercise and chemical exercise is more accurate
29
When is stress testing indicated according to ACC/AHA risk guidelines? What age are you considered high risk with typical angina s/s?
patients with intermediate or high risk both men and women 60-69 with typical angina are considered high risk
30
What is the pt criteria in order to qualify for a stress test?
person can walk on flat ground for greater than 5 minutes or climb 1-2 flights of stairs without needing to stop
31
What is the goal of an exercise stress test? What protocol is followed? What is the formula to calculate max HR?
want to acheive 85% of max HR Bruce TM protocol max HR= 220- age
32
During an exercise stress test, the intensity of exercise is increased and continued until what 3 things? **What is considered a positive test?
The patient reaches maximum HR Changes in heart function are detected on the EKG Patient is symptomatic **positive test: an ST-segment depression of 1mm**
33
What is a draw back of an exercise stress test?
Con is more false-positives than true-positives
34
**What method of calculating HR is used during an exercise stress test? What is the formula?
Haskell and Fox 220-age
35
**What are the absolute indications for terminating an exercise stress test?
36
**What are the absolute CI for exercise stress testing?
37
What are the relative CI for exercise stress testing?
38
** What 4 baseline EKG abnormalities would make an exercise stress test CI?
Preexcitation (WPW) syndrome Electronically paced ventricular rhythm Greater than 1 mm of resting ST depression Complete LBBB
39
When is an EST with imaging indicated? What are the 2 nuclear tracers used?
Thallium 201 Technetium: scan the pt before and after the EST and compare the results
40
41
When is a stress echo used? What is it usually combined with?
Look for regional wall motion abnormalities or LV dilation in response to exercise. combined with exercise EKG to increase sensitivity and specificity of the stress test
42
When is a pharm stress test used? **What is it ALWAYS combined with?
when a pt cannot exercise or EST is CI **Sensitivity of a pharmacologic stress EKG is very low, so these tests are always combined with an imaging modality
43
**What is 1st line pharm stress test agent? **What drug class? **What is the CI? What are the SE?
ADENOSINE vasodilator CI: bronchospasms SE: HA, SOB, flushing, chest pain, dizziness
44
What is the 2nd line pharm stress agent? What drug class? What medication is commonly used as adjunct?
DOBUTAMINE adrenergic stimulating agents adjunct med: atropine
45
**What is the definitive way to dx CAD? What other types of dz can it confirm the presence of?
cardiac cath!!! Evaluate or confirm the presence of coronary artery disease, severe valvular disease, or disease of the aorta also evaluates heart muscle function
46
What is the overall mortality risk with cardiac cath? What are the surgical risks?
Overall low mortality risk with procedure (0.1%) Surgical risks include: CVA, coronary artery dissection, retroperitoneal hemorrhage, AKI, femoral pseudoaneurysm
47
When is cardiac cath used as a first line treatment? What is the required prep? **What is the highlighted one?
high pre-test likelihood Patient must be NPO for 4-6 hours Written consent required IV fluids (NS) ran for ~24 hours to “flush out” the contrast **Hold Metformin for 48 hours to avoid contrast induced nephropathy**
48
What is the difference between a LEFT and RIGHT heart cath?
left: think cardiac valve, left ventricular function, EF and regional wall motion right: think pulmonary HTN
49
What access point do they enter for a LEFT cath vs a RIGHT cath?
LEFT: femoral or radial RIGHT: jugular
50
When would a CXR be used in angina? Chest CT? TTE?
CXR: pulmonary causes of chest pain and may show aortic dissection chest CT: PE and aortic dissection TTE: pericardial effusion and tamponade regional wall motion abnormalities proximal aortic dissection
51
When is CT of coronary arteries used? What must the HR be? Who is it NOT indicated for?
Images the heart with contrast medium and multislice technology, uses both radiation exposure and contrast to produce images of the heart and heart vessels HR must be below 50 NOT indicated for people over 65 because it has not been studied
52
Go review the case studies that are in this lecture
DO IT!!!
53
What is the Levine sign?
patient hunched over clutching their test
54
What is the pharm management for stable angina? **What does everyone with known CAD need?
**high intensity statin
55
What 3 conditions are considered acute coronary syndrome? What is the management? What should you give first?
acute coronary syndrome is considered: unstable angina STEMI NSTEMI Give ASA first (chewed) then NTG
56
you are seeing a pt in the PCP setting who is currently having symptoms of acute coronary syndrome. what should you do?
ASA and NTG can be given in the outpt setting then call EMS
57
What 2 medications should be started within the first 24 hours of ACS?
oral BB and ACEI- if BP can tolerate without bottoming out
58
When are BB CI in ACS management?
Contraindicated in acute HF, bradycardia, heart block
59
What is the STEMI specific management? **What are the associated time frames?
**within 12 hours** on the onset of s/s: PCI (Percutaneous coronary intervention) within **90 minutes** upon arrival is the goal!! or fibrinolytic therapy need fibrinolytic therapy **within 30 minutes ** of hospital presentation and 6-12 hours of onset of symptoms IF PCI is not an option
60
Patients with STEMI who seek medical attention within _____ of the onset of symptoms should be treated with immediate reperfusion therapy with ______ or ________. Primary PCI within ______ of first medical contact is the goal and is superior to thrombolysis
12 hours primary PCI fibrinolytic therapy 90 mins
61
If a pt with s/s of ischemia/infarction present to the ED, what should you do in the first 10 minutes?
62
What treatments should you give the pt when they first arrive in the ED?
Give ASA and O2 first! then NTG then morphine to control pain
63
EKG comes back as a STEMI, what are the next steps? What EKG finding confirms STEMI?
If available and door-to- balloon goal time of 90 minutes -> PCI Door- to- needle time of thrombolytics is 30 minutes ST elevation
64
EKG comes back at ST depressions or T wave inversion. What do you do next? What do you NOT give?
If high risk symptoms and high heart score, PCI tPA is ONLY for STEMI!!!!
65
If EKG comes back normal/nondiagnostic, what do you do next?
serial troponins repeat EKG any abnormal testing comes back, initiate proper protocol
66
_____ MOA Irreversible inhibition of platelet aggregation, stabilize plaque and arrest thrombus, reduce mortality in patients with STEMI
aspirin and P2Y12 inhibitors
67
What dose of ASA is given in the ACS setting?
162-325mg CHEWED do not matter if planning to use fibrinolytic therapy, everyone gets ASA
68
What should pts with ASA allergy get in ACS setting?
P2Y12 inhibitor -> Clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta)
69
a pt with what 3 conditions should you use ASA with caution?
active PUD, hypersensitivity, bleeding disorders
70
What is the loading dose of clopidogrel prior to a cardiac cath? How long should a pt remain on P2Y12 inhibitors following an event?
clopidogrel 600mg prior to cardiac cath 3-12 mo duration depending on scenario
71
What are the 3 drugs in the P2Y12 inhibitor category?
Clopidogrel (Plavix) Prasugrel* (Effient) Ticagrelor* (Brilinta)
72
When would you use a Glycoprotein IIb / IIIa Inhibitors?
In support of PCI intervention as early as possible prior to PCI but NOT REQUIRED in most patients in high risk patients with ongoing ischemia despite ASA and P2Y12 inhibitors large thrombus especially if they have not received P2Y12 To stabilize patients who need urgent CABG in place of P2Y12 until surgical indications defined
73
Tirofiban (Aggrastat) Eptifibatide (Integrilin) Abciximab (Reopro What drug class? What form do they come in?
Glycoprotein IIb / IIIa Inhibitors IV anti-platelets
74
When are anticoagulation therapy used in ACS? What do you NOT want to do?
Adjunct to surgical revascularization and thrombolytic / PCI reperfusion Used in combo with ASA and/or other platelet inhibitors do NOT change from one drug to another drug in the same class
75
What are the indirect thrombin inhibitors? Which one is preferred?
UFH LMWH (preferred) Enoxaparin (Lovenox) Fondaparinux (Arixtra) Dalteparin (Fragmin)
76
_______ is the direct thrombin inhibitor. Where is it commonly used?
Bivalirudin (Angiomax) only used in the cath lab
77
What is the MOA for nitrates?
nitrate enters vascular smooth muscle and is converted to nitric oxide, leading to activation of cGMP and vasodilation. Decreases systemic vascular resistance and preload
78
Under what conditions would you want to be cautious in using a nitrates? What is a common SE?
Use with caution in hypotension (SBP <100), bradycardia, tachycardia, RV infarction HA
79
nitrates are CI with concurrent use of ________. **What type of MI do you NOT want to use nitrates with?
PDE-5 INHIBITORS **do NOT use NTG during an Inferior wall MI**
80
_______ is the long acting nitrate and used for chronic stable angina taken as a DAILY medication. How long does it last? **What is the SE?
Isosorbide Mononitrate (Imdur) must be taken QD- lasts for 8 hours **HA
81
With regards to tolerance what is important to note about the short- acting and long -acting nitrates?
short-acting: do not use continously or for prolonged periods of time due to the development of tolerance long-acting: multi-dose regimens lead to development of tolerance so need to ONLY TAKE QD
82
**What is the NTG pt education point with regards to dosing instructions?
Nitro 0.4mg sublingual prn for chest pain. Take 1 tablet q5 minutes up to 3 tablets. If you take all 3 tablets and still are experiencing chest pain need to IMMEDIATELY go to nearest ER
83
When should BB be used in ACS? What do they decrease the risk of? What are the CI?
should be started 24-48 hours after MI once the pt is STABLE reduces: -Infarct size and complications -Rate of re-infarction -Rate of life threatening tachyarrhythmias and thus reduce mortality CI: cute CHF, heart block, hypotension)
84
______ is the antianginal medication to treat chronic stable angina usually only when can’t tolerate Imdur. **What is the DDI?
Ranexa (Ranolazine) **DDI: May prolong QT so avoid use with other QT prolongation drugs
85
**_______ MOA acts one the late sodium channel blocker, decreases intracellular calcium overload
Ranexa (Ranolazine)
86
Why are ACE/ARBs used post MI?
because post MI there is a progressive increase in ACE activity and AT type 1 receptor activity and by using ACE/ARB's it reduce fibrosis and remodeling at the scar site and remote to the infarct which can help preserve myocardium BP and renal function must be able to tolerate
87
______ start in the days immediately following diagnosis of ACS ______ for selected cases with intracardiac thrombus or embolic events _______ for selected patients with LV dysfunction _____ are used as 3rd line therapy in patients with continuing symptoms on nitrates and beta-blockers or those who are not candidates for these drugs - antianginal properties
STATINS WARFARIN ALDOSTERONE ANTAGONISTS CCB- amlodipine
88
______ are used as "clot busters" in ____ type of MI
Fibrinolytic Therapy ( t-PA, ends in -plase) only in STEMI!!!
89
What is the most serious complication of fibrinolytic therapy? _____ and ______ should be continued after completion of t-PA. What version is preferred?
intracranial hemorrhage ASA and anti-coag LMWH is preferred to heparin
90
When should you use fibrinolytic therapy in a STEMI? When is t-PA of the greatest benefit? _____ should be started alongside all t-PA for all STEMI pts
if it will take longer than 90 minutes to get to cath lab, then give t-PA prefer to give t-PA within first 30 minutes The greatest benefit occurs if treatment is initiated within the first 3 hours after the onset of presentation PPIs and antithrombotic therapy should be used together
91
**What are the absolute CI for thrombolytic therapy?
92
When is PCI beneficial? What are the 2 different types of PCI?
only beneficial for those with unstable disease balloon and stent angioplasty
93
What is happening in a balloon angioplasty?
Inflation of a balloon within the coronary artery to compress plaque against the walls of the artery and open the lumen
94
What is happening in a stent angioplasty?
use of a small, expandable mesh-like tube of thin wire ('stent'), along with the balloon
95
What are the 2 different stent types? Which one is preferred?
bare metal stents: no coating drug-eluting stents: Stent that slowly releases a drug to block cell proliferation drug-eluting stents are preferred!
96
**What is important to note about DES? (drug eluting stents)
DES require a longer period of DAPT to prevent stent thrombosis so they aren't appropriate for all patients aka these pts have to remain on anti-platelet therapy for longer than bare metal stents (BMS)
97
What are the PCI post-procedure instructions?
98
How long post PCI do patients need to stay on dual antiplatelet therapy (DAPT)? What medication classes?
DAPT for minimum 6-12 months prefer lifelong if they can tolerate it ASA PLUS P2Y12 receptor blocker (Effient, Brilinta, Plavix)
99
What is an atherectomy? Do pts still need DAPT? When it is commonly used?
Specialized catheters for mechanical removal of plaque from the arterial walls YES! DAPT is still needed post procedure commonly done before a stent placement to allow for increased space for the balloon
100
What are the indications for CABG?
101
What is enhanced external counterpulsation? What is the goal?
cuffs are placed around the lower extremities and inflate and deflate in rhythm with cardiac cycle. Goal is to reduce cardiac workload and improve blood flow to the heart ECP has been shown to relieve angina and decrease the degree of ischemia in a cardiac stress test supposed to help with stable angina
102

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