Cardiology: Ischemia, CAD, PVD

Created by AK1138 

Upgrade to
remove ads

120 terms · Internal Medicine Cardiology Ischemia related questions

Which drugs help prolong survival in HF?

Beta blockers, Ace inhibitors (or ARBs), spironlactone, hydralazine + nitrates, amlodipine in DCM

What drugs help prolong survival post MI?

Beta-blockers, ACE inhibitors, ARBs, (eplerenone if pt also has HF)

What is the MOST important, easily determinable PROGNOSTIC factor in patient with coronary artery disease?

The DEGREE of LV dysfunction (if severe, it is a reflection of multi-vessel or left main/left main-equivalent dz)

What is the best objective way to determine severity of angina?

Exercise stress test
If can't past stage 1, 50% 5 year survival
If can get to stage 4, 100% 5 year survival

During an exercise stress test, angina causes what EKG abnormality?

ST segment depression

During an exercise stress test, coronary spasm causes what EKG abnormality?

ST segment elevation

What causes a resting ST elevation?

MI and pericarditis

How do you treat angina?

Modify risk factors - correct anemia, HTN, drug abuse and noncompliance.
Medications: B-blockers, nitrates are main-stay, CCB help. Nifedipine can help with vasodilatation. ASA decreases mortality

What is hibernating myocardium?

Chronically under-perfused myocardium. Chronic hypofunction of the heart, if perfusion is restored, then heart may become restored

What is reperfusion injury?

Occurs when severly ischemic myocardium is re-perfused after > 1 hour, causing further irreversible microvascular damage and damage to the myocardial cells.

What is stunned myocardium?

Also a result of acute ischemia. From the time that perfusion is restored, it make take 7-10 days for the ventricular function to return to normal.

Overall, what do anti-anginal drug help do?

(Nitrates, b-blockers, CCBs) All of these decrease myocardial O2 demand and all decrease afterload.

How do nitrates help with angina?

Decrease preload more than afterload. Can cause devere decompensation in patients with R sided MI. Can cause sympathetic reflex increase in HR. Can develop a tolerance (more likely with dinitrates), so recommend having a 6 hour nitrate free window.

How do b-blockers help angina?

Decrease O2 demand by decreasing HR, BP, and contractility. Complement nitrates well.

How do CCBs help angina?

The combined vasodilatory and anti-hypertensive effects make them ideal for patients with angina/ischemia and hypertension.

How does verapamil and b-blockers work on angina?

Trick question. Using both is a relative contra-indication. Both are negative inotropic and chronotropic effects that are additive which can cause HF, heart block and/or bradycardia.

Why is IV heparin or SQ LMWH used in unstable angina?

High likelihood of a coronary thombus. Needs ASA for life and clopidogrel x 1 month to up to one year

What conditions exclude a patient with angina from an exercise stress test?

> 1 mm resting ST depression
Ventricularly paced rhythm
Currently taking digoxin
WPW
LBBB

If the patient with angina is unable to exercise, has NO LBBB, and No paced ventricular rhythm, and no asthma, what test should you do?

Adenosine or dipyridamole myocardial perfusion imagining (MPI) or dobutamine echo

If a patient with angina is unable to exercise, and has a LBBB or paced ventricular rhythm, what test should you order?

Do Adenosine or dipyridamole perfusion imaging
(AVOID dobutamine echo or any other exercise imaging)

How do you evaluate chronic stable angina?

1) determine probability of CAD (pre-test probablitity)
2) determine relative risk
3) determine if patient need angiogram

What are the treatment goals of angina?

Keep BP controlled
ACE in all patients
Daily physical exercise (cardio daily and weight at least 2x/week)
Low waist size: M <37-40 F <35
Encourage omega-3
LDL < 100, < 70 if DM, high dose statin (add niacin if non-HDL is too high)
Flu shot yearly

What are some additional CV disease prevention in women?

Hormone therapy is not a primary or secondary prevention
Antioxidants should not be used as primary/secondary prevention
Folic acid should NOT be used
Do NOT use ASA in healthy women < 65 to prevent an MI

What percentage of heart attacks are asymptomatic?

About 15%
More likely in elderly, diabetic, & women

What are the nuances about non-Q wave MI?

Decreased early mortality, but a higher risk of for persistent angina, re-infarction, and death within several months

If a patient has arrthymias in the first 48 hours after acute ischemia, do they need anti-arrthymic medications?

No, as long as it all occurred within the 1st 48 hours

Mitral regurgitation is due to what time of heart attack?

Papillary muscle dysfunction in inferior MIs

Ventricular Septal defect is due to what time of heart attack?

Anterior and Inferior Mis

Mobitz II or BBBs are usually due to what time of heart attack?

Anterior

Junctional escape rhythm and Mobitz I are usually due to what time of heart attack?

Inferior

Septal rupture is usually due to what time of heart attack?

Anterior or inferior

What are the cardiac markers that are the gold standard for detection of myocardial necrosis?

Troponin I, Troponin T (these are not present in healthy patients)

What is the life-span of the cardiac marker: myoglobin?

Initial elevation: 1-4 hr
Peak elevation: 6-7 hr
Return to normal: 24 hour

What is the life-span of the cardiac marker: troponin I?

Initial elevation: 3-12 hr
Peak elevation: 24 hr
Return to normal: 7-10 days

What is the life-span of the cardiac marker:CKMB?

Initial elevation: 3-12 hr
Peak elevation: 20 hour
Return to normal: 2-3 days

What is the life-span of the cardiac marker: CKMB isoform?

Initial elevation: 2-6 hour
Peak elevation: 18 hour
Return to normal: 2 days

What conditions can cause false elevations of troponin?

Chronic renal failure
Myopericarditis, CHF, PE, cardiac trauma

Which markers are most specific for an MI?

Troponin I and CKMB isoform 1

Which cardiac marker is very sensitive but not very specific for MI?

Myoglobin

If a patient had a heart attack 2-3 days ago and has chest pain again, which cardiac marker would be most helpful for help determine if it was his heart again?

Myoglobin - good test to evaluate recurrent chest pain soon after MI

How do you treat a heart attack in the field?

1) Call 911, want ambulance transport only
2) Give ASA 162-325 mg bite and chew x 1
3) Nitroglycerin x1 (if improving, may repeat; if not, stop taking and wait on ambulance)
4) EKG in field by EMS

How do you treat suspected ACS in the Emergency Department?

All following should be done within 10 min
- get EKG
- draw cardiac markers
- give ASA if no contraindication
- directed H&P

If suspected ACS is treated early in ED and patient's EKG is normal, what do you next?

-repeat EKG q 15-30 min or continuously
-get EKG with leads V7-9 (looking for left circumflex occlusion

What do you do with a patient with possible ACS and nondiagnostic EKG and normal initial serum markers?

-observe for at least 12 hours from onset of pain and repeat serum markers and EKG

If a patient with possible ACS has no recurrent pain and EKG and serum markers are negative, what is the next step?

-perform a stress study to provoke ischemia
- if negative --> low risk for ACS
- if positive --> UA/NSTEMI confirmed

If a patient with possible ACS has recurrent pain, EKG is normal, and serum markers become positive, what is the next step?

Dx of UA/NSTEMI confirmed, admit to the hospital and follow acute ischemia pathway

If a patient with possible ACS has no recurrent pain and EKG and serum markers are negative, also their stress test is negative, what is the next step?

They are low risk for ACS and probable diagnosis is nonischemic discomfort;
Arrange for outpatient follow-up

If cardiac work-up is positive for ACS and the EKG shows a ST elevation, what is the next step?

Evaluate for reperfusion therapy and follow STEMI guidelines

If cardiac work-up is positive for ACS and the EKG shows a new LBBB, what is the next step?

Evaluate for reperfusion therapy and follow LBBB/STEMI guidelines

If cardiac work-up is positive for ACS and the EKG shows a NO ST elevation, but ST changes, what is the next step?

Diagnosis of UA/STEMI and follow acute ischemia pathway

If cardiac work-up is positive for ACS and the EKG shows normal EKG, but patient has ongoing pain and cardiac markers, what is the next step?

Diagnosis of UA/STEMI and follow acute ischemia pathway

What are the general anti-ischemic measure for all patients with ACS?

Continuous EKG monitoring, NTG for ongoing angina, supplement O2 (if sat < 90%), morphine PRN, b-blocker, an ACE if hypertensive or has LV dysfunction

How do beta blockers help during ACS?

B-blockers reduce myocardial O2 consumption. Also, by blocking the often excessive sympathetic activity, they reduce the load on the heart and decrease the likelihood of arrhythmias.

What are contraindications to beta-blockers in ACS?

Bradycardia
Hypotension
2nd or 3rd degree block
Pulmonary edema
Asthma

When is atropine needed during ACS?

For temporary management of acute sinus bradycardia with signs of low cardiac output while preparing for temporary pacing
Bradycardia associated with MI (usually inferior) with maybe temporary pacing
Ventricular asystole

When should ACS patient get aspirin?

Immediately and indefinitely

Which patients should get Plavix in ACS?

Almost everyone unless you know they are getting emergent CABG

How do glycoprotein IIb/IIIa inhibitors work?

Anti-platelet drugs which are more specific than aspirin. The Gp IIb/IIIa is responsible for platelet aggregation - in which the platelet to plate binding occurs.

Should patient with an NSTEMI or UA get fibrinolytic therapy?

No
But it is indicated in STEMI or new LBBB and NO PCI is available

When should patients get lidocaine during ACS?

Only if they have arrhythmias, it is not needed prophalytically

If suspected ACS is treated early and EKG is abnormal, what do you do next?

Go down the ACUTE ISCHEMIC PATHWAY

If a patient has ACS but NO ST-segment elevation, what are your options?

I) early invasive therapy, or
II) Early conservative therapy

Who are the patients with UA/NSTEMI that should get URGENT early invasive therapy?

Life threatening arrthymias, refractory or recurrent angina, CHF or hemodynamic instablity

Who are the patients with UA/NSTEMI that should get early invasive therapy within 72 hours?

Dynamic ST changes, diabetes, GFR <60, EF < 40%, early post-MI angina, PCI w/in last 6 months, prior MI, prior CABG, intermediate/high risk score, elevated cTn-1 or cTn-T

Who are the patients with UA/NSTEMI that should get early conservative therapy?

Patient who respond to intense medical therapy and have none of high risk features.

What is the long-term antithrombotic therapy after UA/NSTEMI on patient who received medical treatment without a stent?

ASA 75-162 mg/d forever
Clopidogrel 75 mg/d x 1 month and up to 1 year

What is the long-term antithrombotic therapy after UA/NSTEMI on patient who received bare metal stent?

ASA 162-325 mg/d x 1 month, then 75-162 mg/d forever
Clopidogrel 75 mg/d x 1 month and up to 1 year

What is the long-term antithrombotic therapy after UA/NSTEMI on patient who received drug eluding stent?

ASA 162-325 mg/d x 3-6 months, then 75-162 mg/d forever
Clopidogrel 75 mg/d for at least 1 year

How do you treat cocaine and meth users who present with UA/NSTEMI?

Give NTG and calcium channel blockers:
- if not better, go to cath immediately if possible
- if cath not available and still symptomatic after NTG and CCB, then give fibrinolytics
- DO NOT go to cath if no ST-segment or T-wave changes and with negative stress test and negative biomarkers

Which patients should you consider emergent perfusion (fibrinolytic therapy or primary PCI)?

All patient who present with STEMI or new (or presumed new) Left bundle branch block.

When and who should get fibrinolytic therapy?

In MI patient who have ST segment elevation in > 2 contiguous EKG leads or a new left bundle branch block, who present within 12 hours of onset of symptoms and are less than age 75. Start within 30 minutes upon arrival to the ER. (this is held if PCI can be done)

Which types of MIs benefit the most from fibrinolytic therapy?

LBBB benefit the most, followed by anterior MI, then inferior MI.

Give some examples of fibrinolytic agents.

t-PA, TNK, anistreplase, streptokinase, urokinase

What are the ABSOLUTE contra-indications to fibrinolytic therapy?

- previous hemorrhage stroke at any time
- any cerebrovascular evens within past 1 year
- intracranial neoplasm
- active internal bleeding
- suspected aortic dissection

What are relative contraindications to fibrinolytic therapy?

- persistant BP > 180/110
- remote CVA (> 1 year ago)
- INR > 2-3; bleeding diathesis
- recent (2-4 weeks) major trauma
- non-compressible vascular puncture
- previous exposure to streptokinase/anistreplase
-pregnancy
-active peptic ulcer
-chronic HTN

How do Gp IIb/IIIa inhibitors affect patients undergoing PCI?

Improves outcomes in high-risk patients undergoing PCI

Primary PCI is particularly indicated in what type of patients?

In patients who develop cardiogenic shock following STEMI or new LBBB MI.

What are the goals of initiation of PCI?

Within 12 hours of symptoms and 90 minutes upon arriving to the ER. Better outcomes with more experienced pracitioners.

What are the 2007 STEMI guidelines regarding medications?

- stop all NSAIDs (except ASA)
- start oral beta-blockers within 24 hours and give IV b-blockers if hypertensive (with no contraindications - HF, shock)
- do not give full dose fibrinolytic therapy if immediate PCI is anticipated
- Clopidogrel is added to ASA for at least 14 days for all STEMI's (up to a year for most)
- LDL should be < 100 for all and probably < 70
- ACE inhibitors for all who can tolerate
-FLU shot yearly

Left ventricular dysfunction after an MI is a predictive...

Of a poor prognosis. (historically having mortality rates of > 85%)

If an MI presents wit the triad of hypotension, clear lung fields, and elevated jugular pressure, think...

Right ventricular infarction (usually accompanies an inferior MI with a R coronary occlusion)

If you perform a right heart cath, what values are specific for RV infarction?

Elevated RA pressure > 10 mmHg and
> 80 of the pulmonary capillary wedge pressure (PCWP)

What are the general anti-ischemic measure for all patients with ACS?

Continuous EKG monitoring, NTG for ongoing angina, supplement O2 (if sat < 90%), morphine PRN, b-blocker, an ACE if hypertensive or has LV dysfunction

What EKG changes are predictive of RV infarction?

Transient ST segment elevation of R sided chest leads (e.g. V4R)

How do you treat RV infarction?

Avoid nitrates and preload reducing agents. Fluid support is necessary. Inotropic support, usually with dopamine, maybe necessary.

Bradycardia and AV block are more common with which type of MIs?

Inferior - usually transient

If a patient has an anterior MI and AV block, what do you need to tell the patient and/of family?

This implies destruction of a large amount of myocardium in the interventricular septum, is associated with high mortality, and frequently requires a pacemaker if patient survives.

What are the indications for temporary pacing at the time of an MI?

-asystole
-symptomatic bradycardia
-bilateral BBB
-new or indeterminate age bifascicular block with first degree AV block
- Mobitz type II second degree AV block

When does rupture of the papillary muscle occur after an MI? which type of MI? and how does it present?

-Usually 3-7 days after an inferior MI
-patient rapidly develops shock, you may ear a short early systolic murmur. Echo is the diagnostic modality. Treat with urgent CTS surgery.

When does rupture of the ventricular septal defect occur after an MI? which type of MI? and how does it present?

-usually occurs 3-7 days after anteroseptal MI
-patient rapidly develops shock. A loud, holosystolic murmur is heard widely over the precordium. Confirm by echo. High mortality rate. Treat with urgent CTS surgery.

When does rupture of the free wall of the LV occur after an MI? which type of MI? and how does it present?

-usually 3-7 days after a large, anterior MI (frequently in elderly hypertensive women).
-sudden syncope is typical
-presentation is tamponade
-there are only few heroic saves from urgent surgery

Which MI patients should get the implantable defibrillators?

MI pts with LVEF < 35% have prolongation of survival if a ICD is placed, especially if there are baseline episodes of ventricular tachycardia.

What are the primary risk factors for CAD:

Age
Male gender
Family hx of early CAD
Smoking
HTN
Elevated LDL
DM

What two factors are INVERSELY related to CAD?

Aerobic exercise and elevated HDL

What factors can modify HDL?

HDL is increased by exercise, estrogen, niacin and small amounts of EtOH
HDL is decreased by smoking and androgens

When should check a lipid panel?

At least every 5 years in healthy persons, starting at age 20

How do you calculate LDL?

LDL = total cholesterol - HDL - 1/5 of triglycerides

When can lipids be falsely low?

Can be upto 2 months post MI or cardiac surgery

How do statins help with CAD?

Statins enhance plaque stabilization and may independently improve long-term prognosis

If a patient has left main CAD or Left main equivalent (i.e. proximal LAD plus proximal circumflex), should patient get PCI vs CABG?

CABG

If a patient has 3 vessel disease and abnormal LV function (EF < 50%), should patient get PCI vs CABG?

CABG

If a patient has 2-vessel disease and significant proximal left anterior descding CAD and either abnormal LV function (EF < 50%) or demonstrable ischemia on non-invasive testing, should patient get PCI vs CABG?

CABG

If a patient presents with 1- or 2- vessel CAD without significant, proximal left anterior descending CAD, but with a large area of viable myocardium and high risk critera on non-invasive testing, should patient get PCI vs CABG?

CABG or PCI

If a patient present with multi-vessel coronary disease with suitable coronary anatomy, with normal LV function, and without diabetes, should patient get PCI vs CABG?

PCI

CABG improves symptoms and survival in which patients?

- left main dz or L main equivalent
- 3-vessel dz with LV dysfunction

CABG improves symptoms, BUT NOT survival in which patients?

1- and 2- vessels disease

Does CABG decrease risk of MI?

Nope, chance of MI is the same after bypass

Name the 2 drugs used with Drug eluting stents?

Sirolimus and Paclitaxel

What is Buerger's disease?

AKA Thromboangiitis obliterans, it involves medium and small arteries, and often affects the areas of the wrists (positive Allen test) and hands

Suspect what with intermittent claudication with walking but not running?

Suspect popliteal artery entrapment

How can you tell the difference b/t lumbar spinal stenosis and claudication?

Vascular claudication is relieved by sitting down or standing still
Spinal stenosis is relieved by sitting down (but not standing still), it is exacerbated by standing and walking (especially down hill)

What is the best way to diagnosis the degree of functional impairment of PVD?

ABI before and after exercise

What is the best test for defining the location of the PVD disease?

Arteriography (CT and MR angiography are very good for noninvasive imaging)

How do you treat PVD?

1) stop smoking
2) regular exercise (30 minutes daily)
3) pentoxifylline tx (Trental)
4) cilostazol (Pletal) (a PDE inhibitor, only use in patient with normal LV)

What are the most two common vasospastic disorders?

Primary raynaud syndrome
Livedo reticularis

How do you treat vasospastic disorders?

Calcium channel blockers, biofeedback and nitroglycerin if needed

What is the treatment of TIAs if no significant lesion is found and h/o of a-fib?

ASA + extended release dipyridamole or plavix

What is the treatment of TIAs if no significant lesion is found, but they do have a-fib?

Warfarin

What is the treatment of TIAs and >70% stenosis?

Enderacterectomy

What should suspect when a patient presents with unilateral headache associated with either TIAs or a dilated pupil?

Suspect spontaneous dissection of the internal carotid artery, look for cholesterol emboli on fundoscopic exam

Please allow access to your computer’s microphone to use Voice Recording.

Having trouble? Click here for help.

We can’t access your microphone!

Click the icon above to update your browser permissions above and try again

Example:

Reload the page to try again!

Reload

Press Cmd-0 to reset your zoom

Press Ctrl-0 to reset your zoom

It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.

Please upgrade Flash or install Chrome
to use Voice Recording.

For more help, see our troubleshooting page.

Your microphone is muted

For help fixing this issue, see this FAQ.

NEW! Voice Recording

Click the mic to start.

Create Set