S2: Ch1 Cv 1-1

Front 1

23. Medical therapy for stable angina/CAD?

Back 1

a. Aspirin
b. β-blockers
c. Nitrates
d. Calcium channel blockers
e. If CHF, is also present, tx w/ACE inhibitors and/or diuretics may be indicated as well.

Front 2

24. Aspirin for Angina/CAD?

Back 2

a. Indicated in all pts w/CAD
b. Decreases morbidity- reduces risk of MI.

Front 3

25. β-blockers for CAD?

Back 3

a. Block sympathetic stimulation of heart.
b. Reduces HR, BP, and contractility, thereby decreasing cardiac work (i.e., β-blockers lower myocardial oxygen consumption).
c. Have been shown to reduce the frequency of coronary events!!!!

Front 4

26. Nitrates for CAD?

Back 4

a. Cause generalized vasodilation
b. Relieve angina
c. Reduce preload!!!!, therefore the load and oxygen demand.
d. May prevent angina when taken before exertion.
e. Effect on prognosis is unknown; main benefit is symptomatic relief.
f. Can be administered orally, sublingually, transdermally, or IV

Front 5

27. Calcium channel blockers for CAD?

Back 5

a. Cause coronary vasodilation and AFTERLOAD reduction.
b. Now considered a Secondary Tx when β-blockers and/or nitrates are not fully effective.

Front 6

28. Revascularization for CAD?

Back 6

a. May be preferred for high-risk pts, although there is some controversy whether revascularization is superior to medical management for a pt w/stable angina and stenosis >70%.
b. 2 Methods- PTCA and CABG.
c. Revascularization does not induce incidence of MI, but does results in significant improvement in symptoms.

Front 7

29. Management decisions for mild disease (normal EF, mild angina, single-vessel disease)?

Back 7

a. Nitrates (for symptoms and as prophylaxis) and a β-blocker are appropriate.
b. Consider calcium channel blockers if symptoms continue despite nitrates and β-blockers.

Front 8

30. Management decisions for moderate disease (normal EF, moderate angina, 2-vessel disease)?

Back 8

a. If the above regimen does not control sx, consider coronary angiography to assess suitability for revascularization (either PTCA or CABG).

Front 9

31. Management decisions for severe disease (Decreased EF, severe angina, and 3-vessel/left main or LAD disease?

Back 9

a. Coronary angiography and consider CABG

Front 10

32. PTCA (Percutaneous transluminal coronary angioplasty)?

Back 10

a. Should be considered in pts w/1 or 2 vessel disease.
b. Best if used for proximal lesions.
c. Restenosis is a significant problem!!!! (Up to 40% w/in first 6 months). However, if there is no evidence of restenosis at 6 months, it usually does not occur.
d. Stents significantly reduce the rate of restenosis.

Front 11

33. CABG?

Back 11

a. Tx of choice in pts w/high risk disease!

Front 12

34. When is CABG recommended?

Back 12

a. Left main disease
b. 3-vessel disease w/reduced L. Ventricular function, 2-vessel disease w/proximal LAD stenosis, or severe ischaemia for palliation of symptoms.

Front 13

35. Pathophys of unstable angina?

Back 13

a. W/unstable angina (USA), oxygen demand is UNCHANGED. Supply is decreased secondary to reduced resting coronary flow. This is in contrast to stable angina, which is due to increased demand.
b. USA is significant bc it indicates stenosis that has enlarged via thrombosis, haemorrhage, or plaque rupture. It may lead to total occlusion of a coronary vessel.

Front 14

36. What patients may be said to have unstable angina?

Back 14

a. Pts w/chronic angina w/increasing frequency, duration, or intensity of chest pain.
b. Pts w/new-onset angina that is severe and worsening.

Front 15

37. Dx of unstable angina?

Back 15

a. Perform a diagnostic workup to exclude MI in all pts.
b. Pts w/USA should be stabilized w/medical management before stress testing or should undergo cardiac cath initially.

Front 16

38. Tx of unstable angina?

Back 16

a. Hospital admission on a floor w/continuous cardiac monitoring.
b. Establish IV access and give supplemental oxygen.
c. Provide control w/nitrates and morphines.
d. Aggressive medical management is indicated.
39. Cardiac cath/revascularization >90% of pts improve w/the above medical

Front 17

40. Medical management of unstable angina?

Back 17

a. Aspirin
b. β-blockers- First-line therapy if there are no contraindications.
c. Low-molecular-weight heparin (LMWH) or unfractionated heparin:
i. Should be continued for at least 2 days.
ii. Keep PTT at 2 to 2.5 normal if using unfractionated heparin; PTT not followed w/LMWH.
d. Enoxaparin

Front 18

41. DOC for unstable angina?

Back 18

a. Enoxaparin (Lovenox)!!! Based on Essence TRIAL.

Front 19

42. Choice of invasive management for unstable angina?

Back 19

a. Early catheterization/revascularization w/in 48hrs) vs. conservative management (cath/Revasc) only if medical therapy fails is controversial.
b. No study has shown a significant difference in outcomes b/t these 2 approaches.

Front 20

43. Conservative management of unstable angina?

Back 20

a. If medical therapy fails to improve sx and/or ecg changes are indicative of ischaemia persistent after 48 hrs, then proceed directly to cath/revascularization.

Front 21

44. After acute tx of unstable angina?

Back 21

a. Continue aspirin (or other antiplatelet therapy), β-blockers, and nitrates.
b. Reduce risk factors:
1. Smoking cessation, wt. loss
2. Tx DM, HTN.
3. Tx hyperlipidemia- pts w/USA (or non-ST segment elevation MI) w/elevated LDL should be started on an HMG-CoA reductase inhibitor. Clinical trials of statins have shown efficacy of such therapy for secondary prevention in CAD.
4. Consider folic acid- It is used for hyperhomocysteinemia, but is also reported to have beneficial effects on endothelial function and as an antioxidant.

Front 22

45. Acute coronary syndrome?

Back 22

a. The clinical manifestation of atherosclerotic plaque rupture and coronary occlusion.
b. Term generally refers to unstable angina or acute MI.

Front 23

46. USA vs. non-ST-segment elevation MI ?

Back 23

a. Often considered together bc it is very difficult to distinguish the two based on pt presentation.
b. If cardiac enzymes are elevated, then the pt has non-ST segment elevation MI.

Front 24

47. Results of ESSENCE trial?

Back 24

a. Showed that in USA and non-ST segment elevation MI, risk of death, MI, or recurrent angina was lower in the enoxaparin group than in the heparin group at 14 days, 30 days, and 1 yr.
b. The need for revascularization was also lower in the enoxaparin group.

Front 25

48. Are thrombolytic therapy and calcium channel blockers beneficial in unstable angina?!?

Back 25

a. NO!!! They have not been proven to be beneficial.

Front 26

49. Variant (Prinzmetal’s) angina?

Back 26

a. Involves transient coronary vasospasm that usually is accompanied by a fixed atherosclerotic lesion (75% of cases), but can also occur in normal coronary arteries.
b. Episodes of angina occur at rest and are associated w/ventricular dysrhythmias.
c. Hallmark is transient S-T segment elevation (not depression) on ECG during chest pain, which represents transmural ischaemia.

Front 27

50. Definitive test for Variant (Prinzmetal’s) angina?

Back 27

a. Coronary angiography is definitive test- displays coronary vasospasm when the pt is given IV ergonovine (to provoke chest pain).

Front 28

51. Tx of Variant (Prinzmetal’s) angina?

Back 28

a. Vasodilators- Ca+ channel blockers and nitrates have been proven to be helpful.

Front 29

52. General characteristics of Myocardial Infarction (MI)?

Back 29

a. MI is due to necrosis of myocardium as a result of an interruption of blood supply (after a thrombotic occlusion of a coronary artery previously narrowed by atherosclerosis).
b. Most cases are due to acute coronary thrombosis. Atheromatous plaque ruptures into the vessel lumen, and thrombus forums on top of this lesion, which causes occlusion of the vessel.
c. MI is associated w/a 30% mortality rate; half of deaths are pre-hospital!!
d. Most pts w/MI have hx of angina, risk factors for CAD, or hx or arrhythmias.

Front 30

53. Clinical features of MI?

Back 30

a. Chest pain
b. Can be asymptomatic in up to 1/3 of pts; painless infarcts or atypical presentations more likely in postoperative pts, the elderly, diabetic pts, and women.
c. Other sx:
i. Dyspnea
ii. Diaphoresis
iii. Weakness, fatigue
iv. N/V
v. Sense of impending doom
vi. Syncope

Front 31

54. What is sudden cardiac death usually due to?

Back 31

a. Ventricular fibrillation (VFib).

Front 32

55. Characteristics of the chest pain associated w/MI?

Back 32

a. Intense substernal pressure sensation, often described as “crushing” and “an elephant standing on my chest”.
b. Radiation to neck, jaw, arms, or back, commonly to the left side.
c. Similar to angina pectoris in character and distribution but much more severe and lasts longer.
d. Some pts may have epigastric discomfort.