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1 CV, Ischemic/CHF
Step Up to Medicine, Chap 1: Ischemic Heart Disease and CHF
| Question | Answer |
|---|---|
| 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
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