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145 Cards in this Set

  • Front
  • Back

CHD stands for? This is a ______ term

CORONARY HEART DISEASE; Umbrella term

CHD includes things such as? (4) Don't really need to know

Angina, MI, SILENT myocardial ischemia, CHD deaths r/tCAD

CAD =Coronary Artery disease, a PATHOLOGICAL process that affects the? Name a main example

Coronary Arteries. Example: Atherosclerosis (Plaque build up in artery wall)

CVD=Affects ENTIRE _____ Circulation.




Name 5 examples

Cardiovascular Disease (arteries THROUGHOUT body are all affected). Affects entire ARTERIAL circulation




Stroke, TIA (interruption in blood supply/neuro dysfunction, prior to stroke) Angina, MI claudication, limb ischemia



While over 17 million Americans have CHD, the incidence in the US is _____ d/t?

DECREASING; medication interventions (Ex: Statins/Lower cholesterol)

There has been a reduction in risk factors, improvement in _____ prevention, and heart failure treatment

Secondary :)

However, ______ and ______ INCREASES WITH AGE for men and women

Incidence + Prevalence (Although postmenopasual women catch up to their male counterparts)

We are treating a lot more of the risk factors: Such as?

1) Stopping Smoking


2) Lowering cholesterol


3) Anti-platelet Therapy (Ex: Aspirin) Prevent blood cells called platelets from forming clots


4) AGGRESSIVELY treating HTN


5) AGGRESSIVELY treating DIABETES




All of these DECREASES THE INCIDENCE in this country

Whats the difference between anticoagulants and anti platelets?

Antiplatlets (Ex: Aspirin) Prevent blood cells called platelets from forming clots




Anticoagulants (Ex: Heparin/Warafrin aka Coumadin): Work on chemical reactions in your body to LENGTHEN the amount of time it takes your body to form a clot

Problem- GLOBABLY, the incidence of cardiovascular disease rapidly increasing outside of the US- WHY?

(Our diet/lifestyle) is influencing other countries. People don't have to walk as far (2nd/3rd developing countries)

Estrogen is protective against heart disease. This is why ____ women catch up to their male coutnerparts Add a new card (or press TAB)

Postmenopausal




(RISK FOR MEN + WOMEN=SAME)

What is the MAJOR cause of CVD? (MESSES UP THE WHOLE CIRCULATION)




A very ____ process

ATHEROSCLEROSIS (PLAQUE BUILD UP IN ARTERIES, EVERYWHERE)




Complex

While many people have plaque in their arteries, it isn't until about ___ of artery blocked that they are SYMPTOMATIC

75% (Now they will show symptoms)




Need a fair amount of narrowing, before you become symptomatic

With atherosclerosis there is damage to the outer lining of the artery, known as the?

Endothelium (inner wall)

Substances traveling in the blood such as?(3) can accumulate that are responsible for the narrowing

Cholesterol, Fats, +Cellular Waste products can gather in arterial wall/damaged area. Chemical reactions then happen d/t build up--> cause cholesterol molecules to OXIDIZE

Oxidized cholesterol/inflammatory response leads to the release of?

Monocytes that turn into macrophages

While the MACS eat the cholesterol, they change in shape and accumulate to form?

PLAQUE

As the plaque increase in size, the arterial wall HARDENS and?

THICKENS

Smooth muscle cells within arterial wall begin to?

MULTIPLY

They cover the plaque (YAMS), but this ends up reducing overall?

Blood supply/oxygen to tissues

Overtime the plaque can erode and break off, being released into the? This can form a ___ AND STOP BLOOD FLOW

Bloodstream; CLOT

Limited blood supply to organs and this can lead to _____ death

Tissue

Blood flow can be reduced or completely ____

BLOCKED

There are NON MODIFIABLE and MODIFIABLE risk factors for CAD. What are the NON-MODIFIABLE risk factors (3)

1) Gender


2) Age


3) Heredity



Name modifiable risk factors

Smoking, high cholesterol, HTN, physical inactivity obesity/overweight, DM (we can help), stress, alcohol

What are 5 things we must OBTAIN when ASSESSING for the presence of CAD?




("ND GAP")

1) Number of risk factors present


2) Description of symptoms


3) Gender


4) Age


5) PRIOR history

Description of symptoms= N-T

N: Normal


O: Onset


P: Precipitating and Palliative Factors (What was going on when you noticed the symptoms. What makes it go away?)


Q: Quality


R: Region/Radiation


S: Severity (0-10/how long)


T: Time

What are some associated symptoms that we may see?

Dyspnea, Diaphoresis/ N/V

Prior history is important. For example, upon assessing for CAD if you have someone come in that notes they had a prior stent in place and notes similar symptoms, we would want to act FAST and call?

911

What are the main categories/branches of CAD?

1) CHRONIC STABLE ANGINA


2) ACUTE coronary syndrome

Acute Coronary Syndrome is divided into 2 more categories, including?

1) Unstable Angina+ NON-st segment elevation MI


2) ST-segment elevation MI

CAD. Chronic Stable Angina. = Paroxysmal meaning? _____ pain. The pain is usually _____

It comes and goes. SUBSTERNAL pain; predictable (pattern, onset, duration of symptoms)

Usually occurs with?

Physical exertion OR EMOTIONAL stress (Ex: Grandma knows when she goes downstairs, she is going to have some chest pain.)

Caused by?

TRANSIENT (short time), REVERSIBLE myocradial ischemia

WITH CHRONIC STABLE ANGINA, pain lasts for?

LESS THAN 15 minutes




Transient/Short lasting, predictable, + REVERSIBLE

Reversible in that Chronic Stable angina can be relieved by what 2 main things?

1) Rest


2) Medications: (Nitro-Vasodilator)

Grandma may have narrowed arteries, but not___ blockage

75% (so she can be diag with CHRONIC stable angina)

What is the GOAL of Chronic stable angina? To either?

1) Increase oxygen supply


2) Decrease oxygen demand

Pharmacological Intervention for CAD- What is the main medication and how does it work?

Nitroglycern (Vasodilates and reduces that myocardial demand by DECREASING PRELOAD

NITRO DECREASES______

PRELOAD/MYOCARDIAL DEMAND

What are the 2 ways we can give Nitro?

1)IV


2) PO

Name 5 main medications affiliated with tx of CAD?

1) ACE Inhibitors (EF <40%)


2) Antiplatelet Therapy: Asprin, PLAVIX, Effient


3) Beta Blockers: reduce mycardial consumption because they reduce contractility, conduction, rate+ velocity(slow) (reduces o2 demand)


4) CCB's- decrease AFTERload, contractility, HR


5) Nitroglycerin: MAINSTAY of therapy

Relieved by?

REST OR NITRO

Most of the interventions go towards ___ oxygen demand

Decreasing

How do we educate for Nitroglycerin?

3 doses, after call 911 (might get 3 more), then if not working, IV

PO: 2 types

1) QUICK sublingual (under the tongue)


2) Long acting (take routinely) Ex: Indir prn

Antiplatelets keep further clots/___ from happening

Narrowing

People can stay with Chronic Stable Angina, or they can progress to?

Acute Coronary Syndrome.

CAD. Acute Coronary Syndrome

:)

With Acute Coronary Syndrome, Ischemia=_____ NOT IMMEDIATELY REVERSIBLE

PROLONGED

With Acute Coronary Syndrome, what are the 2 distinct problems

1) Unstable angina


-----ACUTE MYCOARDIAL INFARCTION (AMI)


2) NSTEMI: Non St Elevation MI: NO set elevations on ECG. But ischemia still severe enough to cause Myocardial damage+ release cardiac biomarkers


3) STEMI: St Elevation MI: ST elevations seen on ECG + POSITIVE cardiac biomarkers

As things collect, they can form a?

THROMBOUS (d/t platelet aggregation)

As severity increases, there is a decrease in lumen and INCREASE in

THROMBOUS

Order of 3 categories based on amount of lumen?

1)Unstable Angina


2) NSTEMI


3) STEMI

With unstable angina, while you have a fair amount of lumen left you are still having?

CHEST PAIN

However, once you enter the "EMI's" you are causing

MYOCARDIAL INJURY (don't have enough room to push blood through to perfuse heart)

STEMI

LUMEN COMPLETELY OCCLUDED WITH THROMBUS/PLATLETS. IT ALSO HAS RUPTURED

Thrombus happens when?

The plaque RUPTURES. It's that thrombus that occludes/restricts blood flow

Eventually STEMI will lead to?

Myocardial necrosis/cell death. COMPLETELY OCCULUDES





Thrombous=

CLOT

Unlike Chronic Stable Angina, UA doesn't just occur during predictable periods of activity. It is ____ NEW, OCCURS EVEN AT REST + can worsen

UNPREDICTABLE (EMERGENCY)

With UA there are ischemic symptoms that last LONGER THAN?

20 minutes (not less than 15)

With unstable angina there is NO elevation in?

Trops




EVEN THOUGH SYMPTOMS, NO ELEVATION OF TROPONIN !!!





Unstable angina may reflect ECG changes or not. Typically indicate?

ISCHEMIA (reduced blood flow)




-May or may not see ischemic changes in EKG

Who can develop Unstable Angina?

Those with previous Chronic Stable Angina, or FIRST STEP OF CAD

Unstable Angina has SAME symptoms as NSTEMI (chest pain, radiating, symptoms, may or may not see EKG changes, BUT- WHAT IS THE DIFFERENCE?)

YOU WILL SEE ELEVATION IN TROPONIN (Refecting that myocardial damage more so now)

Usually elevation happens around after ___ hours of symptoms

6-8

BUT no ST elevations, rather

depressions

May see ____ of a ___ wave

INVERSION OF T WAVE

Just as in UA, a _____ partially is occluding the coronary artery

Thrombus

Someone may be experiencing ischemia, but not any of the "emis" which reflect?

Muscle Damage

Ischemia= Reversible with?

Rest, Nitrates

What kind of ECG changes with Ischemia?

T wave inversion or ST depression


IMBALANCE between myocardial oxygen demand/mycocardial oxygen




(SAME AS NSTEMI)

It is with INJURY to that myocardium that we will see. Is stemi reversible?

ST ELEVATION in leads facing injured area, cellular damage BEYOND ischemia




Yes, but only if RAPID Intervention (within hour) cells SCREAMING FOR O2




(STEMI)




(Grandma who doesn't get better with rest or meds)

Infarction - development of what kind of ways?




INFARCT=

Q waves (downward DEFLEX of QRS complex)


Q waves represent disruptions in electricity/movement d/t nectroic muscle




NECROSIS, DEAD TISSUE (CANT REVERSE)

Can reverse Ischemia, Can reverse injury if WITHIN AN HOUR, but CANT reverse?

INFARCTION. ITS DEAD TISSUE




ABSENCE OF DEPOLARIZATION

Acute Coronary Syndrome: STEMI (ST ELEVATIONS). STEMI= S for _____ Ischemia

SUSTAINED/SUCKS. Not reversible. Only NSTEMIS/ISCHEMIA are. THIS IS IRRIVERSIBLE myocardial cell death (necrosis)

TIME IS MUSCLE. We need to HURRY up & get people to ___ labs

CATH

Takes about ____ before cell death starts to occur. How long for ENTIRE thickness of muscle to die/necrose

20 minutes; 4-6 hours

STEMIS usually described by location of?

DAMAGE

With STEMI that rhonbus forms- Blood flow ___ to blockage stops

DISTAL , causing that tissue necrosis/death

LAD supplies o2 to?

ANTERIOR WALL OF LV. ANY MI's here can cause SIGNIFICANT damage

With vessel occlusion, what is one way the body compensates?

By forming collateral circulation (blood can bypass thrombous on own, so NO intervention necessary)

ACS. Clinical Manifestations of STEMI (IRREVERSIBLE DAMAGE)

1) PAIN:


2) SKIN: Not getting that good blood supply: Cool, clamy, ashen


3) HR/BP: Both may initially elevate for compensation and then BP drops with decrease CO/HR eventually+other signs of decreased CO


4) N/V: From pain/vagus nerve stimulation


5) FEVER: Slightly elevated d/t systemic INFLAMMATORY process, caused by the tissue death

Won't always be just the "elephant on the chest" could be? (RARE)

The guy who burped - previous heart attack, that was his only symptom

Signs of decreased CO

1) Hypotension


2) Crackles of lungs


3) TACHY (trying to compensate)

How do we assess for ACS (Not just plan old CAD)

1) History and Physical


2) ECG: Compare to previous if available. Is it reflecting Dysrythmia, MIschemia, Myocardial injury, or Myocardial Infarction?


3) LAB WORK: CARDIAC MARKERS (TROPONIN)


4) CXR


5) Stress Testing


6) Electrocardiogram


7) Angiogram



Other lab values other than looking at Trop levels include?

CBC, Chemistries, Coags + Lipids




(Trops, Lipids, CCC)

While a Chest X Ray won't show you if they are having an acute MI. But it can show you if they have a?

Large Cardiomyopathy, dropped lung that is causing chest pain, pnuemonia? (could be chest pain)

Diangostic Lab Tests of Serum Cardiac Markers include?

1) TROPONIN (T and I)


2) Creatine Kinase



Troponin = ____ released with?

PROTEINS; heart muscle damage

In MI, trop will elevate when?

3-6 hours

Peaks at?

12-18 hours and remains elevated for 5-9 days

TROP has GREATER sensitivity and specificity for Myocardial injury than does?

Creatine Kinase

This is why we hang onto a lot of chest pain people for?

24 hours (WE WANT TO DRAW SERIAL TROPONIONS)




Want to make sure no elevations.

Creatine Kinase is an ______ found mainly in?

Enzyme; HEART and SKELETAL muscles

Heart muscle damage releases?

CK into the blood (TROP still preferred)

CK-MB damage comes from the HEART though, not ____ muscle

Skeletal

When does this one elevate?

6-8 hours

If Troponin positive, but NO changes on EKG- What does the person have?

NSTEMI (ELEVATED TROP)

If you have chest pain and there are ST elevations, what do I have?

STEMI

History of chest pain, Chronic stable angina chest pain. Can turn into? Not relieved by medications/rest

UNSTABLE ANGINA (Acute Coronary Syndrome)

ACS MANAGEMENT (STEMI) MANAGE ___

FAST

For someone with a STEMI, we are going to see?

INFARCTION/ST ELEVATION




(MI on 12 lead ECG showing these elevations)

Management: What are the steps that we are going to do? What medications are we going to give?

1) IV access


2) Labs drawn


3) CONTINUOUS TELEMETRY


4) GIVE MEDICATIONS -Aspirin (325 mg PO, chew & swallow, Oxygen (Controversial), SL Nitro, Morphine (if other stuff not working)


5) Make decision about a REPERFUSION strategy

For US, reperfusion strategy typically involves?

PCI: Percutaneous Intervention (SAME AS CARDIAC CATH, ANGIOGRAPHY)




OR Fibrinolytic Strategy (8 hours away by car, live in mountains, go to ED with STEMI)

If you live forever away, you will get?

The Fibrolytic Strategy

Explain this:

CLOT BUSTIN. Will break up clot, but NONSELECTIVE (very dangerous) every place you clot, you can disrupt the clot and can have significant bleeding (WHEN PCI not available)

How do we ensure progress?

SERIAL ECG's (With Fibrolytic Therapy) waiting to see if ST elevations get better (breaking up the clot)

CLOT Lysis=

LYSE coronary thrombi by CONVERTING pasminogen to plasmin, causes DEGRADATION OF FIBRIN AND FIBROGEN.

This will stop the ____ process

Infarction:) (DISSOLVES THAT THROMBIS)

Only done when ___ not available

PCI/Angiogram/Cardiac Cath Lab

Has to be done within?

12 hours

If pt. can't get to PCI center within ___ hours

3 of arrival to ED

Ideally infused within ___ upon arrival to hospital

30 (Patient selection criteria important)

What is the TREATMENT OF CHOICE for confirmed MI?

ANGIOGRAM

What medications will we typically see with angiogram?

1) ASPIRIN (ANTI-platelet) ALWAYS


2) P2Y12 receptor blockers (Ex: Ticarelor. Prasugrel, loading dose preferred over clopidogrel (plavix)


.Sometimes IV GP (Anciximab)

With Balloon angioplasty, the plaque is ____ up against

arterial wall. STENT will then be put in place.

Risk:

Can reocclude (body sees it as foreign)




MOST COMMON SITE: RADIAL ARTERY

Reperfusion Intervention Complications

1) CHEST PAIN- Could indicate reocclusion


2) Hemodynamic Instability


3) Evidence of bleeding


(Thrombolytic Therapy: CLOT LYSIS non selective, so patient can bleed anywhere)


PCI therapy/assess insertion site

Complications of MI/Hemodynamic Complications (5)

1) Cardiogenic SHOCK- may require IABP


2) WALL RUPTURE


3) PERICARDITIS


4) Thromboembolic events


5) DYS

Patient Teaching after MI:

1) Pathphysiology of MI


2) Treat risk factors


3) Env. of hospital-tests, procedures


4) lifestyle modifications


5) Emotional adapation


6) Cardiac Rehabilitation (help with adverse physiological/psychological events.



Things that can help with MI

Exercise, stop smoking, lipid management, weight control, bp control, psychological support, return to work, activity (dont ignore sexual activity)

Medications for UA/NSTEMI

1) Antiplatelets


2) BB /CCB


3) LIPID/DM meds


4) Nitrates (short/long acting)



If stent doesn't work, failed medical management, not a candidiate for PCI, failed PCI with chest pain, when long term-benefits of this are superior to those with PCI, presence of LEFT MAIN CORONARY ARTERY or 3 vessel disease=

CABG

When people are taking Statins, we want to see that their lipid levels/cholesterol are going down. We monitor through?

LIVER FUNCTION TESTS . If not, we need to increase the dose.

All chest pain, ___ until proven otherwise

Cardiac

To diagnosis a heart attack, the MOST IMPORTANT THING TO GATHER FROM A PATIENT=

THEIR OWN INDIVIDUAL STORY

Other things to diagnosis a heart attack include

1) LAB (TROP)


2) ECG changes (Q wave, T inversions, ST elevation)


3) Draw blood



When patient is not getting a good blood supply, we will see this with?

Dysrhythmias

We will usually treat the Dysrhythmias with?

MEDICATIONS

So people with heart problems, will need to have a ____ lock in place

SALINE (we want to be able to intervene quickly)

People with heart problems will also have an abnormal?

Na/K/Mg pump. Electrolyte Imbalances, LOW 02 (meaning they are becoming acidodic) ALL CAUSES OF DYS.

Drugs to treat HEART ATTACK:

OXY, NITRO, ASP, MORPHINE (MONA) Not always in that order.

The chest pain is due to?

Ischemia/ACID building up

Nitrate guide = Q ___ min, ___ doses 5;

5, 3

If not any relief, call?

911 (TIME IS MUSCLE)

Nitrates help to decrease workload of heart, so the heart wont have to? (VASODILATE)

Pump as hard. Hopefully will vasodilate coronary arteries

Side effects of nitrates?

HA, HYPOTENSION




Helps the heart to get the o2 that it needs.



You don't want to give the pt. acet/ibu because these dont help with the?

Vasodilation

Nitroglycern: AMBER bottle, active for?

6 months


Check for sizzle



Usually patients would be home, then to ER, get their nitro, if nitro doesn't work, get?

MORPHINE

If patient still not better after morphine, nurse will give?

IV NITRO (Monitor pain, BP (Hypotension)

If they are STILL in pain they are going to increase the dose until?

NO pain or BP is dropping too much

Coronary= ___ sided for artery. Hemodynamic pressure paramers=

L; R