Term
| defin coronary artery disease |
|
Definition
| narrowing of coronary arteries (vessels supplying heart)due to fatty streaks in coronary lumen in adolesence that progress to plaques |
|
|
Term
| non-modifable risk factors for coronary artery disease |
|
Definition
family history: mom <65, dad <55
male gender
age
lipid/HTN/DM disorders |
|
|
Term
| modifiable risk factors for coronary artery disease |
|
Definition
smoking (males x3, female x6)
LDL - primary target for prevention
HTN
obesity BMI >35
diet poor in fish, fiber, fruit
sedentary <20min/d
alcohol: >2/d in males 1/d in female
psychosocial: stress, anger, depression
DM/dyslipidemia/HTN |
|
|
Term
| symptoms of coronary artery disease |
|
Definition
CP radiating to neck, jaw, left shoulder, abdomen
SOB, dyspnea, exercise intolerance
syncope, fatugue, diaphoresis
elevated BP, tachypenia, tachycardia
pale
new murmur (ruptured cordae tendenae)
may be asymptomatic |
|
|
Term
| symptoms of coronary artery disease in diabetic |
|
Definition
| may not be able to feel heart attack due to diabetic neuropathy |
|
|
Term
| symptoms of coronary artery disease in women |
|
Definition
|
|
Term
| what are the 3 tx goals in reducing risk for CAD |
|
Definition
LDL <70%
BP <120/80
HBA1C <&% |
|
|
Term
|
Definition
aspirin 81mg/d
copidogerl, BB, ACEI, Nitro
statins*in some |
|
|
Term
| when sould someone with CAD get a statin |
|
Definition
LDL >190mg/dL
diabetic 40-74yo |
|
|
Term
| what therapies, not meds, can be done for CAD |
|
Definition
oxygen: in acute event
invasive: angioplasty, PCI, stent
coronary bypass grafting: with left main disease or diffuse disease |
|
|
Term
| what is the difference between acute, subacute, and chronic pericarditis |
|
Definition
acute <6wk: fibrous, sanginous or bloody effusion
subacute 6wk-6mo: constrictive, effusion
chronic >6mo: constrictive, effusions, adhesive (sticks to itself) |
|
|
Term
| 3 drugs that can cause pericarditis |
|
Definition
|
|
Term
| signs of acute pericarditis |
|
Definition
mostly young adults
10-12d after URI
remits and relapses in 25%
precordial chest pain
pericardial friction rub |
|
|
Term
| what is precordial chest pain |
|
Definition
back and left trap ridge severe retrosternal, left precordal
relieved by sitting and leaning forward
intensified by laying down |
|
|
Term
| pericardial friction rub: how is it best listened to, whn |
|
Definition
pre-systole, systole, early-diastole
best in expiration |
|
|
Term
| lab changes in pericarditis |
|
Definition
| increased WBC, ESR, CPK, Ldh, AST, CRP |
|
|
Term
| EKG changes in acute pericarditis, why |
|
Definition
| widspread elevation of ST segment due to subepicardial inflammation |
|
|
Term
| EKG changes in late pericarditis, why |
|
Definition
| ST normal --> T inversion --> PR depressio (depressed PR reflects atria involvement) |
|
|
Term
|
Definition
antinflammatory (aspirin), if not responsive use NSAID or prednisone (RO TB)
cochicine may prevent reoccurrance |
|
|
Term
| what should never be given in pericarditis and why |
|
Definition
| anticoagulants: can turn serosangious effusion into bloody pericardial effusion |
|
|
Term
| define pericardial effusion, what are some causes |
|
Definition
abnormal fluid between visceral and parietal pericardium
pericarditis, post MI, aortic dissection, CHF
malignancy, trauma, autoimmune, hypothyroidism (myexedema), TB, uremia |
|
|
Term
| what are the two types of pericardial effusion and their primary symptom |
|
Definition
quick development: cardiac tamponade (200mL min)
chronic development: asymptomatic (2000ml max) |
|
|
Term
| explain what tamponade does to the heart and EKG in acute pericardial effusion, why |
|
Definition
concaving of atria and ventricles so they cannot pump equalizing chamber pressures
causes electrical alterans: alternation of QRS amplitude or axis between beats, wandering baseline. due to heart swinging freely in pericardium |
|
|
Term
| signs of acute pericardial effusion |
|
Definition
SOB
decreased exercise tolerance
CP
cough
orthopnea
fatigue
hypotension
muffled distant heart sounds
jV distention
paradoxical pulse |
|
|
Term
|
Definition
| hypotension, muffled distent heart sounds and JV distention in pericardial effusions |
|
|
Term
| explain what a paradoxical pulse is |
|
Definition
>10mmHg rise in inspiratory systolice pressure deline
inspiratory enlargement of RV compresses LV |
|
|
Term
| acute pericardial effusion: CXR, ECHO, CT changes |
|
Definition
CXR: water bottle heart
ECHO: pericardial fluid, RV small, late diastolic collapse (tamopnade) |
|
|
Term
| tx of acute pericardial effusion |
|
Definition
hospitalize for large effusions
pericardiocentesis |
|
|
Term
| signs of chronic pericardial effusion |
|
Definition
gradual dyspnea and fatigue
abdominal swelling, hepatomeagly, acetes, peripherial edema
pericardial knock (after S2 in diastole)
tachycardia
large heart silhouette
kussmaul's sign |
|
|
Term
|
Definition
| JV distention increases on inspiration |
|
|
Term
| explain the pathology behind chronic pericardial effusion |
|
Definition
| healing followed by chronic effusions form granulation tissue that contracts into scar and calcification inhibits ventricle filling, decreases CO, and increases BP |
|
|
Term
| chronic pericardial effusion: CXR, ECHO, cath signs |
|
Definition
EXR: calcifications on pericardial rim
ECHO: thick pericardium, halt in ventricle diastole filling
Cath: equilization of diastolic pressures in all chambers |
|
|
Term
| tx of chronic pericardial effusion |
|
Definition
| surfical stripping of pericardium: improvement over several months |
|
|
Term
| what is the most common primary pericardial tumor, signs, tx |
|
Definition
mesothelioma
develops bloody effusion
surgical exploration needed to diagnose and tx |
|
|
Term
| what is the gold standard for cardiac diagnosis, what are the down sides |
|
Definition
| coronary angiography: invasive, high cost, unable to provide functional cardiac info |
|
|
Term
| indications for cardiac stress testing |
|
Definition
chest pain: determine MI cause, atypical cardiac sound, angina suggestion, acute
follow up: recent MI, CAD event, high risk CAD, assess if meds working
diagnosis: arrhythmia, sedentary men >45 women >55 with demanding job, assess vascular disease, cardiomyopathy, before surgery and has risk factors |
|
|
Term
| what are the requirements of the paetient before a cardiac stress test |
|
Definition
able to exercise
body habitus
recent EKG
clinical indication
prior history of revascularization |
|
|
Term
| what are the contraindications to stress testing |
|
Definition
acute Mi <2d
unstable angina
uncontrolled arrhythmia or CHF
acute aortic stenosis or dissection
pulmonary or systemic embolism
myocarditis, pericarditis, endocarditis
HTN >200/110 |
|
|
Term
| when should you stop a cardiac stress est |
|
Definition
>10mmHg drop in systole (poor perfusion)
moderate - severe angina
ataxia, dizziness, syncope
desire to stop
sustained Vtach ST elevation
BP >150/115 |
|
|
Term
| explain how a non-perfusion imaging stress test is done |
|
Definition
| bruce protocol: 2 min stages of increasing speed and incline, monitor BP HR EKG |
|
|
Term
| what is the best type of stress test in women, why |
|
Definition
| with perfusion imaging, they have more false positives due to brease attenuation |
|
|
Term
| how does someone "pass" their stress test |
|
Definition
>85% max HR (220-age) without any ST changes, CP, arrhythmia
(some BP increase and unsloping ST depression are normal) |
|
|
Term
| indications and contraindications for adenosine stress test |
|
Definition
unable to ambulate
AV block, sick sinus, bronchospasm, COPD, unstable CAD, caffiene, throphyline |
|
|
Term
| explain how a adenosine stress test is done |
|
Definition
pt lays down
4-6min infusion of adenosine followed by nuclear scan
dilates arteries and parts with plaque will not dilate
pt should show increase in flow post test |
|
|
Term
| explain how a dobutamine stress test is done |
|
Definition
pt lays down
influse and it elevated HR
take nuclear scan
ECHO: looks for wall motion |
|
|
Term
| SE and contraindications of dobutamine stress test |
|
Definition
arrhythmia SE
aortic aneurysm, IHSS, arrhythmi hx, uncontrolled HTN |
|
|
Term
| explain how nuclear imaging of the heart is graded |
|
Definition
1. normal: coronary and axial images fully perfused at rest and stress
2. fixed deficit: area of myocardium is not perfusing at stress and rest (scar or muscle damage)
3. reversible deficit: resting is normal but stressed shows decreased perfusion (blockage) |
|
|
Term
| what is a balanced ischemia |
|
Definition
| >70% lesion in 3 coronary arteries shows normal in testing (usually in diabetic) |
|
|
Term
| what are the indications for cardiac cath |
|
Definition
assess coronary anatomy
confirm left valve dysfunction before surgery
unstable angina
non-ST elevation MI
primary intervention for STEMI
recurrent ischemia after MI
CHF
hemodynamic instability after MI
abnormal stress test
assessment of left valve dysfunction |
|
|
Term
| 4 contraindications for cardiac cath |
|
Definition
pregnancy
severe renal dysfunction
untreated bleeding disorder
allergy to iodine |
|
|
Term
| 4 areas for cardiac cath insertion and their bad/good sides |
|
Definition
femoral: most common, need 4-6h bed rest after
radial: arterial spasm, needs anticoagulation
brachial: most common site for acute thrombosis
axial: avoid median nerve injury, better for compression of artery against humerus |
|
|
Term
| explain the correlation of the degree of stint and risk of injury |
|
Definition
50% could cause MI
it usually does not correlate with risk to patient |
|
|
Term
| when should you stint, what stint should you use, why |
|
Definition
all angioplasty should be followed with stent if able
drug eliminating stents in short term show lower stensois rates that bare stents. they can cause late in-stent thrombosis years later but this is usually due to pt not taking their clopidogerel. so overall drug eluting > bare |
|
|
Term
| risk factors for in stint thrombosis |
|
Definition
advanced age
acute coronary syndrome
diabetes
low EF
prior brachytherapy
renal failure
long stent
multiple lesions
overlaping stents
ostial or bifurcating lesions
small vessels
suboptimal stent results |
|
|
Term
| complications of catheterization |
|
Definition
arrhythmia
perforate myocardium
death
MI
stroke
femoral nerve compression
blue toe syndrome
contrast induced nephropathy
distal emboli
retroperitoneal or femoral hematoma
AV fistula
dissection of vessel
pseudoaneurysm
acute thrombosis |
|
|
Term
| cause and signs of blue toe syndrome |
|
Definition
days-weeks after cath atheroemboli go to...
kidney: eosinophilia in urine, causes failure in 7d
toes: livido reticularis lacy rash on LE
eye: halenhorse plaques
cause hypocomplementemia |
|
|
Term
| how is contrast induced nephropathy caused, how is it diagnosed |
|
Definition
CHF, low volume, multiple myeloma, too much contrast, not hydrated causes renal failure due to effect of contrast
increase in 0.2 CR is norma, 1 increase diagnoses but will recover in 3-5d, 1.5 increase is at risk of failure |
|
|
Term
| 3 complications probablly caused by arterial pucture closing device rather than manual compression |
|
Definition
retroperitoneal or femoral hematoma (seen with in 12h)
pseudoaneurysm: pulsatile mass, systolic bruit (days-wks later)
acute thrombosis: loss of pulse distally, usually in brachial artery approach |
|
|
Term
|
Definition
| acute coronary syndrome: unstable angina, non-ST elevation MI, acute MI |
|
|
Term
|
Definition
| reproducible CP on exertion relieved by 5-10min rest or nitro w/o change in frequency or intensity |
|
|
Term
|
Definition
| CP at rest, severe or new onset, or crescendo |
|
|
Term
| causes of non-ST elevating MI |
|
Definition
reduced O2 supply or increased demand...
plaque rupture - COMMON
dynamic obstruction: prinzmetal
progressive mechanical obstruction
unstable angina due to exercise, anemia, Afib, tachy, sepsis |
|
|
Term
| where is the culpret lesion most common from most to least in non-ST elevation MI |
|
Definition
single vessel
two vessel
three vessel
no apparent (microcirculation)
left main stenosis |
|
|
Term
| signs of non-ST elevation MI |
|
Definition
| CP: substernal/epigastric, radiates to neck, left shoulder, arm |
|
|
Term
| what are angina equlivants |
|
Definition
usually in women
dyspnea, diaphoretic, pale, cool, sinus tachycardia, S3, S4, rales, hypotension |
|
|
Term
| EKG changes in non-ST elevation MI |
|
Definition
ST depression by 0.05mv
T waver incersion - less specific |
|
|
Term
| what are the CPK isoenzymes, when do they show up, peak, and go away |
|
Definition
MM skeletal muscle
MB cardiac muscle
BB brain
rise 3-8h
peak 9-30h
normal 1-3d |
|
|
Term
| what is the most specific marker for MI damage, what does it tell us |
|
Definition
troponin I
degree of elevation correlates with degree of damage |
|
|
Term
| what is the first cardiac enzyme to rise |
|
Definition
|
|
Term
| troponin I: appearance, peak, normal timeline, false positive conditions |
|
Definition
rise 2-6h
peak 10-24h
normal 7-10d
renal dysfunction, CHF, myocarditis, PE, tachycardia, spesis, anemia |
|
|
Term
| what are the risk factors for non-ST elevation MI |
|
Definition
>60yo
3+ risk factors for CAD
50% known stenosis
ST changes over 0.05mv
2+ episodes angina in 24h
aspirin with 7d
elevated cardiac enzymes |
|
|
Term
| what are the tx for non-ST elevation MI and when to use each |
|
Definition
oxygen, blood work, bed rest 24h, EKG monitoring
nitrates: DOC unless slidenafil or hypotension
BB: except with CHF
CCB: if BB contraindicated
ACEI
statin: early administration
morphine: for comfort
anthrombotics |
|
|
Term
| what are the 4 anti thrombotics and when to use |
|
Definition
aspirin non enteric: maintience
clopidogrel: aspirin intolerent
prasurgel: rapid onset, more bleeding
ticagrelor |
|
|
Term
| why would you do invasive PCI in non-ST elevation MI |
|
Definition
recurrent symptoms despite tx
CHF with <40% EF
elevated troponin lots
new ST depression
abnormal stress test
history of CABG or high risk TIMI
vtach
hypotension
shock
PIC <6mo prior |
|
|
Term
| what is the early invasive PCI non-ST elevation MI strategy (pre and post care) |
|
Definition
strat with antithrombotic: aspirin, clopidogrel loading dose, LMW or unfractioned heparin, factor X inhibitor, bivalirudin, GPIIb/IIIa inhibitor
do procedure
after: DC anticoagulation(continue for 48h if placed a stent), continue aspirin high dose for 3mo without stent or 6mo with stent then 81mg/d indefinetly
if choosing clopidogrel or parasurgel just use for 1y after DC anticoagulation stent or not |
|
|
Term
| exolain the conservitive invasive PCI strategy for non-ST elevation MI |
|
Definition
pre treatment: start high dose aspirin, anticoag therapy, or heparin. consider GP IIb/IIIa inhibitor if worsens
if stable for 48h do low level stress test
if positive stress test, EF <40%, arrhythmia, recurrent symptoms do cath
if stress test negative: continue aspirin 81mg indefenetly or clopidogrel 1y |
|
|
Term
| who are the most common patients with non-ST elevation MI that are untreated 3 |
|
Definition
|
|
Term
| explain the pathology of a STEMI |
|
Definition
abrupt decrease in blood flow due to rupture of vulnerable plaque and resulting thrombus
coronary artery with lipid rich lesion in thin fibrous cap are prone to rupture and STEMI |
|
|
Term
|
Definition
percipitated by exercise, stress, illness
pain: heavy, squeeze, crush
diaphoresis, SOB, radiation to neck, left shoulder, arm, nausea, vomiting, weakness, anxiety
often within a few hours of waking |
|
|
Term
| 3 criteria of EKG for STEMI |
|
Definition
new ST elevationin 2 contigous leads equal to or greater than 0.1mV (1mm)
new LBBB
true posterior wall MI |
|
|
Term
| basic management for STEM (before cath/thrombolytic) |
|
Definition
cardiac monitor
oxygen
fluids
nitro
aspirin high dose
blood work
CXR
BB in first 24h
morphine |
|
|
Term
| when are BB contraindicated in STEMI, when should it be IV |
|
Definition
CHF
bradycardia
hypotension
2 deg+ heart block
IV when hypertensive |
|
|
Term
| what should you never use in a STEMI |
|
Definition
|
|
Term
| when should you cath in stemi? |
|
Definition
>15min <24h symptoms
sign of shock or ChF
cath lab is available within 90 min of EMS arrival |
|
|
Term
| when should you not cath a stemi? Now what? |
|
Definition
cath lab isnt open within 90 min of EMS arrival
administer thrombolytic within 30 min of EMS arrival |
|
|
Term
| absolute contraindications of thrombolytic |
|
Definition
HX CNS bleed, vascular lesion, tumor, stroke within 3mo
aortic dissection
active bleeding
head trauma in last 3mo |
|
|
Term
| relative contraindications of thrombolytic |
|
Definition
BP >180/110!!!!
CPR >10 min
surgery within 3wk
bleeding within 4wk
prgnancy
given thrombolytic within 5d
active peptic ulcer
on anticoagulants |
|
|
Term
| after giving thrombolytic what is the acceptable time frame for changes in pain and EKG |
|
Definition
| pain should resolve fast, ST elevations should decrease >50% within 90 min |
|
|
Term
|
Definition
| perusion arrhthythmia: PVC, non-sustained VTach |
|
|
Term
| when do you do a facilitated PCI |
|
Definition
administer of thrombolytics with immediate transfer to cath
not able to get cath within 90 min
pregnant and has low bleeding risk
ONLY USE PARTIAL DOSE OF THROMBOLYTICS |
|
|
Term
| ok so they have a stemi and you decide to take them to cath. what is the prep steps |
|
Definition
clopidogrel, parsugrel, or ticgrelor
IV heparin bolus then maintence
bivalirudin
GP IIb/IIIa inhibitor |
|
|
Term
| the stemi pt just left cath. what are their orders for their hospital stay and within the next 24h |
|
Definition
hospital: statin, ACEI, stop IV heparin if uncomplicated, continue clopidogrel, continue aspirin
24h: continue clopidogrel/aspirin, ACEI |
|
|
Term
| now you just gave your pt a thrombolytic for a stemi. what are the orders for the hopsital stay and the next 24h |
|
Definition
hospital: statin, ACEI, aspirin
24h: BB, ACEI if low EF or anterior wall Mi, aspirin |
|
|
Term
| you gave you pr a thrombolytic for a stemi. what are some indications you need to take them to the cath lab anyways |
|
Definition
EF <40%
recurrent ischemia or persistent EKG findings suggesting MI
hemodynamically unstable
CHF
heart murmur which occurs in 24h or 3-5d later
low level stress test 5-7d from MI bad
chemical stress test 507d from MI bad |
|
|
Term
| what are somme complications of a STEMI |
|
Definition
rupture of ventricle free wall
rupture of intraventricular septum
papillary muscle rupture |
|
|
Term
| who has a high incidence of rupture of ventricular wall with STEMI, when does it occur |
|
Definition
no hx MI or angina
ST elevation on initial EKG
CPK0MB >150
anterior wall MI
>70yo
within 2wk |
|
|
Term
| signs of rupture of ventricle wall |
|
Definition
acute right sided failure
shock
pulseless electrical activity |
|
|
Term
| signs of rupture of intraventricular septum |
|
Definition
left and right sided heart failure
loud holosystolic murmur
hypotension |
|
|
Term
| who is is at risk for rupture of intraventricular septum, when |
|
Definition
2-5d after MI
ST elevation was >72h |
|
|
Term
| sign of papillary muscle rupture after Mi |
|
Definition
hypotension
pulmonary edema
widespread holosystolic murmur |
|
|
