IPT: Cardio > Block 4 > Flashcards

Block 4 Flashcards

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1
Q

What factors contribute to decreased supply of oxygen to myocardium?

A

Coronary vasospasms

Atherosclerotic plaque

Anemia

Increased HR

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2
Q

What factors contribute to increased demand of oxygen to myocardium?

A

Increased contractility

Increased HR

Intramyocardial wall tension

Increased BP

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3
Q

What is the spectrum of IHD?

A

SIDH (stable)

USA (unstable)

MI (infarction)

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4
Q

What are the main left coronary arteries and where do they supply blood to?

A

Left anterior descending coronary artery (LAD) - front left heart chambers

Circumflex - outer side and back of left heart chambers

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5
Q

What are the main right coronary arteries and where do they supply blood to?

A

Both Right posterior descending and acute marginal - Right ventricle and atrium, SA + AV nodes

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6
Q

What is ischemic heart disease?

A

Imbalance between myocardial oxygen supply and demand -> myocardial hypoxia

Synonymous w/ coronary artery disease

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7
Q

What is angina pectoris?

A

Due to myocardial ischemia

Typical pain in chest, jaw, shoulder, back, or arm

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8
Q

Chronic Stable Angina
Unstable Angina
Prinzmetal’s Angina

Which one is not typically relieved by nitroglycerin?

A

Unstable Angina

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9
Q

Chronic Stable Angina
Unstable Angina
Prinzmetal’s Angina

Which one is often occurs in young patients w/ few to no cardiac risk factors?

A

Prinzmetal’s Angina

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10
Q

Chronic Stable Angina
Unstable Angina
Prinzmetal’s Angina

Which one is caused by pain upon exertion or emotional stress?

A

Chronic stable Angina

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11
Q

Chronic Stable Angina
Unstable Angina
Prinzmetal’s Angina

Which one is relieved by nitroglycerin and rest?

A

Chronic stable Angina

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12
Q

Chronic Stable Angina
Unstable Angina
Prinzmetal’s Angina

Which one is caused by unprovoked coronary artery spasms?

A

Prinzmetal’s Angina

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13
Q

Chronic Stable Angina
Unstable Angina
Prinzmetal’s Angina

Which one often increases in frequency/severity over weeks?

A

Unstable Angina

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14
Q

Chronic Stable Angina
Unstable Angina
Prinzmetal’s Angina

Which one has unpredictable development of chest pain at rest or during minal exertion?

A

Unstable Angina

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15
Q

What is myocardial infarction?

A

Region of myocardial necrosis due to prolonged cessation of blood supply

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16
Q

Low vs Medium and High risk ACS, whats the cutoff?

A

<70yrs old + pain lasting <20 mins

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17
Q

Who should not be evaluated using pooled cohort equation?

A

Anyone with history of acute coronary syndrome

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18
Q

Stress test types in SIHD?

A

Exercise (preferred) and pharmacologic

Pharmacologic is used if they cant tolerate exercise test. Also can be used with EKG or radionucleotide imaging

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19
Q

When should you stop stress test in SIHD?

A

Hypotension or EKG changes consistent with IHD

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20
Q

What Tx for IHD are considered revascularization?

A

Percutaneous coronary intervention +/- stent

Coronary artery bypass grafting (CABG)

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21
Q

What Tx for IHD are reperfusion therapies?

A

Revascularization + Fibrinolytics

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22
Q

Traits of bare metal stent?

A

Made of metal

Older tech

Risk of restenosis ~ 25%

Endothelium coats stent in <3months

Requires at least 1 month of dual antiplatelet therapy

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23
Q

Traits of drug eluting stent?

A

Made of metal + antiproliferative drug (Everolimus or zotarolimus)

Risk of restenosis ~ 10%

Endothelium coats stent in 1 yr

Requires at least 3-6 months of dual antiplatelet therapy

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24
Q

Fibrinolytics are contraindicated in patients that had ischemic stroke within what time period?

A

3 months

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25
What is the loading dose of aspirin in ACS or prior PCI/CABG in SIDH?
162-325mg 75-100mg in dual antiplatelet therapy **No more than 100mg w/ Ticagrelor
26
What class of Rx make up the dual antiplatelet therapy?
Aspirin + P2Y12 antagonists
27
Clopidogrel brand, loading and maintenance dose?
Plavix 300-600mg PO 75mg PO daily
28
Prasugrel brand and loading and maintenance dose?
Effient 60mg PO 10mg PO daily
29
Ticagrelor brand and loading and maintenance dose?
Brilinta 180mg PO 90mg PO BID* 60mg PO BID after 1 yr
30
Any dose adjustments for the P2Y12 receptor antagonists?
Only for Prasugrel Wt <60kg consider 5mg daily
31
P2Y12 receptor antagonists, which ones are reversible, and which ones have higher degree of platelet inhibition?
Only Ticagrelor is reversible Both Prasugrel and Ticagrelor have higher degree of inhibition
32
P2Y12 receptor antagonists, time to peak action and metabolism?
Clopidogrel - 6 hrs Prasugrel - 30min Ticagrelor - 90min Only Ticagrelor ISN'T a prodrug, and is metabolized by CYP3A4
33
Any Rx interaction concerns with P2Y12 receptor antagonists?
Only for clopidogrel Avoid with omeprazole, esomeprazole, and fluoxetine
34
P2Y12 receptor antagonists bleeding risks?
All have them, but Prasugrel and Ticagrelor have a higher %
35
Contraindications of P2Y12 receptor antagonists??
All of them include active bleeding Prasugrel has additions of history on CVA or TIA
36
When should you d/c P2Y12 receptor antagonists prior to surgery?
All of them are 5 days prior except Prasugrel, which is 7
37
Which P2Y12 receptor antagonists have generics?
Only clopidogrel and prasugrel
38
Pearls of Clopidogrel?
25-30% of pt have a genetic polymorphism that causes reduced efficacy of this drug, there is a platelet reactivity test
39
Pearls of Prasugrel?
More beneficial vs clopidogrel if pt has diabetes or history of MI No benefit has been shown in pt ≥75yrs old or wt <60kg
40
Pearls of Ticagrelor?
Showed mortality benefit in PLATO trial vs clopidogrel
41
What is the IV P2Y12 receptor antagonist? How would you transition to an oral dosage form?
Cangrelor (Kengreal) Give loading dose immediately after d/cing infusion
42
Which IIb/IIIa inhibitor binding is reversible?
Eptifibatide and Tirofiban (NOT Abciximab) Only Abciximab can be reversed w/ platelet infusion
43
A positive result of a stress test for SIHD via exercise is when....
ST segment depression is evident Pt has arrhythmia Hypotensive or Chest pain
44
What Rx are administered for the pharmacologic stress test on SIHD?
Adenosine, dipyradamole, dobutamine
45
What should pt diet be on SIHD or ACS?
Saturated fat <7% total calories Cholesterol <200mg/day
46
Which Rx are indicated for all patients with CAD?
Beta blockers + Aspirin
47
Which BB should be used in CAD with HFrEF?
Bisoprolol Carvedilol Metoprolol succinate
48
How does nitrates affect preload/afterload?
Lowers preload
49
Nitrates are indicated for whom in CAD?
Pt w/ angina Symptomatic relief with NO effect on mortality
50
P2Y12 receptor antagonists are used only for (primary/secondary) prevention
Secondary
51
Are NSAIDs okay to take with CAD?
Nope
52
If there is a contraindication to using BB for CAD, what other Rx can you use?
Long-acting Nitrates or Non-DHP CCB
53
What RXs are you supposed to use prior to recieivng PCI w/ stent?
325mg Aspirin 24 hrs prior
54
What is the DAPT scoring chart?
- 2 if ≥75yrs - 1 if 65-74 0 if <65 If they smoke, have DM, MI, prior MI or PCI, stent diamter <3mm, of use paclitaxel-eluting stent = 1 point CHF, LVEF <30%, or vein graft PCI = 2 points ≥2 points = favorable for prolonged DAPT <2 points - unfavorable
55
EKG, what values are the atria and ventricles?
P-Q = Atria Right before Q to end of T = Ventricles
56
How do you identify the heart rate with R-R interval?
300/RR interval
57
Big square and little square standaridization..?
Little square = 0.04 sec or 0.1mV Big square (5 little squares) = 0.2 sec or 0.5mV
58
Explain the entire depolarization/repolarization phase of heart
Atrial depolarization (P wave) initiated via SA node Impulse is delayed via AV node Ventricular depolarization occurs (QRS complex) + Atrial repolarization occurs Ventricular depolarization is done and repolarization begins (T wave)
59
What are the P-R wave issues?
Short PR interval = Wolff-parkinsons-white syndrome Long PR interval = heart block
60
What is a U wave?
Prominent in hypokalemia and/or bradycardia Small bump after T wave
61
What is a J point?
End of QRS complex and start of ST segment
62
T wave inversion may indicate what?
Recent MI
63
What is the primary pacemaker?
SA node
64
EKG and A. Fib, how do the waves look like?
There is no P wave
65
HR, EKG, and A. Fib, what is the HR threshold?
>100 = rapid ventricular response <100 = controlled A. Fib AV node blocks most inappropraite impulses sent by atria in attempt to control HR
66
EKG and A. Flutter, how do the waves look like?
≥1 P waves per every QRS complex "Sawtooth appearance"
67
EKG and Wolff-Parkinson-White Syndrome, how do the waves look like?
There is a delta wave between P wave and QRS complex Delta wave = gradual positive slope Leads to supraventricular tachycardia
68
EKG and Premature Ventricular Complex, how do the waves look like?
Not P wave prior to QRS complex Wide QRS complex
69
EKG and Ventricular Fibrillation, how do the waves look like?
Cannot tell HR, literally looks like a squiggle.
70
What is Torsades de Pointes?
QT prolongation causing ventricular fibrillation Caused by Sotalol, Quinidine, Amiodarone, low potassium and magnesium, or even congenital
71
What is first degree heart block?
P wave is present AV node holds longer for each impulse Prolonged PR interval Asymptomatic
72
What is second degree heart block, Mobitze Type I?
Progressive lengthening of PR interval followed by a "drop" of QRS complex More common than type II Doesnt usually progress to third degree
73
What is second degree heart block, Mobitze Type II?
More P waves than QRS complex + intermittent block of AV node May progress to third degree
74
What is third degree heart block?
More P waves than QRS complex + complete block of AV node Atria and ventricles beat independently of each other Treated w/ pacemaker
75
What are the class IA antiarrhythmics?
Sodium channel blockers - moderate IA - qunidine and procainamide
76
What are the class IB antiarrhythmics?
Sodium channel blockers - weak IB - Lidocaine and Mexiletine
77
What are the class IC antiarrhythmics?
Sodium channel blockers - strong Flecainide and propafenone
78
What are the class II antiarrhythmics?
Beta blockers Propranaolol
79
What are the class III antiarrhythmics?
Potassium channel blockers Amiodarone Dofetilide Dronedarone Ibutilide Sotalol
80
Explain the myocardium contractile diagram
Depolarization (sodium in) - 0 Partial repolarization (potassium and chloride out) - 1 Plateau (calcium in) -2 Repolarization (potassium out) - 3 Plateau (rectifier) - 4
81
How does a class 1A antiarrhythmic Rx affect the myocardium contractile diagram?
Decreases max rate of depolarization and slows down phase 3 repolarization, increases refractory period and increases Q-T interval **shorter and longer
82
What is the main structure found in class 1A antiarrhythmic Rx?
N-containing heterocycles - generally basic and no pharmacophore
83
Which class 1A antiarrhythmic Rx has a quinoline ring?
Quinidine
84
Which class 1A antiarrhythmic Rx has an ester group replaced with an amide group?
Procainamide; longer half-life compared to procaine
85
What is the major metabolite in procainamide?
NAPA
86
How does a class 1B antiarrhythmic Rx affect the myocardium contractile diagram?
Does not affect depolarization max rate like IA, but does accelerate phase 3 repolarization, decreases refractory period **same height, but shorter
87
What kind of internal bond does Mexiletine have?
Ether bond; more stable vs amide (in lidocaine) and increases half life
88
How does a class 1C antiarrhythmic Rx affect the myocardium contractile diagram?
Greatest effect on depolarization **shorter and a big longer, slanted to the right
89
What structures are commonly found in class 1C antiarrhythmic Rx?
Benzamide + N-containing heterocyclicles Fluorination improves potency
90
How does a class III antiarrhythmic Rx affect the myocardium contractile diagram?
Prolongs repolarization, increases refractory period **same height, but longer
91
What structures are commonly found in class III antiarrhythmic Rx?
Iodine compound
92
What is the difference between amiodarone and dronedarone?
Amiodarone has a iodine group Dronedarone has a methylsulfonamide group which increases polarity and reduces neurotoxic effects (and less potent)
93
What is the difference between amiodarone and dofetilide?
Adds 2 whole methylsulfonamide groups which further makes it more polar (vs dronedarone) and has no neurotoxic effects
94
Describe the action potential of the SA node?
Slow influx of sodium (propotential) until -40mV Rapid influx of calcium (depolarization) Outflux of potassium (repolarization)
95
Classes of antiarrhythmics, which one controls rhythm and which ones are rate control?
1 + 3 = rhythm, prolongs refractory or slows conduction 2 + 4 = rate control, slows down pacemaker by calcium or indirectly as a beta blocker
96
Quinidine AE?
Given PO only GI side effects Higher doses = cinchonism (tinnitus, dizziness, blurry vision)
97
On an EKG, how does Procainamide differ from Quinidine?
Procainamide prolongs QRS and Q-T interval duration whereas Quinidine prolongs just Q-T interval
98
Procainamide AE?
Given IV or PO Syndromes resembling lupus and arthritis Hypotension
99
Disopyramide AE?
Given PO only (type 1a drug) Negative inotropic and antimuscarinic effects Caution in elderly and HF pt
100
Lidocaine AE?
Given IV only In pre-exisiting HF, may cause hypotension
101
What causes increased automaticity (and therefore abnormal impulse formation to arrhythmias)?
Increased phase 4 depolarization
102
What causes afterdepolarization (and therefore abnormal impulse formation to arrhythmias)?
Transient depolarizations that interrupt phase 3
103
Procainamide use?
Atrial or ventricular arrhythmias Usually 2nd or 3rd drug of choice
104
Lidocaine use?
Acute ventricular arrhythmias (usually post-MI) Prevent ventricular Fib. during acute ischemia
105
Flecainide use?
Normal hearts who have supraventricular arrhythmias
106
Flecainide AE?
Proarrhythmic in pt with coronary artery disease or congestive HF
107
Propafenone AE?
Metallic taste, constipation, arrhythmia exacerbation
108
Propafenone use?
Treat supraventricular arrhythmias
109
Class II antiarrhythmics use?
Treat/suppress supraventricular and ventricular arrhythmias
110
Metoprolol AE?
Dyslipidemia
111
Esmolol fun fact?
Extremely short half-life
112
Which class II antiarrhythmics is non-selective?
Labetolol
113
Amiodarone fun fact?
Very long half-life (60 days) + inhibits most CYP Rx
114
Amiodarone AE?
Hyper/hypothyroidism, pulmonary fibrosis, bradycardia, hypotension
115
Amiodarone use?
Supraventricular tachycardia
116
Black box warning of class IV antiarrhythmics or class III with recent decompensation
Increased mortality in HF pt
117
What are the class IV antiarrhythmics?
Non DHP CCBs: verapamil and diltiazem
118
Verapamil and diltiazem use?
Rate control in AF or atrial flutter First line for suppression of proximal supraventricular tachycardia
119
Cautions in using class IV antiarrhythmics?
CI with AV block, ventricular dysfunction, severe hypotension, or IV BB
IPT: Cardio
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