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Cards Ischemia & ACS


2 pathways for ischemic heart dz progression Progressive intraluminal narrowing; Sudden disruption/fissuring of plaques
Progressive intraluminal narrowing tend to: produce collateral blood supply & more likely to cause worsening stable/unstable angina (>75%)
Sudden disruption/fissuring of plaques likely to: rupture, causing ACS (Acute Coronary Syndrome) or Acute MI (25-75%)
Tobacco: CAD risks 2x risk for 1/2 to 1 pack/day; 3x risk for > 1 pack/day; risk declines 50% after one year of tobacco cessation
CAD signs/symptoms Chest pain/pressure/tightness; Jaw/ neck/ throat/scapular/ arm pain; SOB/ Dyspnea on exertion; N&V; Diaphoresis; Fatigue
MI Pathophysiology steps 1 Plaque rupture; 2 Platelet activation/aggregation; 3 Fibrin generation; 4 Thrombus formation
Cardiac ischemia risk factors Age; Gender ? FH; Sedentary Lifestyle; Tobacco; HTN; DM/insulin resistance; Hyperlipidemia
Causes of coronary ischemia leading to chest pain Atherosclerosis; Vasospastic disorders; stenosis or HCM; Coronary thrombosis/ embolization; Acute aortic dissection
Before a dx of CAD, diabetic patients' risk of MI = risk of non-diabetic patient with hx of prior MI
Almost all MI’s result from: coronary atherosclerosis & superimposed coronary thrombosis
What percent of MIs are unrecognized by clinicians? 30%
Most common MI complaint other than chest pain = dyspnea
Which sx of MI is report most commonly in the elderly? Shortness of breath
Symptoms of MI in elderly patients commonly include: confusion, syncope, and vertigo
MI tx: morphine, oxygen, NTG, ASA. What next? Beta blockers
In a 65yo male with hx of CP x7 minutes with SOB, negative TnT, normal ECG, what is next step in mgmt? Repeat TnT in 3 hrs
Elevated troponin is a sensitive AND specific indicator of: cardiac myonecrosis (2/2 troponin release from myocytes into circulation)
In patients with ESRD, what cardiac enzyme changes should be used to define an MI? Dynamic changes in TnT values >20% over 6-9 hours
What is prognostic significance of an elevated troponin level? TnT elevation imparts a worse prognosis, regardless of the underlying etiology
Crushing CP, dyspnea, palpitations, radiation to neck or left arm: Angina (if lasts minutes), AMI if lasts >30 minutes. Acute Ischemia: ST elevation; Injury: T wave depression; Infarct: Q wave
Prinzmetal angina: Vasospastic Angina; W<50 yo; assoc w/migraine, Raynaud; early AM; ST elevation; usually RCA
Tobacco: CAD risks 2x risk for 1/2 to 1 pack/day; 3x risk for > 1 pack/day; risk declines 50% after one year of tobacco cessation
Most common etiology of angina pectoris: atherosclerotic stenosis of coronary arteries
Etiologies of angina pectoris: coronary artery sclerosis; artery spasm; congenital; AS; HCM; pHTN; HTN; collagen vasc dz
Stable angina: sxs substernal pressure with exertion; relieved by rest
Unstable angina: sxs chest discomfort at rest, or new & severe (within 2 months and brought on by exertion), or increasing frequency, duration, intensity
Anginal equivalent = DOE caused by myocardial ischemia
Silent ischemia (evidence on stress test) is more common among: patients with DM
In MI, CK-MB rises within: 4-8 hours; peaks at 12-24 hours; normal in 2-3 days
In MI, LDH rises within: 14-24 h; peak at 2-3 days; normal in 8-14 days
In MI, troponins rise within: 4 hours; peak at 36 hours; normal in (7 days for TnI, 10-14 days for TnT)
Which med decreases comorbidity and comortality in CAD? Beta blocker
Treatment of choice for Prinzmetal angina Cardizem (diltiazem)
Which coronary artery is associated with a lateral MI? Left circumflex
Which coronary artery is associated with an anterior MI? LAD (left anterior descending). V2-V4 on ECG
Which coronary artery is associated with an inferior MI? RCA (right coronary artery)
Which measure (lipids, BMI, homocysteine level) is the best predictor of cardiovascular mortality? Homocysteine level
Which coronary artery is associated with a septal MI? LAD (V1-V2 on ECG)
Which coronary artery is associated with an anterolateral MI? left main (V4-V6 on ECG)
Which coronary artery is associated with a posterior MI? RCA (right coronary artery) (ST depression, changes at V1-V2 on ECG)
Most specific cardiac enzyme for ACS troponin I
Which cardiac enzyme rises earliest myoglobin
In ACS, which enzymes becomes elevated in 3-12 hours troponin I, troponin T, CK-MB
In MI, myoglobin peaks within 0-1 hr (normal within 36 hours)
CAD risk factors M>F. AA>W. Lower SES. FH. Obesity. Decreased physical activity. Smoking. HTN. LDL >160. HDL <40. DM. LVH.
CAD screening Smoking. BP. Chol (M>35 yo, F >45yo). AAA: 65-75 if h/o smoking; exam & US
Created by: Abarnard