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59 Cards in this Set
- Front
- Back
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Why do a stress ECG (3)
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-confirm diagnosis of angina
-evaluate response of therapy in pts with documented with CAD -identify pts with CAD who may be at high risk for acute coronary events |
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What constitutes a positive stress test (4)
Next step in management if positive stress test? |
-ST segment changes (depression)
-chest pain -hypotension -significant arrhythmia during exercise -Cardiac Catherization |
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What are the indications for cardiac catherization? (4)
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-positive stress test
-angina (meds not helping, soon after MI, noninvasive tests negative) -pt severely symptomatic -eval of valvular disease (need for surgery) |
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What are the three agents used to perform a pharmacologic stress test?
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-adenosine
-dipyramidole -dobutamine NB: adenosine and dipyramidole cause coronary vasodilation while dobutamine increases myocardial oxygen demand by increasing HR, BP and cardiac contractility |
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What would you do if a pt reported cardiac symptoms and the ECG was normal, or showed no changes? (silent ischemia) (1)
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Holter monitoring
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What is the definitive test for CAD
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cardiac catherization with coronary angiography
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How do beta blockers benefit pts with CAD? (2)
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-reduce cardiac work (decr. HR, BP, contractility)
-shown to reduce frequency of coronary events |
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Why give all pts with CAD aspirin?
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it decreases the morbidity- reduces the risk of MI
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Side effects of nitrates? (4)
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-headache
-orthostatic hypotension -syncope -tolerance |
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What are the two types of revascularization and what is the advatange?
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-PTCA
-CABG Advantage is significant improvement in symptoms, however DOES NOT reduce incidence of MI |
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How would you manage mild disease (normal EF, mild angina, single-vessel dz)? (2)
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-nitrates
-beta blocker NB: consider calcium channel blocker if sxs persist in spite of above |
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How would you manage moderate disease (normal EF, moderate angina, two-vessel dz)? (3)
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-nitrates
-beta blocker NB: consider CABG or PTCA if sxs persist despite above |
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How would you manage severe disease?
(decreased EF, severe angina, three-vessel disease/left main or LAD) |
-coronary angiography and consider for CABG
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When would you do PTCA? (2)
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done for reversible ischemia
-one or two vessel disease -best for proximal lesions problems: restenosis (so using stents reduces this) |
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When would you do CABG? (6)
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-TOC for high risk dz but with reversible ischemia
-left main dz -three vessel dz -reduced LVEF -two vessel dz with proximal LAD stenosis -severe ischemia |
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what is normal left ventricular ejection fraction?
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> 50%
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what do Q-waves on ECG mean?
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consistant w/ a prior MI
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what do you look for (considered positive) during a stress ECG?
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positive stress test:
- ST-depression (subendocardial ischemia) - heart failure - ventricular arrhythmia - hypotension - significant pain |
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what do you do if you have a positive stress test?
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cardiac catheterization
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what is the radioisotope used to determine perfusion since it's taken up by the myocardial cells?
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thallium 201
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if a patient with stable angina remains sypmtomatic following B-blocker/nitrate therapy, what is the next step?
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calcium channel blockers
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what is considered mild stable angina?
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normal EF
mild angina 1-vessel disease |
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what is considered moderate stable angina?
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normal EF
moderate angina 2-vessel disease |
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what is considered severe stable angina?
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decreased EF
severe angina 3-vessel/left-main/LAD disease |
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what drugs are used to treat unstable angina pectoris?
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B-blockers (1st-line)
nitrates (1st-line) aspirin heparin (LMWH) glycoprotein IIb/IIIa inhibitors (abciximab) |
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describe the details of heparin use in unstable angina pectoris
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enoxaparin #1
LMWH > unfractionated PTT 2 to 2.5 x normal (not followed for LMWH) |
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in a pt with unstable angina, how long do you wait prior to making the decision to go to revascularization (cath)?
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if sxs or ECG indicative for ischemia persists for >48 hrs following medical therapy
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what is used to treat hyperhomocytinemia in pts post-treatment for unstable angina?
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folic acid
(also an antioxidant) |
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how does variant (Prinzmetal's) angina typically present?
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females > males
usually no risk factors awaken pts at night hallmark: transient S-T segment elevation (transmural ischemia) |
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how do you make the definitive diagnosis of variant (Prinzmetal's) angina?
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coronary angiography displays coronary vasospasm when pt is given IV ergonovine
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what drugs should be used/avoided in variant (Prinzmetal's) angina?
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use:
- CCBs - nitrates avoid: (cause vasospasm) - B-blockers - aspirin |
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what is the mortality rate of a myocardial infarction?
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30%
(half are pre-hospital) |
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what is the mcc of death in pts with an MI?
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re-entrant ventricular arrythmia
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what are the different markers of ischemia/infarction on ECG?
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peaked T-waves - (early)
ST elevation - (transmural) Q waves - (late and specific for necrosis) T wave inversion (sensitive, not specific) ST depression - (subendocardial injury) |
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how does a RV infarct present?
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inferior ECG changes
hypotension elevated JVD hepatomegaly clear lungs |
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what drugs are recommended/contraindicated in a RV infarct?
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use:
- nitrates + CCB's + fluids - increase the filling of the RV avoid: - B-blockers - decr HR = hypotension |
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what are the indications for thrombolytic therapy in a myocardial infarction?
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ST elevation in 2 contiguous ECG leads
< 24 hrs post onset of sxs < 6 hrs best t-PA > (streptokinase/urokinase/etc) |
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what is the difference in pathlology between a STEMI and a non-STEMI?
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STEMI:
- transmural (entire thickness) - larger non-STEMI: - subendocardial (inner 1/3-1/2) - smaller) [note: cardiac enzymes differentiate the two] |
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what is the gold-standard for myocardial injury diagnosis?
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cardiac enzymes:
- creatine kinase-MB - troponins (I and T) |
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how does a RV infarct present?
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inferior ECG changes
hypotension elevated JVD hepatomegaly clear lungs |
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what drugs are recommended/contraindicated in a RV infarct?
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use:
- nitrates + CCB's + fluids - increase the filling of the RV avoid: - B-blockers - decr HR = hypotension |
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what are the indications for thrombolytic therapy in a myocardial infarction?
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ST elevation in 2 contiguous ECG leads
< 24 hrs post onset of sxs < 6 hrs best t-PA > (streptokinase/urokinase/etc) |
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what is the difference in pathlology between a STEMI and a non-STEMI?
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STEMI:
- transmural (entire thickness) - larger non-STEMI: - subendocardial (inner 1/3-1/2) - smaller) [note: cardiac enzymes differentiate the two] |
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what is the gold-standard for myocardial injury diagnosis?
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cardiac enzymes:
- creatine kinase-MB - troponins (I and T) [note: troponins > CKMB] |
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what are the characteristics of creatine kinase-MB (CKMB) cardiac enzymes?
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increases at 4-8 hrs
peaks at 24 hrs normal at 48-72 hrs - measure at admission and every 8hrs - good for assessment of re-occlusion |
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what are the characteristics of troponin cardiac enzymes?
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increase at 3-5 hrs
peak at 24-48 hrs normal at 5-14 d - most important test to order - measure at admission and every 8hrs - troponin I falsely elevated w/ renal failure |
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what are the only pharmacologic agents shown to reduce mortality in the setting of an MI?
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"ABC's"
- Aspirin - Beta-blockers (carvedilol) - aCe-inhibitors (*all should be part of long-term maintenance therapy) |
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what is the role of morphine sulfate in the treatment of an acute myocardial infarction?
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analgesia
venodilation (decr preload) |
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what is first-line for the treatment of cocaine-induced cardiac complications?
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benzodiazepines
(note: cardiac enzymes not elevated) |
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what are the two different types of post-MI sustained ventricular tachycardia and how do you treat each?
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hemodynamically unstable:
- electrical cardioversion hemodynamically stable: - antiarrhythmic therapy (IV amiodarone) |
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how do you treat post-MI ventricular fibrillation?
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immediate unsynchronized defibrillation and CPR
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if sinus bradycardia post-MI is severe or syptomatic, what drug can be used?
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atropine (incr HR)
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what AV blocks need/don't need treatment?
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no treatment:
- 1st degree - 2nd degree (type I) treat: - 2nd degree (type II) - 3rd degree |
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what are the different treatments of a 2nd degree (type II) or 3rd degree AV block?
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anterior MI:
- emergent placement of temp pacemaker - eventual placment of permanent pacemaker inferior MI: - IV atropine initially - temp pacemaker if conduction not restored |
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when do free wall ruptures typically occur?
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2 wks post-MI (90%)
most w/in 1-4 days |
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what happens in a papillary muscle rupture and what is treatment?
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-> mitral regurgitation
treatment: - emergent surgery (valve replacment) - afterload reduction (sodium nitroprusside) or - intra-aortic balloon pump (IABP) |
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what is the hallmark of a ventricular aneurysm on ECG?
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persistent ST elevations
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how do you treat acute pericarditis?
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aspirin
(NSAIDs/corticosteroids are contraindicated as they may hinder myocardial scar formation) |
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what is Dressler's syndrome?
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"postmyocardial infarction syndrome"
- immunologically based - fever/malaise/leukocytosis - pericarditis/pleuritis - weeks to months post-MI - aspirin is first line |
