1
Q
CAD - the most clearly agreed-upon RFs
A
- DM
- Tobacco
- Hypertension
- Hyperlipidemia
- Family history of premature CAD
- men above 45
- women above 55
2
Q
CAD - RF with the highest rate (1) and MC (2)
A
- highest rate: DM (after 10 years)
2. Hypertension (20% of total population)
3
Q
CAD - Familiy history
A
- first degree relatives (siblings and parents)
- premature: male under 55 or female under 65
4
Q
CAD - female
A
- Menstruating women virtually never have MI
- more women will eventually die of heart disease thatn men
5
Q
Less reliable but probable RF for CAD
A
- Physical inactivity
- Excess alcohol ingestion
- Insufficient fruits and vegetables in the diet
- Emotional stress
- Elevated cardiac CT scan calcium scores
- PET scanning
6
Q
Tako-Tsubo cardiomyopathy? (causes and findings)
A
acute myocardial damage most often occuring in postmenopausal women immediately following an overwhelming, emotionally stresful events (divorce, financial issies, earthquakes, hypoglycemia etc) –> LEADS to balloning and LV dyskenesis. (symptoms labs and ECG like MI) (CAN CAUSE SUDDEN DEATH)
7
Q
Tako-Tsubo cardiomyopathy - treatment
A
as with ischaemic disease, manage with β-blockers and ACE inhibitos.
Revasculization will not help (since coronary arteries are normal)
8
Q
Unreliable (Unproven) RF for CAD
A
- elevated homocysteine levels
- Chlamydia infection
- elevated C-reactive protein levels
9
Q
Correcting which RF for CAD will result in the most immediate benefit for the patient
A
Tobacco smoking –> within a year, the risk of CAD decreases by 50%, within 2 years by 90
10
Q
- chest pain - fever - diagnosis
- the best initial test for all forms of chest pain
- which non-specific associated with chest pain has the worst prognostic significance
A
- PE or pneumonia
- ECG
- shortness of breath (dyspnea)
11
Q
Stress (Exercise Tolerance) Testing?
is based in 2 facors
A
is the indispensable tool to evaluate chest pain when the etiology is not clear an the EKG is not diagnosticd
- You can read the EKG
- The patient can exercise (means that the patient can get his/her heart rate up above 85% of maximum
12
Q
Stress (Exercise Tolerance) Testing - what if you cannot read the EKG
A
- because of baseline EKG abnormality, you must find a different way of detecting ischemia in the heart. The best 2 methods of detecting ischemia without ECG use
1. Nuclear isotope uptake (thallium or sestamibi)
2. Echocardiographic detection of wall motion abnormalities
13
Q
Stress (Exercise Tolerance) Testing - reasons of baseline EKG abnormalities
A
- Left bunde branch block
- left ventricular hypertrophy
- pacemaker
- effect of dygoxin
14
Q
Stress (Exercise Tolerance) Testing - Nuclear isotope uptake (thallium or sestamibi)
A
If the myocardium is alive and perfused, isotopes will be picked up by Na/K+ ATPase
15
Q
Stress (Exercise Tolerance) Testing - What if the patient cannot exercise
A
an alternate method of increasing myocardial O2 consumption must be performed:
- Persantine (dihydrodamole) or adenosine in combination with the use of isotopes (thallium or sestamibi)
- Dobutamine in combination with Echocardiography
16
Q
dihydrodamole - side effects
A
may provoke bronchospasm (avoid in asthmatics)
17
Q
stress test - methods when ECG reading is not possible (and compare their sensitivity and specificity)
A
Exercise thallium = exercise Echo
Dipyridamole Thallium = dobutamine echo
(echo = nuclear)
18
Q
CAD - proportions of stenosis and management
A
less than 50 –> insignificant
70 or more –> surgically correctable
19
Q
Chest pain (high likelihood of Coronary heart Disease) - management
A
Resting EKG: abnormalities?
no: if able to exercise to exercise test. If not able do a chemical stress test
yes: stress echocardiogram or nuclear stress test
IF POSITIVE TEST –> angiography
decide between stent placement (1 or 2 vessels disease) or CABG (3 vessels or left main or 2 vessels in DM)
20
Q
Chronic angina - treatment
A
- aspirin
- beta blockers (specific - not proranolol)
- nitroglicerin (orally or by trandermal patch)
21
Q
Antiplatelet therapy - chronic vs acute coronary syndrome
A
- acute: 2 antiplatelets medications immediately upon arrival in the emergency room (aspirin + clopidogrel or prasurgel or ticagrelor: all 3 are P2Y12 receptor inhibitors). When angioplasty and stenting is planned, choose prasurgel or ticagrelor (both beneficial for restenosis)
- only aspirin
22
Q
Clopidogrel is used in … / an advantage
A
- combination with aspirin on all acute coronary syn
- aspirin intolerance (such as aspirin)
- Recent angioplasty with stenting
Thrombotic thrombocytopenic purpura
23
Q
Best mortality benefit in chronic angina (drugs)
A
- aspirin
2. β-blockers
24
Q
ADP receptor inhibitors (drugs and mechanism)
A
Clopidogrel, prasurgel, ticagrelor (the only reversible), ticlopidine
inhibit platelet aggregation by ADP receptor blocking (prevnet expression of gpIIb/IIIa)
25
the best ADP receptor inhibitor for thise undergoing angioplasty and stenting .... (what is the disadvantage)
Prasurgel
| in patients 75 and older because of the risk risk of hemorrhagic stroke
26
Ticlopidine - when to use ... / SE
intolerance in both aspirin and clopidogrel
(but not if the reason of intolerance is bleeding)
- 1. neutropenia 2. TTP
27
statins in CAD and guidelines
the goal is at least an LDL less than 100 or even 70
| guidelines vary.
28
statins use beside CAD
goal of LDL is below 100 and statins should be used:
1. peripheral artery disease
2. carotid disease
3. aortic disease (artery)
4. stroke
5. DM
29
CABG - grafts comparison
- internal mammary artery grafts last on average for 10 years before they occlude
- saphenous vein grafts remain patent reliably for only 5 years
- half of vein grafts are patent at 10 years
30
Coronary artery bypass grafting (CABG) lowers mortality only in a few specific circumstances with very severe diseases such as
1. 3 vessels with at least 70% stenosis in each
2. Left main coronary artery occlusion
3. 2-vessel disease + DM
4. persistent symptoms despite maximal medical therapy
Long term mortality benefit is greater with the most severe disease (such as LV dysfunction). The immediate operative mortality may be greater in patients with EF less than 35, but in long term, these surviving the procedure will do better in those with 3-vessel disease and LV dysfunction
31
PCI - acute coronary syndromes vs stable patients
- PCI is the best acute syndromes (particularly with ST elevation
- not provide clear mortality in stable
32
stable angina - PCI vs medically treatment
no clear which is better
maximal medical therapy with aspirin, beta blockers, ACEi and statnes has proven to have equal or even superior benefit is stable CAD
Pci IS MORE DEFINITIVE IN TERMS OF DECREASING DEPENDENCE ON MEDICATION AND DECREASING FREQUENCY OF PAINFUL ANGINA EPISODES
33
route of nitroglicerin administration in chronic angina
orally or by trandermal patch (sublingual, paste and IV are used in ACS)
34
patient with CAD under ACEi develops hyperkalemia - what to do
switch to hydralazine and nitrates (you cannot just switch it to angiotensic receptor blocker)
35
a clinical finding that found in patients with ASC (and why)
S4 gallop: iscemia leading to noncompliance of the LV
36
which MI has the worse prognosis (anterior vs inferior)
anterior
37
Premature ventricular complexes (PVCs) - treatment
associated with later development of more severe arrhythmia, but no additional therapy is needed for them if Mg and K+ are normal
PVCs should not be treated even when associated with an acute infratction (may worsen outcome)
38
ACS - Myoglobin - time to becoming abnormal at onset of pain, duration of abnormality
1-4h
| 1-2 days
39
ACS - CK MB - time to becoming abnormal at onset of pain, duration of abnormality
4-6h
| 1-2d
40
ACS - Troponin - time to becoming abnormal at onset of pain, duration of abnormality
4-6h
| 10-14d
41
Reinfraction - diagnosis
1. perform an EKG to detect NEW ST segment abnormalities
| 2. Check CK-MB levels
42
Angioplasty vs Thrombolytics
Angioplasty is superior to thrombolytics in terms of:
1. survival and mortality benefit
2. Fewer complications
3. Likelihood of developing complications of MI (less arrhythmia, less CHF, fewer ruptures of septum free wall and papillary muscles)
43
Complications of PCI
1. Rupture of the coronary artery on inflation of the ballon
2. Restenosis (thrombosis) of the vessel after angioplasty
3. Hematoma at the site of the entry into the artery (eg. femoral area hematoma)
44
Which is most important way to decrease the risk of restenosis of coronary artery after PCI
Placement of drug-eluting stent (paclitaxel, sirolimu): inhibits local T-cell response
45
Rates of restenosis within 6 months of PCI
No stenting: 30-40%
Bare metal stent: 15-30%
Drug eluting stent: less than 10%
46
Absolute contraindications to thrombolytics
1. major bleeding into the bowel (melena) or brain (any type of CNS bleeding)
(heme+ brown stool is not absolute contraindication)
2. recent surgery (within the last 2 wks)
3. Severe hypertension (above 180/110)
4. Nonhemorrhagic stroke within the last 6 months)
IF contraindication --> transfer to facility performing PCI
HEME (+) BROWN STOOL IS NOT ABSOLUTE CONTRAINDICATION
47
What is more beneficial in a STEMI - thrombolysis vs tranfer to a hospital for angioplasty
Immediate thrombolytics is far more beneficial
| unless if available PCI in 90 mins
48
thrombolitics - when
The mortality benefit of thrombolytics extends out to 12 h from the onset of pain
The mortality benefits is as much as a 50% relative risk reduxtion within the first 2 hours of the onset of pain. This is why a patient with chest pain who arrves in the emergency department should receive thrombolytics within 30 mins of coming through the door
49
all the treatment for ACS
1. Aspirin 2. Beta-blockers 3. ACEi/ARB 4. Statis
5. O2/nitrates 6. heparin 7. Calcium chanel blockers
8. clopidogrel or prasurgel or ticagrelor
9. Revascularization
50
ACS - clopidogrel or prasurgel or ticagrelor
- Clopidogrel is often used if there is an allergy to aspirin, but prasugrel and ticagrelor are alternatives to clopidogrel that seem to have superior benefit when stenting is done
- ALL PATIENTS WITH ACS SHOULD RECEIVE 2 ANTIPLATELET MEDICATIONS IMMEDIATELY UPON ARRIVAL IN THE EMERGENCY ROOM (aspirin plus an ADH inhibor, when angioplasty is planned, ticagrelor or prasugrel are better)
- after stent, aspirin + clopiegrole for 1 year
51
ACS - ACEi/ARB
everyone, benefit best with ejection fraction below 40%
52
1. ACS - statins
| 2. ACS - oxygen nitrates
1. - everyone
- goal LDL under 100
2. Everyone, no clear mortality benefit
53
ACS - heparin
- after (or during) thrombolitics/PCI to prevent restenosis
| - initial therapy with ST depression and unstable angina
54
ACS - calcium blocker
- can't use beta-blockers
- cocaine induced pain
- prinzmetal or vasospastic variant angina
55
ST segment depression - next step after aspirin
Heparin (to prevent a clot from forming)
56
GPIIb/IIIa inhibitors - drugs
1. abciximab
2. tirofiban
3. eptifibatide
57
GPIIb/IIIa inhibitors - clinical use / pt
acute coronary sundromes (only unstable angina and non-stemi) in those who are to undergo angioplasty and stenting
they lead to reduction in mortality on those with ST depression, esp with high enzymes who then develop muocardial infraction requiring PCI with stenting
58
Stable angina vs Unstable/NOSTEMI vs STEMI - heparin (enoxaparin)
```
stable: NO
Unstable/NONSTEMI: yes
STEMI: yes (but only after revasuclarization, or during)
HEPARIN IS BEST FOR NON-ST ELEVATION MI
- LMWH is better
```
59
Stable angina vs Unstable/NOSTEMI vs STEMI - GPIIB/IIIa
only Unstable/NONSTEMI:
60
Stable angina vs Unstable/NOSTEMI vs STEMI - thrmobolytics
only STEMI (PCI is better)
61
in NON-STEMI ACS - when PCI
- early (first 48 h)
| - but when all medicationshave been given and the patient is not better --> urgent angiography and possibly angioplasty
62
NON-STEMI ACS - patient is not better - means
1. persistent pain
2. S3 gallop or CHF developing
3. Worse EKG changes or sustained VT
4. Rising troponin levels
(--> urgent angiography and possibly angioplasty)
63
ACS - general management
- Aspirin/clopidogrel, β-blockers, statin, ACEIs, morphine, Nitrates
- If ST elevation: PCI if available in less than 90 mins after patient arrives, Thrombolytics if PCI is not available and within 12 h of start of chest pain
- NONSTEMI / unstable: Heparin, early PCI
64
complication of Acute myocardial infraction - their common symptom/manifestation
hypotension
65
complication of Acute myocardial infraction - Bradycardia (and the best way to distinguish them)
- Sinus bradycardia is very common assoaciation with MI because of vascular insufficiency of the SA node
- Third degree (complete) AV block
Cannon A waves in 3rd degree AV block
66
Cannon A waves
produced by Atrial systole against a close tricuspid valve. The tricuspid valve in 3rd AV block becayse the very essence of 3rd degree block is that atria and ventricles are contracting separately and out of coordination with each other. The cannon is the boudning jugulovenous wave bouncing up (pulsation) into the neck. Look for an association with right ventricular infraction and 3rd degree AV block
67
complication of Acute myocardial infraction - Aneurysm / mural thrombi - diagnosis and treatment
- detected with echocardiography
- no treatment for aneurysm
- treat mural thrombi with heparin followed by warfarin
68
postinfraction routine medication
everyone should go home on:
1. aspirin 2. β-blockers (metoprolol) 3. statins 4. ACEi
5. Clopidogrel or prasurgrel or ticagrelor (intolerant of aspirin OR post-stenting)
69
postinfraction at home - prophylactic antiarrhythmuc medications
DO not use amiodarone, flecainide or any rhythm-controlling medication to prevent VT or VF. they increase mortality
70
post MI - sexual issues
1. Not combine nitrates with sildenafil (both vasodilators --> hypotension)
2. erectile dysfunction is most commonly from anxiety (also b-blockers are the most common medication that cause erectile dysfunction)
3. Does not have to wait after an MI to reengage in sexual activity
4. If the post-MI stress test is described as normal, the patient can reengage in any form of exercise program as tolerated, including sex
Cardiovascular FA
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