ASHD/ACS

Question 1

Who gets heart attacks?

Answer 1

Males, overweight, central obesity, sedentary, smoker

Question 2

ASHD

ACS

Answer 2

Arteriosclerotic heart disease (ASHD)

Acute coronary syndrome (ACS)

Question 3

Risk Factors for CAD (coronary artery disease)

EXAM

Answer 3

• Positive family history (the younger the onset in a first-degree relative, the greater the risk)
• Male sex
• Diabetes mellitus
• Hypertension
• Physical inactivity
• Abdominal obesity
• Cigarette smoking
• Psychosocial factors
• Diet
• **Hypercholesterolemia is an important modifiable risk factor for coronary heart disease
• *Metabolic syndrome

Question 4

Metabolic Syndrome

Answer 4

Constellation of three or more of the following: abdominal obesity, triglycerides 150 mg/dL or higher, HDL cholesterol less than 40 mg/dL for men and less than 50 mg/dL for women, fasting glucose 110 mg/dL or higher, and hypertension

Question 5

Atherosclerotic plaques may rupture, what are factors that increase plaque vulnerability?

Answer 5

• Higher lipid content
• Higher concentration of macrophages
• Very thin fibrous cap

Question 6

Precipitants to plaque rupture include:

Answer 6

include exercise, eating, cold weather, and emotional stress

Question 7

Myocardial ischemia can be symptomatic, causing _____; others are completely silent

Answer 7

angina pectoris

Question 8

Myocardial hibernation (describe)

Answer 8

• Chronic
• Areas of myocardium that are persistently underperfused but still viable may develop sustained contractile dysfunction
• Reversible following coronary revascularization

Question 9

Myocardial stunning (describe)

Answer 9

• Acute
• Persistent contractile dysfunction following prolonged or repetitive episodes of myocardial ischemia
• Often seen after reperfusion of acute myocardial infarction and is defined with improvement following revascularization
• Sends blood to other parts of heart to keep you alive- reversible

Question 10

Circumstances that precipitate and relieve angina

Answer 10

rest and nitro usually relieve stable angina; exacerbated by exertion

Question 11

Characteristics of the discomfort

Answer 11

“true” chest pain presents as substernal pain, crushing, tightness, squeezing, epigastric pain (inferior wall MI, posterior wall), may radiate to jaw or left arm or back (may never radiate)

Question 12

Duration of attacks

Answer 12

if lasting for 30 seconds and goes away, probably not angina; if it last between 5-30 mins, probably angina chest pain; if lasting about 4 months- not angina

Question 13

Associated symptoms

Answer 13

nausea, diaphoresis, SOB, impending sense of doom, palpitations

Question 14

Physical signs of angina pectoris

Answer 14

1. Significant elevation in systolic and diastolic BP
2. Hypotension may also occur, and may reflect more severe ischemia or inferior ischemia (especially with bradycardia) due to a Bezold-Jarisch reflex
3. Gallop rhythm and an apical systolic murmur due to transient mitral regurgitation from papillary muscle dysfunction are present during pain only
4. Supraventricular or ventricular arrhythmias may be present

Question 15

Never give nitro for

Answer 15

posterior wall MI (decreases preload, BP drops so low you die, cardiogenic shock gets worse)

Question 16

Labs

Answer 16

Standard laboratory tests to evaluate for acute coronary syndrome (troponin and CK-MB)

If you catch MI in first few hours, Troponin wont be elevated
EKG may even be normal

Use MYOGLOBIN for acute phase (will be greater than 900 with acute MI)

Question 17

EKG changes

Answer 17

• Often normal in pts w/ angina
• Old myocardial infarction, nonspecific ST–T changes, and changes of LVH
• Horizontal or downsloping ST-segment depression that reverses after the ischemia disappears, T wave flattening or inversion
• Transient ST-segment elevation

Question 18

Anterior leads are

Answer 18

V1-V4

Question 19

Lateral leads are

Answer 19

V5, V6

Question 20

Inferior leads are

Answer 20

V2, V3, aVF (will see reciprocal depressions here)

Question 21

Pretest probability factors

Answer 21

• History & Physical
• Laboratory and ECG
• Age
• Sex
• Patients with low to intermediate pretest probability for CAD should undergo noninvasive stress testing whereas patients with high pretest probability are generally referred for cardiac catheterization***

Question 22

Healthy looking young person- his pretest probability is VERY low, so even if you get a positive stress, __________

Answer 22

it doesn’t mean anything (results won’t help with treatment/diagnosis)

Question 23

If pt has anginal symptoms you give nitro unless _____

Answer 23

posterior or inferior wall MI

Question 24

If you can’t give pt aspirin, instead use

Answer 24

Plavix or clopidogrel

Question 25

TIMI risk score

Answer 25

Each is worth 1 point: - Age of 60 or older - 3 or more risk factors (HTN, family hx, DM, high cholesterol, smoker) - Known CAD (stenosis of 50% or more) - Aspirin use in past 7 days (presentation: ) - Recent severe angina (w/ in 24 hrs) - Increased cardiac markers - ST deviation of 0.5mm or more

Question 26

TIMI risk score, scoring:

Answer 26

Total 0-7 points TIMI of 7: go to cath lab TIMI of 0: go home TIMI in between: not sure if pt is high or low risk, STRESS TEST (point of this is to risk stratify people)

Question 27

Precautions and risks of exercise stress tests

Answer 27

- Risk of exercise testing is about one infarction or death per 1000 tests - Individuals who have pain at rest or minimal activity are at higher risk and should not be tested - Patient must be stable and ambulatory

Question 28

Indications to perform exercise stress test

Answer 28

- To confirm the diagnosis of angina - To determine the severity of limitation of activity due to angina - To assess prognosis in patients with known coronary disease - To evaluate responses to therapy

Question 29

Positive stress test is

Answer 29

``` 1 mm (0.1 mV) horizontal or downsloping ST-segment depression (beyond baseline) measured 80 msec after the J point (examples of abnormal EKGs on slides 18 & 19) ```

Question 30

Myocardial Stress Imaging helps to:

Answer 30

- confirm the results of the EKG (if they are different than clinical s/s) - to localize the region of ischemia - determine ischemia from infarction - assess amount of revascularization after bypass or angioplasty - Prognostic indicator in patients with known CAD

Question 31

Myocardial perfusion scintigraphy (radionuclide imaging)

Answer 31

- Scintigraphic defects indicate a zone of hypoperfusion that may represent either ischemia or scar - If the myocardium is viable, as relative blood flow equalizes over time or during a scintigram performed under resting conditions, these defects tend to "fill in" or reverse, indicating reversible ischemia

Question 32

To get coronaries to stress, agent used is ________

Answer 32

Adenosine at lower doses | regadenosine is isomer that is usually used; vasodilates coronary vessels

Question 33

During Myocardial perfusion scintigraphy, if rest and stress are same; both missing, this indicates If rest is fills in and stress it doesn’t fill in, this indicates

Answer 33

irreversible damage REVERSIBLE ISCHEMIA

Question 34

Radionuclide angiography (Multi Gated Acquisition Scan, or MUGA scan) U\uses radionuclide tracers to image _________

Answer 34

the LV and measures its EF and wall motion The test is also used for monitoring patients exposed to cardiotoxic therapies (such as chemotherapeutic agents)

Question 35

During MUGA scan- In coronary disease, resting abnormalities usually represent _______, and those that occur only with exercise usually indicate ______

Answer 35

infarction stress-induced ischemia

Question 36

Stress echocardiography: | Echocardiograms performed during supine exercise or immediately following upright exercise may demonstrate

Answer 36

exercise-induced segmental wall motion abnormalities as an indicator of ischemia (High-dose dobutamine can be used as an alternative)

Question 37

Positron emission tomography Can accurately distinguish

Answer 37

transiently dysfunctional (“stunned”) myocardium from scar tissue

Question 38

CT scanning has high sensitivity for excluding

Answer 38

significant CAD | -good for quantifying coronary artery calcification

Question 39

Cardiac MRI is excellent for assessing

Answer 39

pericardial disease, neoplastic disease of the heart, myocardial thickness, chamber size, and many congenital heart defects

Question 40

Who gets coronary angiogram in cath lab?

Answer 40

- Patients with life-limiting stable angina despite an adequate medical regime - Clinical S/S of unstable angina, postinfarction angina, or high risk disease - Concomitant aortic valve disease and angina pectoris - Asymptomatic older patients undergoing valve surgery - Recurrence of symptoms after coronary revascularization to determine if there are occlusions - more on slide 30

Question 41

_____ can induce myocardial ischemia and infarction by causing coronary artery vasoconstriction or by increasing myocardial energy requirements and contribute to accelerated atherosclerosis and thrombosis

Answer 41

Cocaine

Question 42

Ischemia in Prinzmetal (variant) angina usually results from _______

Answer 42

coronary vasoconstriction

Question 43

Patients with chest pain associated with ST-segment elevation should undergo __________

Answer 43

coronary arteriography

Question 44

If significant lesions are not seen and coronary vasospasm is suspected, avoid ______

Answer 44

precipitants, such as cigarette smoking and cocaine -Treat with nitrates and calcium channel blockers

Question 45

People on cocaine don't get beta blockers because of

Answer 45

unopposed alphas, very dangerous

Question 46

Unstable angina (UA) S/S:

Answer 46

Change in nature of pain Change in response to meds -give aspirin

Question 47

NSTEMI

Answer 47

- Cardiac enzyme elevation - Can have EKG changes, however not ST segment elevation - give aspirin

Question 48

STEMI S/S

Answer 48

Sudden but not instantaneous development of prolonged (more than 30 minutes) anterior chest discomfort (sometimes felt as “gas” or pressure). Sometimes painless, masquerading as acute heart failure, syncope, stroke, or shock.

Question 49

STEMI on EKG

Answer 49

ST-segment elevation or left bundle branch block | -must be NEW LBBB (MUST compare to old EKG)

Question 50

If you’re within (less than) _____ of a hospital (NEED to get to cath lab), if nothing is around can go to nearest hospital to get _____

Answer 50

45 mins TPA (fibrinolytic therapy)

Question 51

Complications of MI

Answer 51

``` Postinfarction ischemia Arrhythmias Acute LV failure RV infarction Mechanical defects Myocardial rupture ```