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164 Cards in this Set

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Order of Ischemia

Ischemia-RWMA-ECG Changes- Painrep

Repeat echoes are done on patients suffering from CAD T or F

True

Stress echo is valuable in predicting what two things?

Myocardial viability (prognosis)


Detection of CAD

Role of echo in CAD

Diagnose CAD


Detect MI


RWMA after reperfusion therapy


Post MI function


Assess myocardial viability

What is the most commonly encountered problem in adult cardiology in the US?

CAD

Define ischemia

Inadequate blood supply and oxygen to myocardium

FUNCTIONAL outcome of CAD

Systolic function (wall motion and systolic thickening)


Diastolic function

What happens with no blockage of coronary artery?

No CAD, refer pt back to doctor

What happens with a small blockage of a coronary artery?

Pt referred back for medical therapy

What happens with one or two blockages in coronary artery?

Continue with angioplasty- gold standard

What happens with multiple blockages of coronary artery?

Candidate for CABG

Define PTCA


Explain procedure of PTCA

Percutaneous Transluminal Coronary Angioplasty



Thin wire across the area of the blockage, balloon is inflated one or more times to open artery, stent may be deployed

What is another name for prinzmetals angina

Variant angina

Meds used in CAD

Nitrates


BB


Calcium antagonist


Digitalis glycosides

Name kinds of Nitrates used to treat CAD

Isordil


Isosorbide dinitrate


Nitroglycerin


Cardolite


Nitrobid

What do nitrates do?

Vasodilator


Reduces RV and LV preload


Decreases cardiac work


Lowers o2 requirements

What is the first drug of choice for treating acute anginal attacks?

Nitrates (NTG most common)

Names for Beta Blockers?

Inderal


Corgard


Lopressor


Tenormin


Atenolol

What do beta blockers do?

Reduce HR


Reduces contractility


Reduces systemic BP

What are names of calcium channel blockers (calcium antagonists)?

Calan


Cardizem


Diltiazem


Nifedipine


Procardia


Verapamil

How do calcium channel blockers work?

Potent arterial vasodilators


Decreases contractility


Decreases HR


Potent coronary vasodilators


Increases coronary flow

N+B=C

Vasodilators+ decreases HR and contractility= potent vasodilator and decrease HR/ Contractility

What are other names for digitalis?

Digoxin


Lanoxin

What are other names for digitalis?

Digoxin


Lanoxin

What do digitalis glycosides do?

Increase resistance


Increase contractility


Increase HR


promotes fluid elimination from tissues


Used to treat some arrhythmias

Names for ACE inhibitors

Lasix


Furosemide

What do ACE inhibitors do?

Prevents constriction of blood vessels


Decreases after load


Increases contractility

Define stroke volume


What is the formula

Amount of blood ejected from the ventricle with each beat


SV (cc)=LVOT D^2(cm) x .785 xLVOT TVI (Cm)

Define cardiac output


What is the formula

Volume of blood ejected per minute


CO (L/min)= SV x HR

Define cardiac output


What is the formula

Volume of blood ejected per minute


CO (L/min)= SV x HR

What is cardiac index


What is the formula

Cardiac output per square meter of BSA


CI (L/min/m^2) = CO/BSA

Define cardiac output


What is the formula

Volume of blood ejected per minute


CO (L/min)= SV x HR

Describe athrectomy

Catheter with grinding device


Plaque ground into small bits and float away

Know coronary arteries

Which artery nourishes the most volume of the LV?

LAD

The dominant artery (PDA) supplies the _____________ wall of the LV

INFEROLATERAL

What prevent of LV is nourished by the LAD?

50%

What percent of the LV is nourished by the RCA?

25%

What percent of the LV is nourished by the LCX?

25%

What are the branches of the Lefr Main?

LAD (50%) LCX (25%)

Order of wall motion scoring:

1- norm


2-hypo


3-akinetic


4-dys


5-aneueysmal

Normal WMSI means what?

Systolic contraction and wall thickening >50%

Hypokinetic WMSI means what?

Reduced systolic wall thinking <40%

Akinetic WMSI means what?

Diastolic wall thickness is thin and thinking in <10% or none

Aneurysmal WMSI means what?

Constantly deformed segment through entire cycle

Coronary arteries primarily fill in______________

Diastole

WMSI equals ?

Sum of scores/ # of segments visualized. No less than 1 and anything greater than 2 is at risk of CHF, Arrythmias, death

Course of Ischemia (time frame)

Ischemia 00s-RWMA 20S- ECG 30S-Pain40s

WHY STRESS echo with CAD

A decrease in wall thickening=immediate MI


non-inv


Inexpensive


Imm results


God idea for treatment/ prognosis

What characterizes significant stenosis?

>50% lumen


>70% lumen can cause disabling angina

Describe PTCA

Balloon catheter inserted through coronary artery


Passed through lesion and expanded


Relieves angina and reduce RWMA from exercise

What is CABG

Creates other pathways as healthy vessels called collaterals

What is the purpose of stress test?

TO INDUCE ISCHEMIA

What is the goal of stress test?

To have patient REACH TARGET HR

Name the types of stress testing

SEKG


TMSE


SMSE


DSE

Procedure for SEKG

12 lead EKG


Resting EGK and BP


Exeecised


_______ and _______ coronary arteries feed the free wall

LAD, LCX

End points of SEGK

Targt HR


EKG changes develop


Abnormal BP response


Shows symptoms

Describe TMSE

12 lead EKG


Baseline echo


Impost echo


_______________


Final rest echo (not everywhere rakes these images)

Name the indications for TMSE

CAD- known/ suspected


CP, SOB


Risky patients before surgery


Abnormal ECG


To identify viable stunned and hibernation

When NOT to do a TMSE

Acute MI (2 days)


Unstable CP


Vent. Arrythmias


AS>50mmHg


Acute PE


PERICARDITIS


PREGNANCY

Protocol for TMSE

12Lead EKG


Resting echo


Bruce protocol


Impost echo


Final test echo

What is BRUCE protocol

3 minute stages until may HR (85%) reached


Starts at 1.7 mph at 10% incline

What is modified BRUCE protocol

Used for elderly/sedentary

First 2 stages at 1.7 mph and 0% grade

Know naughton protocol for TMSE

2 minute stages increase by 3.5% each time. Used for people who are elderly/ sedentary and can still exercise

Stop stressing if:

Target HR reached


EGK changes show ST depression


Abnormal BP


Showing significant symptoms

Advantages of TMSE


Disadvantages of TMSE

Non invasive


High total work load



Imaging after exercise


RWMA could be missed

_______ and _______ arteries feed the septum

LAD, RCA

When is DSE used?

Used for elderly or for patients who have skeletal problems or past surgeries that make it difficult to exercise

DSE consists of:

Medication via IV infusion that mimics physical exercise. Performed for the same reasons as TMSE

Whay happens Pre DSE

12 lead resting ECK


IV started


Resting echo

During DSE after set up:

Infusion begins


5,10,20,30,40 MCG/KG/MIN


3 minute stages and 5 total stages


ATROPINE may be added

Echo images for DSE:

Resting echo


Low dose (1 or 2) echo


Peak dose (5 or sooner if HR reached) echo


Recoceey final echo

Side effects of Dobutamine

Tingling in head, scalp, face


Tremors, nauseous

Why do DSE? (Two big reasons)

Determine if one will benefit from revasvularization


Determine Stunned, hinernating, or infected heart muscle

___________ myocardium is hypo or akinetic at rest and improved with low doses of Dobutamine

Hinernating

___________ myocardium can have a bi-phasic response to dobitamine- can get better with low doses and worse with high doses

Hibernating

What word is mostly related to "stunned" myocardium

REPERFUSION- after the act of opening up blocked arteries

How do you define coronary artery dominance?

The origin of the PDA

SBSE have the same indications as TMSE and can asses patients with AS or MS

Blank

Protocol for SBSE

Rest images


Exercised at 25 watts and 60 RPM


Icreases every 2 minutes by 25watts


Peak images


Impost images


Final rest images

Quad screen for SBSE

REST


PEAK


IMPOST


FINAL

Quad screen for TMSE

REST


IMPOST


A4C, A2C, A3C/ PLAX, PSAX MID

Advantage is SBSE


Disadvantages of SBSE

Able to image at exact peak stress



Problem of workload- pt finds it hard to bike supine and have inadequate level of stress

Creatine kinase (CK) is a later marker in cardiac cell damage. Elevates in ___ to___ hours


Peaks ___ to ___ house


Falls ____ to ____

3-12


12-24


1-3

Negative stress echo means______

-tested negative for CAD


-Normal wall motion and


-hyperdynamic with stress

Positive stress test means _________

Wall motion became either


-hypo


-akinetic


-dyskinetic


-Increase in size and shape of LV


-Decrease in EF%

False positive stress test means__________

Positive SEKG but negative stress test

What is a normal response to stress of the myocardium?

Decrease in ESV and EDV

Interpreting stress echoes **know this chart

What is an abnormal response to stressing the myocardium?

Failure of ESV to decrease


Increase in volume can indicate severe and extensive multi-velles disease

The LV should always increase in size when stressing the myocardium T or F?

False- should ALWAYS decrease

False negative

Not reaching target HR collaterals from single vessel disease present

Which of these are reversible: ischemia, stunned, hibernating?

All are reversible and viable

Ischemia will show wall motion abnormalities of what kind?

Hypokinetic or akinetic


Wall motion will return to normal at rest

Stunned myocardium is viable and occurs after opening up previously blocked arteries T or F?

True

What kind of wall motion abnormalities is irreversible?

Necrtoic tissue caused by infarction

What to expect for wall motion with an active MI?

Akinetic with normal wall thickness



Opposing walls may be hyperkinetic

Name some other modalities to assess ischemia

Doppler stress echo


Intravascular US


Contrast Agents


Ultrafast CT


Angiography **gold standard


Nice med uses thallium as a tag


PET Positron Emission Tomography

This term means disease of the intima that gets thick with fatty deposits and fibrous tissue

Atherosclerosis

LCX gives rise to the PDA ___% Of the time

10%

With atherosclerosis the intima gets _______ and the lumen gets_________

Smaller, bigger

Acute lesions due to atherosclerosis can cause ruptures and thrombus formations. These are unpredictable and can lead to:

Unstable anyone


Acute MI


Sudden death

How narrowed does a coronary artery have to be before a patient experiences symptoms with exercise?

75%

How narrowed does a coronary artery have to be u til a patient experiences symptoms at rest?

90% (critical lesions)

3 vessel disease can happen and this is when all the vessels are narrowed at the same time T or F

True

How the heart works is a better indicator than how occluded an artery is for prognosis of CAD T or F

True

Arteriosclerosis consists of:

Hardening of art walls


Loss of elasticity of art walls


Thickening of arterial walls

ASHD (Arteriosclerotic heart disease) is defined as:

Thickening and hardening of Walls of the coronary arteries leads to narrowing of the coronary lumen

When the RCA supplies the PDA it is ________ dominance

Right

When the LCX gives rise to the PDA it is ______ dominance

Left

Both RCA and LCX gives rise to the PDA____% Of the time

20% co dominant

Troponin is an early marker of cardiac cell damage. Elevates ____ to ____ hours after an MI.


Peaks within ____ to ____ hours.


Falls >____ days

3-6


10-24


7

Aspartate transaminase (AST) Elevates in ____ to ____ house.


Peaks ___ to ____ hours


Falls ___ to ___ days

8-12


24-48


3-5

Aspartate transaminase (AST) Elevates in ____ to ____ house.


Peaks ___ to ____ hours


Falls ___ to ___ days

8-12


24-48


3-5

Lactic (Lactate) Dehydrogenase (LDH) gives a longer period of time is cardiac enzymes were missed. Elevates in ___ to ___ hours


Peaks in ___ to ___ hours


Falls ___ to ___ days

24-48


48-72


7-14

What happens during a follow up for an MI

Look for stunned myocardium


Observe WMA


Observe other MI related complications short and long term

Describe each week after an MI:


Week 1:


Week 2:


Week 3-4:

Week 1: inflammation stage increase in WBC


Week 2: clean up stage cleans out tissue debris


Week 3-4: healing phase, scarring forms

This disease consists of areas of akinesis and thinned myocardium. Also RV could be functioning and looking normal.


-MR may be present


-Creates elevated PA pressures

Ischemia Heart Disease

Characteristics of DCM

Imore gloabal RWMA


Both LV and RV are DILATED


Hypokinetic


Moderate to severe TR


Elevated PA pressures

Lifestyle changes for CAD

SMOKING


HTN


HIGH LDL


DIABETES


OBESITY


SEDENRARY


STRESS

Lifestyle changes for CAD

SMOKING


HTN


HIGH LDL


DIABETES


OBESITY


SEDENRARY


STRESS

Things you cannot control for CAD

AGE


FAMILY HISTORY


MALE


POST-Menapausal

Lifestyle changes for CAD

SMOKING


HTN


HIGH LDL


DIABETES


OBESITY


SEDENRARY


STRESS

Things you cannot control for CAD

AGE


FAMILY HISTORY


MALE


POST-Menapausal

What are the warning signs of a heart attack?

CP


PAIN IN UPPER BODY (Arms neck jaw back stomach)


SOB


Nausea


Anxiety


Lightheadedness

Fact: among people with coronary atherosclerosis who suffer and acute MI 50% will die within one hour

Blank

Fact: among people with coronary atherosclerosis who suffer and acute MI 50% will die within one hour

Blank

Fact: of those who survive and have a diagnosis of MI 50% will have uncomplicated Hosp. Stay and 50% will experience complications

Blank

When an infarct expands the volume does not increase but the region stretches and thins causing an outward bulging of the area during SYSTOLE known as dyskinesis

Not a good prognosis

A Ture aneurysm is lined by _______ and has no ______

Myocardium, neck

True aneurysms are only found in __________ MI

Transmural

A pseudoaneurysm is contained by the ___________due to a ventricular rupture. Has a ______

Pericardium, neck

A pseudoaneurysm is contained by the ___________due to a ventricular rupture. Has a ______

Pericardium, neck

Pseudoaneurysm S see only found in ___________ MI

Transmural

Cardiac ruptures are very likely with pseudoaneurysms and tend to occur within the first ________

Week

This is a common response to having an acute MI:

Pericaardial effusion

What is the biggest indicator for healing after an MI?

How good the LV is functioning

EKG consist of ______ wires and ______ leads

10,12

Papillary muscle rupture creates rocking or flail at valve site


**80% posteromedial


**20% anterolateral

What are the 6 chest leada?

V1,V2,V3,V4,V5,V6

What is another name for the bipolar leads on an EKG?

Limb leads

What are the three bipolar leads?

1,2,3

What is another name for unipolar leads on an EKG?

Augmented limb leads (hence the a)

What are the three augmented or unipolar limb leads?

aVR, aVL, aVF

Order of EKG wave form:

P wave


PR


QRS


ST


T


T TO P

Name three types of pseudoaneurysm

Free wall


Ventricular septal


Papillary muscle

Interpreting EGK: ST segment depression and any lead but a VR means



ISCHEMIA


SUBENDOCARDIAL INFARCT

BLANK

Interperetinf EKG: an ST segment elevation any lead but aVR indicates



ACUTE MI


PERICARDITIS


TAMPONADE


CARDIAC CONTUSION

BLANK

Interpreting EKG: significant Q waves any lead but aVR represents an old MI or an MI. **1mm wide (.04 sec) and at least 1/3 the height of QRS

**know stars

Normal finding on EKG:


-T wave in V2-V6 upright


Abnormal finfing:


-flattened T wave means ischemia


-inberted T wave means ichemia


T wave:


Upright= normal


Flattened= ischemia


Inverted=ischemia

Anterior infarct will show on leads____ ______

V3, V4

Lateral infarct will show on leads ____ ____ _____ _____

V5, V6, 1, aVL

Inferior infarct will show on leads ___ ___ ____

2, 3, aVF

Septal infarct will appear on leads ___ ____

V1, V2

RV infarct will show on leads :

V4R

A free wall rupture causes pressure buildup causing cardiac tamponade (an irregular way of beating due to pressure)


**85% of cases


**look for effusion


** Only in transmural MI

Know the stars**

A ventricular septal rupture can lead to a shunt VSD


- new loud harsh systolic murmur


-bad prognosis


-50% mortality

Blank

Papillary muscle rupture creates rocking or flail at valve site


**80% posteromedial


**20% anterolateral

Clots form in areas where:

Dilated areas


Areas with WMA

Define "smoke"

"smoke" means spontaneous echo contrast and represents blood pooling and stagnation

Types of thrombus:

**Predunculated: finger like and protrudes into LV and moves around


Mural: adheres to the ENDOcardium and creates areas that are dense and thickened


Hyper eosinophilia: common in apex not related to MI

** Dressler's syndrome is a syndrome that occurs post MI WEEKS TO MONTHS LATER. Symptoms include:

Chest pain


Low grade fever


Friction rub


PE

Cariogenic shock consists of the loss of at least 40% of LV mass and may lead to death. People have abnormal CO

Blank