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CV <3 > Lecture 10: Ischemic Heart Disease Part 2 > Flashcards

Lecture 10: Ischemic Heart Disease Part 2 Flashcards

1
Q

What is always the initial test for anyone presenting with chest pain?

A

EKG

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2
Q

How fast should an EKG be done if someone presents with ACS symptoms to the ER?

A

10 minutes!

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3
Q

What is the initial presentation of an EKG with ACS findings?

A

Hyperacute T waves

Only exists 20-30 minutes

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4
Q

What are the 3 types of cardiac enzymes we can order?

A
  • Myoglobin
  • CK-MB
  • Troponin I, T (the best)

This comes AFTER EKG.

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5
Q

Why are troponins the preferred marker for myocardial study?

A
  • Increases within 3-6 hours
  • Peaks within 24-48 hrs
  • Takes 5-14 days to recover.
  • ONLY RELEASED when myocardial necrosis occurs.
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6
Q

How often should we repeat troponin?

A
  1. Initial presentation
  2. 90 Minutes
  3. 6-8 hrs after x3 or unil trending down.
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7
Q

What are we specifically looking for in serial troponin readings?

A

A trend.

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8
Q

What is considered a positive CK-MB?

A

> 5%

Not preferred test

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9
Q

What might cause a false positive of CK-MB?

A
  • Exercise
  • Trauma
  • Muscle disease
  • DM
  • PE
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10
Q

What cardiac biomarker is the earliest marker for MI?

A

Myoglobin

Highly sensitive, but poor specificity.

Could appear within 2 hrs.

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11
Q

What is the order of enzyme elevation in ACS?

A
  1. Myoglobin
  2. CK-MB
  3. Troponin
  4. LDH

Trop takes longer to elevate.

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12
Q

What 3 lab levels may elevate as a result of ACS?

A
  • Leukocytosis
  • ESR
  • CRP
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13
Q

What is the general minimum for doing an exercise stress test?

A
  • Walk 5 minutes on flat ground
  • 1-2 flights without stopping
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14
Q

What are the indications for a stress test?

A
  • Confirm angina
  • Determine severity of limitation
  • Assess prognosis of known CAD and MI recovery
  • Evaluate response to therapy
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15
Q

Who is an exercise stress test most useful for?

A
  • Low pretest likelihood and normal baseline EKGs
  • Best in young, females with atypical symptoms.
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16
Q

What is the max HR for a stress test and the finding that makes it positive?

A
  • 85% of max HR (220-age)
  • ST depression of 1mm = positive
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17
Q

When do you absolutely need to terminate a stress test?

A
  • SBP drop of 10mm Hg from baseline
  • Mod-severe angina
  • Nervous system symptoms
  • Poor perfusion
  • Subject wants to stop
  • Sustained Vtach
  • ST elevation without Q-waves
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18
Q

What are the absolute contraindications to TMSTs? (treadmill stress tests)

A
  • Acute MI within 2d
  • High-risk, unstable angina
  • Uncontrolled arrhythmias resulting in hemodynamic instability
  • Severe, symptomatic AS
  • Uncontrolled symptomatic HF
  • Acute PE
  • Acute myocarditis or pericarditis
  • Acute aortic dissection
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19
Q

When do we add imaging to an exercise stress test?

A

Resting EKG is difficult to interpret (LBBB, baseline changes, low voltage)

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20
Q

What scan is associated with a nuclear stress test?

A

SPECT (single photon emission CT)

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21
Q

What adaptation can be added to an exercise stress test to look for regional wall motion abnormalities?

A

Stress echo

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22
Q

Why does a pharmacological stress test require imaging?

A

Poor sensitivity, so it requires an imaging modality.

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23
Q

What are the 3 vasodilators used for pharmacological stress tests?

A
  • Adenosine
  • Dipyridamole
  • Regadenoson

Direct CORONARY ARTERY VASODILATION

Preferred agents.

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24
Q

What is the primary contraindication to pharmacological stress agents?

A

Bronchospasms

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25
Q

What are the 2nd line stress agents used in pharmacological stress tests?

A
  • Dobutamine
  • Atropine

Adrenergic stimulants

B1 and B2 stimulation.
Only used if you can’t use a vasodilator (i.e. asthma)

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26
Q

What is the definitive diagnostic procedure to evaluate CAD and heart muscle function?

A

Coronary angiogram.

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27
Q

What common medication MUST BE HELD for 48 hours prior to cath?

A

Metformin!!!!

Contrast = nephrotoxic

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28
Q

What is the prep required for a coronary angiogram?

A
  • NPO 4-6 hrs
  • Written consent
  • IV NS to flush contrast
  • Hold metformin for 48hrs to avoid contrast induced nephropathy
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29
Q

When is coronary angiography indicated?

A
  • Life limiting stable angina
  • High pretest likelihood
  • Aortic valve disease
  • Valve surgery
  • Survivors of sudden death
  • Chest pain of unknown etiology or idiopathic cardiomyopathy
  • STEMI patients requiring immediate revascularization
30
Q

If a patient has a contrast allergy, can we still perform coronary angiography?

A

If it is a life-threatening emergency, yes.

Add benadryl and steroids prophylactically.

31
Q

What is a CXR mainly used for in chest pain?

A

R/o pulmonary causes

32
Q

What must HR be for a CT of the coronary arteries?

A

Under 50 to prevent artifact.

33
Q

What is the most sensitive and specific NON-invasive imaging modality for CAD?

A

CT Angiography

34
Q

For inpatient workup of unstable angina, what are the diagnostic tests we should order?

A
  1. Low: obs
  2. Intermediate: stress test with nuclear imaging
  3. High: cath
35
Q

What is the primary difference between unstable angina and NSTEMI?

A

Troponin is negative in unstable angina.

EKG is the same usually.

36
Q

If we have ST elevation >= 1mm in two contiguous leads, what is the workup?

A

No labs, straight to cath lab!

37
Q

What are the drug classes indicated for stable angina managment?

A
  • NTG
  • BB
  • CCB
  • Ranexa (Metabolic modulator)
38
Q

What are the first-line therapies for unstable angina/NSTEMI/STEMI?

A
  • Supplemental O2 (only if hypoxemic)
  • Nitrates
  • ASA (162-324mg chewable)

ASA is given regardless of fibrinolytic therapy.

39
Q

If a patient has an ASA allergy, what is the alternative for them in ACS?

A
  • P2Y12 inhibitors
  • Clopidogrel
  • Prasugrel
  • Ticagrelor
40
Q

After the first-line therapies for ACS managment, what are the next meds?

A
  • Morphine/benzos for pain
  • Oral BB within 24 hrs unless CHF, brady, or AVB
  • ACEI within 24 hrs
  • Statin within 48 hrs

Consider: CCB for persistent ischemia

41
Q

What are the reperfusion goals?

A
  • Door to balloon in 90 minutes
  • Door to needle in 30 minutes

Preferred is PCI, but if not available, then we use tPA for thrombolysis.

42
Q

What does NTG do?

A
  • Nitrate conversion to nitric oxide, leading to cGMP activation and coronary vasodilation.
  • Decreases SVR and preload
  • First line for patients with ACS except IWMI.

IWMI involves the RV, which will affect preload too much if treated.

43
Q

When should NTG be used in caution?

A
  • Hypotension < 100
  • Brady
  • Tachy
  • RV infarction

RV infarction already presents with decreased preload, and decreasing it further will bottom out a patient.

44
Q

What is the shortest acting NTG?

A

SL

45
Q

What is the main concern with using long-acting nitrates?

A
  • Tachyphylaxis if no breaks are given.
  • Need to dose at least 8-12 hours apart to prevent it.
  • Long-term nitrates can lower angina threshold as well.

Avoid high doses!

46
Q

What should you never give a nitrate with?

A

PDE-5 inhibitors!!!!!!!!!!!!!!!!!!!!!!!

Works on cGMP the same way.

47
Q

What does morphine do in terms of the heart?

A
  • Decreases sympathetic tone
  • Decreases SVR
  • O2 demand

Reduction of afterload.

Often used for refractory angina during ACS.

48
Q

Why do we give chewable asa for ACS?

A
  • Antiplatelet aggregation
  • Stabilize plaque and prevent it from forming a big thrombus.
  • Chewable ASA absorbs much more quickly.
49
Q

What are the main concerns with ASA?

A
  • PUD
  • Allergy
  • Bleeding disorders

Often treated with PPI.

50
Q

What drug is bolused prior to a cardiac cath?

A

600mg of plavix

51
Q

What do glycoprotein 2b/3a inhibitors do?

A
  • Inhibition of platelet aggregation
  • Supports PCI
  • High risk patients only

Aggrastat
Integrilin
Reopro

52
Q

What 3 situations might glycoprotein 2b/3a inhibitors be used?

A
  • Ongoing ischemia despite ASA and P2Y12 inhibitor use
  • Large thrombus during angiography
  • Stabilize urgent CABG patients in place of using a P2Y12.
53
Q

When are BBs indicated in regards to ACS?

A
  • Added to post-MI patients that are STABLE
  • Reduction in infarct size, rate, and life-threatening tachyarrhythmias
  • Reduction in cardiac remodeling and enlargement
54
Q

When are BBs NOT indicated?

A
  • Acute CHF
  • Heart Block
  • Hypotension
55
Q

What BBs are typically used in post-MI patients?

A
  • Metoprolol tartrate
  • Carvedilol
56
Q

What is ranolazine?
(MOA, indication, danger)

A
  • MOA: late Na channel blocker.
  • Indication: Chronic, stable angina
  • Danger: QT prolongation

500mg PO BID

57
Q

What is the role of ACEis and ARBs post MI?

A
  • Reduction in fibrosis and remodeling
  • Preserve myocardium in setting of a MI
58
Q

What other medications are indicated for post MI patients?

A
  • Statins post ACS
  • Warfarin for intracardiac thrombus or embolic events
  • Aldosterone antagonists for LV dysfunction
  • CCBs NOT usually used, 3rd line!!
59
Q

What are the two formulations of fibrinolytics?

A
  • Alteplase (Recombinant)
  • Tenecteplase (genetically engineered)
60
Q

What is the life-threatening complication that can occur due to tPA administration?

A

ICH

61
Q

What must be done post-tPA?

A
  • ASA
  • AC with LMWH
62
Q

How quickly does tPA needed to be administered for STEMI?

A
  • Ideal: 30 minutes to ED arrival
  • Reducion in mortality within first 3 hours of presentation.

CATH IS PREFERRED

63
Q

If a patient requires fibrinolytics for a STEMI, what two medications must they be started on after?

A
  • PPIs
  • H2 Blockers
64
Q

What are the absolute CIs to fibrinolytics?

A
  • Prior ICH
  • Known AVM
  • Known malignancy
  • Ischemic stroke within past 3 months (unless within past 3 hrs)
  • Active internal bleeding
  • Suspected aortic dissection
  • Active bleeding or bleeding diathesis
  • Significant closed head or facial trauma within 3 mo.
65
Q

When is PCI indicated?

A

Unstable disease

GOLD STANDARD

66
Q

What therapy follows PCI?

A
  • Dual antiplatelet therapy (DAPT)
  • P2Y12 receptor blocker + ASA for 3-12 months.
67
Q

What exactly is a stent?

A
  • Thin-wire mesh used to keep an artery open.
  • Can contain drugs
  • Supports the artery.
68
Q

What is the caveat to a drug-eluting stent?

A
  • Longer period of DAPT
  • However, it is the preferred stent in PCI.

Drug-eluting gives off a drug slowly to help prevent cell proliferaiton.

69
Q

What is atherectomy?

A
  • Specialized catheter that removes plaque
  • Requires DAPT post-procedure
70
Q

When is CABG preferred for revascularization?

A
  • Left main trunk artery stenosis
  • Poor LV function
  • Significant 3-vessel CAD or 2-vessel disease involving proximal LAD
  • DM with focal stenosis in more than 1 vesse;
  • Concomitant severe valvular disease that necessitates open heart surgery
  • Diffuse disease not amenable to treatment with PCI

CV <3 (25 decks)

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