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1 CV, Ischemic/CHF

Step Up to Medicine, Chap 1: Ischemic Heart Disease and CHF

QuestionAnswer
Involvement of which artery in stable angina has the worst prognosis? Why? Left main coronary artery b/c it supplies 2/3 of the heart
Chest pain caused by fixed atherosclerotic lesions which narrow major coronary aa Stable angina pectoris
Exercise-induced ischemia will show what findings on EKG? ST segment depression (subendocardial ischemia)
Which EKG finding suggests prior MI? Q waves
How should pts with a positive stress test be managed? Cardiac catheterization
Wall motion abnormalities on EKG indicate what? Exercise induced ischemia
Name 4 factors that make a stress test positive. 1. ST segment depression, 2. chest pain, 3. hypotension, 4. significant arrhythmias
Name 3 agents used in a pharm stress test. 1. Adenosine, 2. dipyrimadole, 3. dobutamine (IV)
Smoking cessation cuts the risk of CAD in half after how long? 1 year
Side effects of nitrates? Headache, orthostatic hypotension, tolerance, syncope
Which decreases morbidity in angina: aspirin or nitrates? Aspirin only (main benefit of nitrates is symptomatic relief)
Does revascularization reduce the incidence of MI? No; improves sypmtoms
When should CCBs be used in pts with angina? If pt does not fully respond to beta blockers and/or nitrates (CCBs considered secondary tx)
Define ACS. Clinical manifestation of atherosclerotic plaque rupture and coronary occlusion.
Differentiate between the cause of stable vs unstable angina. Stable is due to oxygen demand that exceeds blood supply. Unstable is due to reduced resting coronary flow (oxygen demand is unchanged)
Medical management of unstable angina? Aspirin, beta blockers, LMWH (enoxaparin x3-5days), nitrates, glycoprotein IIb/IIIa inhibitors
Target PTT for unstable angina using unfractionated heparin? 2-2.5 times normal
Are thromboyltic therapy and CCBs useful in unstable angina? No
Hallmark EKG finding during chest pain with Prinzmetal's (variant) angina? Transient S-T segment elevation (not depression); represents transmural ischemia
Definitive test for Prinzmetal's (variant) angina? Positive test? Coronary angiography; coronary vasospasm when pt is given IV ergonovine (provokes chest pain)
Tx for Prinzmetal's? CCBs and nitrates
Mortality rate in MI? Percentage of pre-hospital deaths? 30% mortality. 50% pre-hospital deaths.
Name 3 types of pts who are more likely to have silent MIs. 1. Eldery, 2. Post-op, 3. Diabetics
Substernal pain >30min + diaphoresis MI
What causes sudden cardiac death in MI? V fib
Where did the MI occur?: inferior EKG changes, hypotension, elevated JVP, hepatomegaly, and clear lungs R ventricular infarct
Where did the MI occur?: lung crackles Suggests LV failure
ST segment elevation indicates what type of infarct? Transmural; diagnostic of an acute infarct
ST segment depression indicates what? Subendocardial injury
What EKG finding is specific for necrosis? Q waves
Is T wave inversion sensitive or specific for infarct? Sensitive (not specific)
Describe the difference between a Q-wave and non-Q-wave infarct. Q wave is transmural and tends to be larger. Non-Q is subendocardial (inner 1/3-1/2 of wall) and presentation is similar to unstable angina (cardiac enzymes differentiate the two).
Name that cardiac enzyme!: increases within 4-8h, peaks in 24h, returns to normal in 48h CK-MB
Name that cardiac enzyme!: Should be measured on admission and q8h after x24h CK-MB AND troponins (gotcha!)
Name that cardiac enzyme!: Increase within 3-5 hours, peaks in 24-48h, return to normal in 5-14d Troponins
Which is more sensitive and specific for myocyte injury: CK-MB or troponins? Troponins
What are the only agents shown to reduce mortality in MI? Aspirin (reduces coronary reocclusion), beta blockers (reduces afterload, lowers HR and contractility), and ACE-i
What is the purpose of using heparin after an MI? Who should receive it? Prevents progression of thrombus (not proven to reduce mortality). Initiate in ALL pts with MI. LMWH, spec enoxaparin, is drug of choice.
What effect does cardiac rehabilitation have on pt outcomes after an MI? Reduces symptoms and prolongs survival.
Indication for thrombolytic therapy in MI? ST segment elevation in 2 contiguous leads in pt with pain onset within 6h and refractory to nitro
Time frame for thrombolytic therapy in MI? Up to 24h after onset of pain. B/f 6h is best.
Name 6 contraindications to thrombolytic therapy. 1. Uncontrolled HTN (180/110+; control first), 2. Trauma (recent head or CPR), 3. Active PUD, 4. Recent invasive procedure or surgery, 5. Previous stroke, 6. Dissecting aortic aneurysm
Alternative to thrombolytic therapy for MI in pts with contraindications? PTCA (percutaneous transmluminal coronary angioplasty).
Which reduces mortality in MI more: thrombolytic therapy or PTCA? PTCA (PAMI trial)
MCC in-hospital mortality in acute MI? Pump failure (CHF)
Tx for PVCs after MI? Nothing. Just observe. If they convert to V tach or V fib, that's another story...
Where's the infarct?: Q waves in V1-V4, ST seg elevation in V1-V4 Anterior
Where's the infarct?: large R wave in V1 and V2, ST seg depression in V1 and V2, upright and prominent T waves in V1 and V2 Posterior
Where's the infarct?: Q waves leads I and aVL Lateral
Where's the infarct?: Q waves in leads II, III, and aVF Inferior
Tx for 2nd/3rd degree block in setting of anterior MI? Emergent placement of a temporary pacemaker (put in permanent pacemaker later)
Tx for 2nd/3rd degree block in setting of posterior MI? IV atropine initially. Temporary pacemaker if conduction is not restored. (prognosis better than anterior infarct)
Best labs to detect a re-infarction soon after initial MI? CK-MB (returns to normal faster): re-elevation after 36-48h indicates recurrent infarct. Also repeat ST seg elevation points towards recurrent infarct.
Time frame for free wall rupture post-MI? Usually 1-4 days s/p MI. Up to 2 weeks possible.
Likely cause of mitral regurg s/p MI? Papillary m rupture (2-10 days post MI)
Tx of choice for acute pericarditis? Aspirin
Why are NSAIDs and corticosteroids contraindicated in acute pericarditis? May hinder myocardial scar formation
What is Dressler's syndrome? How is it treated? Immuno syndrome w/fever, malaise, pericarditis, leukocytosis, and pleuritis that occurs weeks to months s/p MI. Tx is aspirin.
Pt with chronic stable angina presents with sx suggestive of unstable angina. What are the initial steps in management? Order EKG and cardiac enzymes, give aspirin, start IV heparin
Which radiograph is part of a standard ACS rule out? CXR
MCC systolic dysfunction? Recent MI
MCC diastolic dysfunction? HTN leading to myocardial hypertrophy (stiffened ventricle can't relax)
A nocturnal, non-productive cough that is worsened when supine is indicative of which sided heart failure? Left-sided
Which heart sound is normal in children, but in adults is one of the most specific findings for CHF? S3
What are Kerley B lines? Short, horizontal lines near periphery of lung near costophrenic angles. Indicate pulmonary congestion 2/2 dilation of pulmonary lymphatics
What is BNP? Chemical released from ventricles in response to ventricular volume expansion and pressure overload
Which BNP levels correspond to decompensated CHF? BNP >100pg/mL
Which diuretic is the only one shown to decrease morbidity and mortality in pts with class III or IV heart failure? Contraindications? Spironolactone. Contraindicated in renal failure.
Combination of which two drugs should be the intitial tx of choice in symptomatic CHF pts? ACE-i and diuretic
Does digitalis improve mortality in severe CHF pts? No! Only symptomatic relief.
Signs of digoxin toxicity? GI: n/v, anorexia. Cardiac: ectopic beats, AV block, Afib. CNS: visual disturbances, disorientation
Created by: sarah3148