Cardio Midterm 1

Front 1

*What is ischemic heart disease?

Back 1

insufficient oxygen supply to the myocardium most often caused by narrowing or occlusion of the coronary arteries

Front 2

What does myocardial ischemia result in?

Back 2

angina pectoris

Front 3

What is angina pectoris characterized by?

Back 3

chest squeezing, tightness, pressure

Front 4

What is the leading cause of death in the US?

Back 4

-coronary artery disease (CAD)
-1:5 deaths in the US

Front 5

What are 9 risk factors for atherosclerosis?

Back 5

age
HTN
elevated lipids
tobacco use
DM
family hx
gender (male)
sedentary lifestyle
post-menopausal state

Front 6

What is chronic stable angina?

Back 6

-angina of effort
-frequency of angina can be related to effort expended (also psych/emotional upset)
-when supply < demand=angina

Front 7

If a patient has an occluded coronary artery, will they always have angina?

Back 7

-no, only when supply < demand
-if supply=demand, they feel ok

Front 8

How do we describe angina?

Back 8

-substernal chest discomfort
-provoked by exertion
-relieved with rest
-lasts less than 3 minutes
-relieved by sublingual nitro

Front 9

Manifestations of angina

Back 9

-jaw pain
-arm pain
-back pain
-toothache

Front 10

What are the various manifestations of angina also known as?

Back 10

angina equivalents

Front 11

What can patients with CSA be managed effectively with?

Back 11

-medical therapy and lifestyle modification as outpatients
-don't need to be hospitalized as long as they are 'stable'

Front 12

Will all patients with CSA develop unstable angina or a MI?

Back 12

no

Front 13

What is CSA not the same as?

Back 13

acute coronary syndrome (ACS)

Front 14

What are the 3 entities covered by ACS?

Back 14

-unstable angina
-NSTEMI
-STEMI

Front 15

What does CSA share with ACS?

Back 15

-atherosclerosis as their underlying etiology

Front 16

What can be seen on an EKG?

Back 16

-ischemic changes, ST segment depressed/sagged with ischemia
-may appear normal under normal circumstances (i.e. at rest)

Front 17

Does a normal EKG exclude ischemia/CAD?

Back 17

no

Front 18

Does MI get better with rest?

Back 18

NO

Front 19

When approaching a patient with angina, what is crucial?

Back 19

detailed history! OPQRST
-change in pain?
-similar to heartburn?
-is pain predictable with activity?
-awaken at night/pain @ rest?
-associated symptoms (i.e. dyspnea, diaphoresis)

Front 20

Patient with angina: pt assessment

Back 20

-risk factor profile (does the patient have multiple risk factors?

Front 21

Patient with angina: PE clues

Back 21

-vital signs
-xanthomas
-bruits
-diminished peripheral pulses
-venous stasis changes
-murmurs
-GET A 12 LEAD EKG!
-possibly refer to cardiologist/specialist

Front 22

What are some medical interventions for a patient with coronary artery disease?

Back 22

-beta blocker
-calcium channel blocker
-aspirin
-statin
-sublingual nitro

Front 23

What are 2 non-invasive tests for pt with angina?

Back 23

-cardiac US
-stress test (stress echo, nuclear perfusion study, other imaging modality i.e. 64 slice CT angiography)

Front 24

What are 2 invasive tests for pt with angina?

Back 24

-cardiac catheterization
-coronary angioplasty or stenting

Front 25

What can cardiac US (echocardiogram) assess?

Back 25

-structure and function of the heart
-left ventricular ejection fraction
-integrity/function of the valves

Front 26

What can stress tests with imaging show?

Back 26

-modality to screen for ischemic burden

Front 27

What is a normal EF?

Back 27

55-65%

Front 28

Stress ECHO

Back 28

-US images of the heart are taken before and after exertion
-if heart appears hypocontractile after exertion, ischemia is suspect

Front 29

Nuclear stress test

Back 29

-2 sets of pictures taken of the heart (at rest and after exercise)
-shows how well blood flows to the heart by creating/comparing images

Front 30

On a nuclear stress test, what will inadequate coronary circulation appear as?

Back 30

light areas (b/c radioisotope not reaching that area of myocardium under physiologic stress)

Front 31

What does a nuclear stress test NOT show?

Back 31

where blockage actually is...only suggest heart is devoid of oxygen (stress echo also does not show where blockage is)

Front 32

What is the gold standard to define the coronary anatomy?

Back 32

-cardiac cath

Front 33

What is an angiogram?

Back 33

study that looks at arteries within the body

Front 34

64 slice angiogram

Back 34

-new, non-invasive technology
-excellent imaging quality
-provides detailed anatomic pics of the coronary arteries

Front 35

Angina treated with drugs that...

Back 35

-improve blood supply to heart muscle
-decrease myocardial oxygen demand
-lower BP

Front 36

What is an example of a vasodilator used for angina pectoris?

Back 36

-nitroglycerin (sub-lingual is best route)
-also, nitro patch applied daily or oral isosorbide

Front 37

What are drugs that slow the heart rate down?

Back 37

-Ca channel blockers (Diltiazem)
-Beta blockers (Metoprolol)

Front 38

What are 6 drugs for use in patients with chronic stable angina?

Back 38

-anti-platelet tx (aspirin)
-lipid lowering therapy (statin)
-beta blocker
-calcium channel blocker
-nitrates
-ace inhibitor or ARB (for left ventricular dysfunction)

Front 39

What is a side effect of nitrates?

Back 39

-hypotension,headache (headache is most ominous side effect b/c vessels in the head are dilated too)

Front 40

What is a side effect of beta blockers?

Back 40

-fatigue, erectile dysfunction

Front 41

CSA lifestyle changes

Back 41

-stop smoking
-lose weight
-medication compliance
-dietary modification
-exercise
-glycemic control
-positive attitude

Front 42

Prinzmetal's/Variant Angina

Back 42

-symptoms of angina are experienced due to coronary vasospasm
-often occurs at rest
-pts can develop ischemic EKG changes during periods of vasospasm
-NORMAL arteries

Front 43

What are 2 meds for Prinzmetal's Angina?

Back 43

-calcium channel blockers i.e. Verapamil, Amlodipine

Front 44

What is an MI?

Back 44

AKA acute coronary syndrome - death of or damage to part of the heart b/c blood supply stopped or severely reduced

Front 45

What is included in ACS?

Back 45

MI and unstable angina (NOT stable angina)

Front 46

Aside from ischemia, what else can cause ACS?

Back 46

-cocaine (b/c vasoconstrictor)
-embolic is not a common cause

Front 47

Roughly what percent of people who experience an MI die from it?

Back 47

37%

Front 48

What is the leading cause of cardiac death and disability?

Back 48

atherosclerosis

Front 49

For every 10% increase in adherence to treatment guidelines, what results?

Back 49

10% decrease in mortality

Front 50

What is myocardial ischemia most often secondary to?

Back 50

ahterosclerosis

Front 51

What do patients with a STEMI often have?

Back 51

a thrombus occluding the infarcted artery

Front 52

What is the common theme in all acut coronary syndromes?

Back 52

-plaque and/or thrombus obstructing blood flow within the coronary circulation
-degree of obstruction is determining factor of clinical presentations and consequences

Front 53

NSTEMI

Back 53

-subendocardial or non-Q wave MI
-EKG often non-diagnostic
-clinical hx difficult to distinguish from unstable angina

Front 54

What is a useful distinction b/w unstable angina and NSTEMI?

Back 54

cardiac biomarkers

Front 55

STEMI

Back 55

-most dangerous condition in the spectrum of ACS
-leading cause of cardiac death
-TOTAL occlusion of a coronary artery leading to myocardial injury and necrosis
-ST elevation

Front 56

NSTEMI vs unstable angina (very simply)

Back 56

NSTEMI is severe reduction of blood flow, unstable angina is significant reduction of blood flow

Front 57

Risk factors for ACS

Back 57

-HTN
-high cholestrol
-tobacco
-familial history
-age
-obesity
-DM
-sedentary lifestyle

Front 58

Who often presents with atypical symptoms?

Back 58

women and the elderly

Front 59

Can ACS diagnosis be made on PE alone?

Back 59

no

Front 60

Who can sometimes have "painless angina"?

Back 60

-patients with diabetes (neuropathy) b/c have defective anginal warning mechanisms

Front 61

Clinical features of angina/ACS

Back 61

-chest pain (not always severe)
-sweating
-dyspnea
-weakness
-anxiety
-nausea
-back/arm pain
-feeling of "impending doom"

Front 62

What is an important distinction b/w stable and unstable angina?

Back 62

-stable angina is relieved with rest, unstable is not

Front 63

Suspected MI/ACS/Cardiac Arrest action plan

Back 63

-early access (911)
-EKG
-defibrillation for VF then ACLS
-ST elevation?
-rapid transport to med facility

Front 64

PE of MI

Back 64

-exam may be normal!
-vital signs
-JVD
-wheezes, rales, rhonchi
-murmurs, rubs, gallops
-exam does NOT make diagnosis

Front 65

What are 4 things someone with an MI can develop?

Back 65

-hyper/hypotension
-brady/tachycardia
-arrhythmias
-cardiogenic shock

Front 66

4 special considerations in PE of MI

Back 66

-new murmurs
-mitral regurgitation in inferoposterior infarct
-rales due to large myocardial infarct
-cardiogenic shock/poor urine output

Front 67

What is TIMI?

Back 67

-thrombolysis in MI
-rating system used to risk stratify your patients and assist in determining a triage and management plan

Front 68

TIMI score

Back 68

-age greater than 65
-3 or more risk factors for CAD
-use of aspirin within the past 7 days
-known CAD (50% stenosis in a vessel)
-rest angina (more than 1x in past 24 hrs)
-abnormal ST segments
-abnormal cardiac enzymes

Front 69

What is considered high risk TIMI score?

Back 69

greater than 3

Front 70

MI/ACS simplified tx plan (first 6 steps)

Back 70

-rapid hospital transport for reperfusion
-labs/EKG
-antiplatelet tx: heparin/aspirin
-nitrates
-morphine
-oxygen

Front 71

MI/ACS simplified tx plan (2nd 6 steps)

Back 71

-establish large bore IV access
-beta blocker
-cardiac cath or thrombolysis
-intravenous heparin (if appropriate)
-glycoprotein 2B3A inhibitors if appropriate
-statins

Front 72

What do statins help do?

Back 72

stabilize plaques

Front 73

If there is STE on EKG, what should be done next?

Back 73

cath lab!

Front 74

If EKG is low risk, what should be done next?

Back 74

compare to prior EKG to screen for new ST/T wave changes

Front 75

What does ST segment depression suggest?

Back 75

myocardial ischemia

Front 76

Whta does ST segment elevation suggest?

Back 76

myocardial injury or infarction

Front 77

What does T wave inversion suggest?

Back 77

ischemia

Front 78

What do Q waves help with?

Back 78

make the diagnosis of prior infarction

Front 79

What is the most sensitive and specific marker for cardiac injury?

Back 79

troponins

Front 80

What can location of changes on EKG determine?

Back 80

location of insult

Front 81

In terms of cardiac enzymes, what has yet to be identified?

Back 81

-a specific, sensitive marker that is present within one hour after the onset or a cardiac event

Front 82

What are the 3 enzymes predominantly used?

Back 82

troponins (I and T)
CK
CK-MB

Front 83

What are elevated enzymes strongly suggestive of?

Back 83

ACS

Front 84

What can a triathlete have after a triathlon?

Back 84

elevated CK-MB (doesn't mean they're having a heart attack)

Front 85

CK is typically increased in MI, but what else can cause it to increase?

Back 85

-trauma, post-op, extreme exertion

Front 86

Troponins

Back 86

-rises 2-6 hours after injury
-peaks in 12-16 hours
-stays elevated for 7-12 days

Front 87

CK

Back 87

-rises 6 hours after injury
-peaks at 24 hrs
-stays elevated for 3-5 days