IM CV CAD / MI USMLE 2
Terms
undefined, object
copy deck
- (5)* deadly causes of chest pain
-
TAPUM:
Tension pneumothorax;
Aortic Dissection;
PE;
Unstable Angina;
MI - how is the maximum HR determined?
- 220-patient's age = Max HR
-
(6) Major risk factors for CAD which is most prevetable?
which is the greatest risk? -
Diabetes (greatest);
Smoking (most preventable);
HTN;
Hypercholesterolemia;
Family Hx;
Age -
Dx:
Chest pain that has an established character, timing and duration; pain is transient, reproducable and predictable.
What is cause?
What is Tx? (2 together) -
Dx: Stable Angina
Cause: Reduced coronary blood flow through fixed athrosclerotic plaque in vessel of heart
Tx: rest + Nitroglyerin -
exertional substernal (precordial) chest pressure and pain radiating to left arm, jaw or back. N/V, diaphoresis, dyspnea, HTN and tachycardia can accompany it.
Name the types -
Angina:
Stable
Unstable
Variant (Prinzmetal's) -
Angina type that is also considered an Acute Coronary Syndrome (ACS).
What (3) factors must it have for diagnosis? -
Unstable Angina
1) New-onset
2) angina that changes or accelerates in pattern, location or severity
3) Occurs at REST -
Dx:
Similar characteristics of stable angina, but due to vasospasm instead of atherosclerosis.
Tx? (2 drugs together) -
Variant (Prinzmetal's) Angina
Tx:
1. Calcium Channel blockers
+
2. Nitrates -
what (2) groups of patients may not show the classic signs pain seen in stable angina?
Why? - Elderly and diabetics (b/c: neuropathies)
- What does the EKG look like for the (3) angina types?
-
Stable + Unstable:
- ST Depression
- T-wave Inversion
Variant:
- ST elevation -
62-yo smoker w/ 3 episodes of severe heavy chest pain in the morning. Each lasted 3 - 5 minutes, but he has no pain now. He has never had this before.
What is it? - Unstable Angina
-
62-yo man w/ frequent episodes of chest pain on and off for 8 months. He says the pain wakes him from sleep at night.
What is it? - Variant (Prinzmetal's) Angina
- what is the alternative to an exercise Stress Test if the patient cannot get on a treadmill?
- IV Dobutamine is given to stimulate myocardial function
- What is the criteria for a "positive" Stress Test? (5)
-
either:
- ST elevation
- ST depression >1 mm in multiple leads
- Dec BP
- failure to go more than 2 minutes
- failure to complete for reason other then cardiac symptoms (i.e. arthritis) - what does Myocardial Perfusion Imaging detect? (3)
-
- Myocardial perfusion
- Ventricular volume
- Ejection Fraction - An ultrasound of the heart revealing abnormal wall motion due to ischemia or infarction. It also assesses left ventricular function and EF
- Echocardiography
-
What are (5) Dx that need a cardiac catherization?
Describe procedure for each -
1) MI / Unstable angina: stent or angiography
2) Valvular disease: valvuloplasty
3) Arrhythmias: mapping bypass tracts
4) Myocardial dz Bx: glycogen storage dz or cardiomyopathies
5) Congenital heart dz identification: angiography and closure of defects - (4) serum markers for MI
-
Myoglobin;
Troponin T/I;
CK;
Lactate Dehydrogenase -
How is the right heart accessed in a cardiac catherization? (2)
Left heart? (2) -
Right:
Femoral or Internal Jugular
Left:
Femoral or Radial artery (from right heart) - what is the wave morphology changes sequence in a MI ECG? (6)
-
1. peaked T-waves
2. T-wave inversion
3. ST elevation
4. Q-waves
5. ST normalization
6. T-waves return upright - which cardiac enzyme is the most sensitive and specific for acute MI?
- Troponin-I/T
- which cardiac enzyme remains increased (peaked) the longest?
- LDH
- what does ST depression mean?
- ST goes in the opposite direction of the QRS
- what does a Q-wave on an EKG in the presence of an infarction indicate?
-
Transmural infarction
(extends through full thickness of the myocardial wall) - Time of onset for the (4) serum markers for MI
-
Myoglobin (1-4 hrs)
Troponin-I/T (3-12)
CK-MB (3-12)
LDH (6-12) -
which cardiac enzyme has the shortest duration?
Longest? -
Myoglobin (1 day)
Troponin-I/T (7-10 days) - ST elevation in II, III & aVF
- Inferior wall MI
- ST depression in II, III & aVF
-
Cor Pulmonale
(right-sided heart failure) - ST elevation in V1, V2, V3
- Anterior/septal MI
- ST elevation in V4, V5, V6
- Lateral wall MI
- ST depression in V1, V2
- Posterior wall MI
- difference b/t unstable angina & non-ST elevation MI? (2)
-
non-ST elevation MI has:
1. more severe lack of Oxygen (more severe myocardial damage)
2. Enzyme leakage (Unstable angina has none) - Tx for Unstable angina & MI (6)
-
MONA has HEP B:
Morphine
Oxygen
Nitrates
Aspirin
HEParin
Beta-blockers -
primary Tx (2) for the acute MI w/in 6 hours of infarct
(name 3 other drugs) -
Throbolytics:
1. tPA
+
2. Heparin (DOC)
- Urokinase
- streptokinase
- Alteplase -
At what level should LDL be in person w/ MI history?
What is given to lower it? -
less then 100
statins - When are throbolytics indicated in MI? (3)
-
- patients < 80 yo
- within 6-12 hrs of chest pain
- evidence of infarct on ECG - Contra-indications of Throbolytics (9)
-
Having Some Breaks A Blood Clot In Small Pieces:
- Hx of intracranial bleed
- stroke < 1 year - BP > 180/110
- active internal bleed
- bleeding disorder
- CPR
- Intracranial tumor
- suspected aortic dissection
- Peptic ulcer - drug class that is used to break up clots
- thrombolytics
- name a specific drug that prevents future clots from forming
- heparin
- procedure Tx of choice for MI if there is a high risk of ST elevation (cardiogenic shock) or it has been 3 hours since initial symptoms presented?
-
PTCA
(Percutaneous Transluminal Coronary Angioplasty) - which throbolytic is highly immunogenic and cannot be used in the same patient twice in a 6 month period?
- streptokinase
- what should be given 48 hours post infarct if tPA was used?
- heparin
- drug class that is excellent for late and long-term therapy for acute MI to decrease afterload and prevent remodeling?
- ACEi
-
58-yo man discharged from hospital after MI 2 weeks ago presents w/ fever, chest pain and malaise. EKG shows diffuse ST-T wave changes.
What is Dx?
What is Tx?
(2 possible meds) -
Dressler's syndrome
Tx:
1. NSAIDs
or
2. Corticosteroids - Medication orders w/ discharge of an ACS (post-MI) patient? (5)
-
easy AS ABC:
- Aspirin (indefinitely)
- Statin to lower LDL < 100
- ACE-inh (if EF <40%)
- Beta-blocker (indefinitely)
- Clopidogrel for 1 - 12 mo depending on stent placement -
Dx:
fever, pericarditis and possible pericardial or pleural effusions post cardiac surgery - Dressler's syndrome