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68 Cards in this Set
- Front
- Back
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What is the worst risk factor for ischemic heart disease?
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Diabetes Mellitus
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What is the most common risk factor for ischemic heart disease?
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HTN
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What are the two syndromes termed "Syndrome X"?
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1. Metabolic Syndrome X
2. Syndrome X |
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What is Metabolic Syndrome X?
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Any combination of hypercholersterolemia, hypertriglyceridemia, impaired glucose tolerance, diabetes, hyperuricemia, HTN
The key underlying factor is insulin resistance (due to obesity) |
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What is "Syndrome X"?
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Exertional angina with NORMAL coronary ateriogram: pts present with chest pain after exertion but have no coronary stenoses at cardiac catherization.
Exercise testing and nuclear imaging show evidence of myocardial ischemia Prognosis is excellent |
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When is a STRESS TEST useful for pts?
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useful for pts with an INTERMEDIATE pretest probability of CAD based upon age, gender, and symptoms.
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Stress EKG (exercise testing) is used in the following 3 situations . . .
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1. To confirm the diagnosis of angina
2. to evaulate response of therapy in pts with documented CAD 3. to identify pts with CAD who may a high risk of acute coronary events. |
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The sensitivity of a stress EKG is . . .
this sensitivity only applies IF . . . How does one calculate the maximum predicted heart rate? |
75% sensitive IF pts are able to exercise sufficiently to increase heart rate to 85% of maximum predicted value for age.
Maximum predicted heart rate = 220 - age |
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A stress test is considered positive if the pt develops any of the following 4 during exercise . . .
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1. ST segment depression
2. chest pain 3 .hypOtension 4. arrhythmias |
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If a pt has a POSITIVE STRESS TEST what is the NEXT STEP?
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Cardiac catherization
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Stress echocardiography is performed . . .
Ischemia is evidenced . . . |
before and after exercise.
wall motion abnormalities (akinesis or dyskinesis) not present at rest |
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Why is stress echocardiography favored by cardiologists (compared to exercise stress testing)?
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1. More sensitive at detecting ischemia
2. Can detect LV size and fucntion 3. Can diagnose valvular disease 4. Can be used to identify CAD in thre presence of preeisting ECG abnormalities |
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What are the three types of stress test?
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1. Exercise tolerance test
2. Exercise or dobutamine echocardiogram 3. Exercise or dipyridamole thallium |
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What is the method for detecting ischemia with an exercise tolerance test?
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ST segment depression
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What is the method of detecting ischemia with an exercise or dobutamine ECHOCARDIOGRAM?
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wall motion abnormalities
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What is the method of detection for exercise or dpyridamole thallium?
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decreased uptake of the nuclear isotope during exercise
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information gained from a stress test can be enhanced . . .
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stress myocardial perfusion imaging after IV administration of a radioisotope such as thallium 201 during exercise
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It is important to determine if ischemia is . . .
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reversible
(that is whether areas of hypoperfusion are perfused over time as blood flow eventually equalizes) |
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Areas of ischemia that are reversible can be . . .
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rescued with PCI or CABG
(irreversible ischemia indicates infarcted tissue that cannot be salvaged) |
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What are the 3 agents used during a pharmacologic stress test?
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1. IV adenosine
2. dipyriamole 3. dobutamine |
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What is the MOA for IV adenosine and dipyridamole during an exercise stress test?
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both agents cause generalized CORONARY VASODILATION. Since diseased coronary arteries are already maximally dilated at rest to increase blood flow, they receive relatively less blood flow when the entire coronary system is dilated.
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What is the MOA for DOBUTAMINE during an exercise stress test?
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This increases myocardial oxygen demand by increasing heart rate, blood pressure, and cardiac contractility
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Holter monitoring (ambulatory EKG) can be useful in detecting . . .
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1. SILENT ISCHEMIA
2. evaluating for arrhythmias 3. heart rate variability 4. pacemaker function 5. implantable cardioverter-defibrillator (ICD) functio |
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Holer monitoring is used for pts who experience. . .
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syncope
and dizziness |
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What are the most common indications for coronary angiography?
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Performed after:
1. positive stress test 2. in a pt with angina when noninvasive tests are nondiagnostic 3. angina that occurs despite medical therapy 4. angina that occurs soon after an MI 5. any agina that is a diagnostic dilemma 6. if a pt is severely symptomatic and urgent dx and mgmt are needed 7. eval for valvular disease 8. determine the need for surgical intervention |
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What is the most accurate method for determing CAD?
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coronary angiography
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If CAD is severe (left main or three-vessel disease), refer pt for . . .
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surgical revascularization (CABG)
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Standard of care for stable angina is . . .
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ASA and Beta-blocker
(and nitrates for chest pain) |
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In the context of CAD, ASA and Beta-blockers. . .
Is this true for nitrate? |
lower mortality
(No, nitrates only alleviate pain, but do not lower mortality) |
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Do calcium channel blockers decrease mortality in pts with CAD?
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No (in fact they may increase mortality bc dihydropyridines increase HR)
Do not routinely use these agents in individuals with CAD unless they are on a beta-blocker |
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What did the COURAGE trial show?
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that there was essentially no difference in all cause mortality and nonfatal MIs between pts with stable angina treated with maximal medical therapy alone versus medical therapy with PCI and bare metal stenting
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PCI is aka. . .
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angioplasty
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Does revascularization (two methods PCI and CABG) reduce the incidence of MI?
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NO!
it reduces symptoms of CAD |
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Manage pts with CAD accoding to . . .
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risk
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A pt with normal EF, mild angina, and SINGLE-VESSEL DISEASE has what risk level of CAD?
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Mild
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What is the management for someone with MILD CAD?
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1. ASA
2. Nitrates (for symptoms and as prophylaxis) 3. Beta-blocker 4. Consider a CCB if symptoms persist despite being given the medications above |
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A pt with CAD is what risk level if they have:
normal EF moderate angina TWO-VESSEL DISEASE |
MODERATE DISEASE
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What is the mgmt for someone with MODERATE CAD?
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use the same regimen for someone with mild disease, but consider CORONARY ANGIOGRAPHY to assess suitability for revascularization (either PCI or CABG)
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A pt with CAD is what risk level if they have:
DECREASED EF SEVERE angina THREE-VESSEL, LEFT MAIN, or LAD disease |
SEVERE CAD
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What is the mgmt for a pt with SEVERE disease?
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Coronary agionography and consider CABG
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What is a drawback to PCI?
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higher frequency of revascularization procedures in pts who received a stent
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PTCA (PercuTaneous Cornary Angioplasty) is best for . . .
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proximal lesions
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What is a significant problem with PTCA?
. . . what percent? |
RESTENOSIS
up to 40% restenosis in 6 months. However, if there is no evidenceof restonosis at 6 mo, it usually does not occur. Drug eluting stents reduce this problem |
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PRECOMBAT and SYNTAX trials have shown that . . .
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PTCA with stenting may be as good as CABG even in pts with left main coroanary artery disease.
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What are the main indications for CABG?
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1. Three vessel disease with > 70% stenosis in each vessel
2. Left main coronary disease with >50% stenosis 3. Left ventricular dysfunction |
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Distinction between unstable angina (USA) and NSTEMI is based entirely on . . .
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cariac enzymes
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What did the CURE trial show?
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showed that clopidogrel reduced the incidence of MI in pts with USA compared with ASA alone. Pts should be treated for 9 - 12 months
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What did the ESSENCE trial show?
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sho2ed that in unstable angina and NSTEMI, the risk of death, MI, or recurrent angina was lower in teh enoxaparin group than in the heparin group at 14 days, 30 days, and 1 year. The need for revascularization was also lower in the enoxaparin group.
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In someone with unstable angina, what is the goal PTT when using LMWH?
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2 to 2.5 times normal PTT
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thrombolytic therapy and CCBs have not been proven to be beneficial in . . .
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unstable angina
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What did the CARE trial show?
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Pts with prior hx of MI were randomized to treatment with statins or placebo. The statin group had a reduced risk of death (by 24%), a reduced risk of stroke (by 31%), and a reduction in need for CABG or coronary angioplasty (by 27%).
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What does the "TIMI" stand for in the TIMI risk score?
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Thrombolysis In Myocardial Infarction
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What is the TIMI risk score?
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prognostication scheme that categorizes a patient's risk of death and ischemic events and provides a basis for therapeutic decision making
(doesn't actually have anything to do with Thrombolysis) |
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What are the 7 "points" in the TIMI risk score?
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Age > 65
more than three risk factors for CAD known CAD (stenosis > 50%) at least two episodes of severe angina in past 24 hrs ASA use in past 7 days Elevated serum cardiac enzymes WT changes >0.5mm |
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TIMI risk calculates the likelihood of a cardiac event at . . .
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14 days (based on the number of points, which then correlates to a percentage scale)
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What is the mortality rate of MI?
How many deaths occur prehospital? |
30%
about half |
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Unlike anginal chest pain, chest pain resulting from an MI does not respond to . . .
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nitroglycerin
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A right ventricular infarct will present with what ECG changes?
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Inferior ECG changes
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What are the symptoms of a right ventricular infarct?
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1. Hypotension
2. elevaed jugular venous pressure 3. hepatomegaly 4. CLEAR LUNGS |
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ST segment elevation indicates. . .
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TRANSMURAL injury and can be diagnostic of an acute infarct
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Where is the infarct occuring if you see the following ECG changes:
ST segment elevation in V1-V4 Q waves in leads V1-V4 |
Anterior Wall MI
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Where is the infarct occuring if you see the following ECG changes:
Large R wave in V1 ST segment depression in V1 and V2 Upright prominent T waves in V1 and V2 |
Posterior infarct
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Where is the infarct occuring if you see the following ECG changes:
Q waves in leads I and aVL |
Lateral infarct
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Where is the infarct occuring if you see the following ECG changes:
Q waves in leads II, III, and aVF |
Inferior infarct
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ST segment depression is indicative of . . .
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Subendocardial injury
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NSTEMI affects which part of the myocardium?
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subendocardial
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Pts with an MI should be placed on what medications?
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Morphine
Oxygen Nitrates ASA Beta Blockers IV Heparin ACE Inhibitor |
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Which agents are the only three agents that have been shown to decrease mortality in an MI?
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ASA
Beta Blockers ACE Inhibitors |
