Term
One-third of these individuals will die as a result of complications of their heart attack (< 500K).
Approximately one-half of these deaths (<250K) will occur out-of-hospital within the first hour of symptom onset.
The quality of life for those who survive may be significantly diminished as a result of heart failure and other complications |
|
Definition
|
|
Term
| Mcc of death is electrical problems resulting from ischemia damaging the conduction system. |
|
Definition
|
|
Term
| Number 1 cause of heart failure in the United States: |
|
Definition
|
|
Term
| Angina equiv: diaphoresis, cough, shortness of breath, back pain, dyspepsia |
|
Definition
|
|
Term
|
Definition
Cardiac: ACS, Pericarditis, Myocarditis
Noncardiac:
Chest/Lung: Pulmonary Embolism, Thoracic Aortic Dissection, Pneumothorax, Pneumomediastinum, Pneumonia, Pleural Effusion
Gastrointestinal: Peptic Ulcer Disease, Pancreatitis, Biliary Colic, Choleycystitis
Anxiety, GERD, Musculoskeletal, Herpes Zoster |
|
|
Term
Dull crushing pain for heart and coronary pain.
Sharp pain for PE.
Thoracic aneurysm dissection: tearing ripping pain
Pneumothorax: shortness of breath |
|
Definition
|
|
Term
| How would you assess pericardial effusion? |
|
Definition
|
|
Term
| What vasodilator can cause pericardial effusion? |
|
Definition
|
|
Term
| __, __, __ __, and a new __ __ are all concerning signs of significant __ __ and indicate a pt is at high risk for death/MI. |
|
Definition
- JVD
- S3
- pulmonary edema
- heart murmur
- myocardial damage |
|
|
Term
| Symptoms of stable angina: |
|
Definition
- mild-substernal chest pain
- squeezing, pressure like
- closed fist- Levine's sign
- SOB
- sweating
- nausea
- waxes and wanes- builds to a peak and lasts 2-20 minutes
- radiation to left arm, jaw, or back |
|
|
Term
|
Definition
- nonspecific EKG changes
- ST depression
- flat T waves |
|
|
Term
| stable angina can be exacerbated by: |
|
Definition
- cold
- exertion
- heavy meals
- stress |
|
|
Term
| Stable angina is relieved by __ and __. |
|
Definition
|
|
Term
|
Definition
- Ordinary activity does NOT cause symptoms- walking, stairs
- Strenuous activity causes symptoms |
|
|
Term
| Class II angina pectoris: |
|
Definition
| normal activity causes symptoms (more than blocks of walking, 2 flights of stairs) |
|
|
Term
| Class III angina pectoris: |
|
Definition
| symptoms with minimal activity |
|
|
Term
| Class IV angina pectoris: |
|
Definition
|
|
Term
Class I : ordinary activity no symptoms
Class II: slight limitation from regular activity (can walk up stairs or flat parking lot slowly with no symptoms but if up hill or walk fast may have problem)
Class III: even walking up stairs slowly, still have symptoms, no symptoms of rest
Class IV: symptoms at rest |
|
Definition
| this is Barron's example, KNOW IT |
|
|
Term
Atypical presentations - 20% of patients are asymptomatic or have
atypical symptoms |
|
Definition
|
|
Term
|
Definition
women tend to present more commonly with atypical symptoms such as sharp pain, fatigue, weakness, back pain
diabetics - generalized weakness or dizziness
elderly patients may present with altered mental status
abdominal discomfort or jaw pain
shortness of breath
nausea/vomiting
diaphoresis
palpitations |
|
|
Term
| Unstable Angina is part of ACS. Symptoms occur at __ and are less or unresponsive to __. |
|
Definition
|
|
Term
| Would you perform a stress test on a pt with unstable angina? |
|
Definition
|
|
Term
| With unstable angina there are/are not enzymes released. |
|
Definition
|
|
Term
| A non-transmural myocardial infarction (NTMI or Nstemi) is part of __ __ __. There will be __ __, _ __ __, or a __ EKG. There are no _ __. The following enzymes are released: |
|
Definition
- acute coronary syndrome
- ST depression, T wave inversion, or a normal EKG
- NO Q waves
- enzymes: CPK, LDH, possibly Triponin |
|
|
Term
| With a NTMI, there are/are not Q waves. |
|
Definition
|
|
Term
| T wave changes are first thing to be seen after MI, but go away rapdily so may miss them. |
|
Definition
|
|
Term
| A Transmural MI aka STEMI is part of acute coronary syndrome. There is ST __ and __ __. And __, __, and __ are released. |
|
Definition
- elevation
- Q waves
- CPK
- LDH
- Triponin |
|
|
Term
| Acute Coronary syndromes: |
|
Definition
- Unstable angina
- Non-transmural MI
- Transmural MI |
|
|
Term
| Acute Coronary Syndrome is defined as the spectrum of __ __ related syndromes ranging from UA to MI with or without ST elevation that are __ to __ __ __ or __ __. |
|
Definition
- acute ischemia related
- secondary to acute plaque rupture or plaque erosion |
|
|
Term
| Unstable angina has a __ thrombus, ___ EKG changes, and __ enzyme release. |
|
Definition
- non-occlusive thrombus
- non-specific EKG changes
- no enzymes released |
|
|
Term
| NSTEMI has a __ thrombus that was sufficient enough to cause __ and myocardial __. There is __ __ and possibly _ __ __ on EKG. There are __ cardiac enzymes. |
|
Definition
- non-occlusive thrombus
- damage
- myocardial necrosis
- ST depression
- T wave inversion
- elevated |
|
|
Term
| STEMI has complete thrombus __, __ __ or __ __ on EKG. Cardiac enzymes are __. |
|
Definition
- occlusion
- ST elevation or new LBBB
- elevated |
|
|
Term
| Name 2 situations in which you cannot diagnose STEMI from an EKG. |
|
Definition
|
|
Term
| To have a Dx of ACS, must have 2 of the following: |
|
Definition
- angina/angina equivalents
- ischemic EKG changes (st depression or elevation (infarct)
- typical rise and fall of cardiac enzymes
- absence of other identifiable cause |
|
|
Term
| Initial eval of non-ST elevation ACS: |
|
Definition
- H&P
- EKG
- Cardiac biomarkers |
|
|
Term
Only Approx 50% of AMI patients have diagnostic changes on their initial ECG
1 ECG cannot exclude AMI
Brief sample of a dynamic process
Small regions of ischemia or infarction may be missed
Peter J. Zimetbaum, M.D., N Engl |
|
Definition
|
|
Term
I and AVL : high lateral
II, III, and avF: inferior
V3, V4 anterior
V5, V6: lateral |
|
Definition
|
|
Term
|
Definition
Troponin: High sensitivity, high specificity for myocardial tissue
CK-MB: less tissue specific, but better specificity for irreversible injury
Myoglobin: for rapid diagnosis
These biomarkers reflect myocardial damage but do not indicate its mechanism. (e.g. myocarditis…) |
|
|
Term
| Biomarkers are more sensitive, more specific and less costly than imaging techniques for the diagnosis of myocardial necrosis. Injury involving >20% of myocardial wall thickness is required before a segmental wall motion abnormality can be detected by echocardiography. In general, >10 g of myocardial tissue must be injured before a radionuclide perfusion defect can be resolved. Neither technique can distinguish ischemia from infarction. |
|
Definition
|
|
Term
| For patients in need of an early diagnosis, a rapidly appearing biomarker (such as CK-MB isoforms or myoglobin), plus a biomarker that rises later (e.g., cardiac troponin), is recommended for confirmation of the diagnosis |
|
Definition
|
|
Term
| minimal myocardial damage may only elevate __ and not the other biomarkers. |
|
Definition
triponin
there is a continuous relation between minimal myocardial damage, characterized by elevation of cardiac troponin without elevation of other cardiac biomarkers (e.g., CK-MB) and large infarcts, characterized by complications such as heart failure or shock |
|
|
Term
| The magnitude of triponin elevation has been correlated with the risk of __ irrespective of if pt has st elevation or depression. |
|
Definition
|
|
Term
| __ and __ are early biochemical cardiac markers. |
|
Definition
|
|
Term
|
Definition
Very specific and more sensitive than CK
May remain elevated for up to two weeks
Can provide prognostic information
Troponin T may be elevated with renal dz, poly/dermatomyositis
Up to 6 hours before raised blood levels no early MI diagnosis possible
Raised blood levels for many days troublesome diagnosis of re-infarction |
|
|
Term
| Don’t measure cardiac enzymes as a screening test. NOT A SCREENING TEST. You have to have suspicion to order it. DO NOT ORDER IT OUTPATIENT B/C SHOULD HAVE SENT THEM TO THE HOSPITAL IF THEY HAVE MI. |
|
Definition
|
|
Term
|
Definition
Initial elevation : 1 to 4h after onset better early marker than troponins
Validated as marker for MI.
Remains elevated 36-48 hours
Duration of elevation : 24 – 48h useful for re-infarction diagnosis
Rapid rise and fall (instead of gradual fall for troponins) allowing more accurate estimation of MI extent
However:
Can increase after muscle injury, muscular diseases.
Can be found in tongue, intestine, diaphragm, uterus, prostate. |
|
|
Term
| If someone comes into ER and you think they have had an MI> serial enzymes, they measure them every 8 hours to monitor enzymes. |
|
Definition
|
|
Term
|
Definition
- rapid rise
- non-specific
- cannot be used alone to confirm MI |
|
|
Term
| Non-MI causes of elevated triponin: |
|
Definition
- tachycardia
- PE with right ventricular infarct
- cardiac failure with myonecrosis
- cardiac surgery
- myocarditis
- renal failure |
|
|
Term
Renal failure and any damage to the heart, even if it not an MI, can cause triponin-I to come up.
Trauma (including contusion; ablation; pacing; ICD firings,, endomyocardial biopsy, cardiac surgery, after-interventional closure of ASDs)
Congestive heart failure (acute and chronic)
Aortic valve disease and HOCM with significant LVH
Hypertension
Hypotension, often with arrhythmias
Noncardiac surgery
Renal failure
Critically ill patients, especially with diabetes, respiratory failure
Drug toxicity (eg, adriamycin, 5 FU, herceptin, snake venoms)
Hypothyroidism
Coronary vasospasm, including apical ballooning syndrome
Inflammatory diseases (eg, myocarditis, Kawasaki disease, smallpox vaccination,
Post-PCI
Pulmonary embolism, severe pulmonary hypertension
Sepsis
Burns, especially if TBSA greater than 30%
Infiltrative diseases: amyloidosis, hemachromatosis, sarcoidosis, and scleroderma
Acute neurologic disease, including CVA, subarchnoid bleeds
Rhabdomyolysis with cardiac injury
Transplant vasculopathy
Vital exhaustion |
|
Definition
|
|
Term
| Acute therapy for Unstable Angina and NSTEMI: |
|
Definition
- Morphine, Oxygen, Nitro, Aspirin
- bed rest
- EKG monitoring
- ACE-I
- Beta blocker
- Antiplatelet therapy
- Anticoagulation therapy |
|
|
Term
| Maintenance therapy for Unstable Angina and NSTEMI: |
|
Definition
- Antiplatelet therapy
- ACE-I
- Beta blockers
- Calcium channel blockers
- Lipid lowering agents |
|
|
Term
|
Definition
Initial
ABC’s
IV Access
MONA
Morphine – relief of pain (2-4 mgm)
Oxygen (2-4 liters) Nasal prongs OK
Nitroglycerin first choice for pain relief Sublingual if possible IV if responsive
Aspirin First line anti-platelet (chewable quicker into system)
Second-Line Meds
Beta – Blocker decreases myocardial oxygen demand. May help with pain, decrease mortality
ACEI
Heparin Unless contraindicated , heparin is started
Glycoprotein IIb/IIIa Receptor Inhibitors (non-ST elevation)
Dysrhythmia management |
|
|
Term
|
Definition
|
|
Term
| Nitro hits all smooth muscle, not just vascular smooth muscle. But if given in vascular system> goes to vasculature first. |
|
Definition
|
|
Term
| Nitrovasodilators action : |
|
Definition
Primary - Peripheral venodilatation especially large venous capacitance vessels
this reduces venous return which reduces cardiac preload and thus myocardial workload
Secondary - Arteriolar dilatation: reducing cardiac afterload and thus myocardial work and oxygen demand
Third - Increasing oxygen supply to ischemic areas of the myocardium. |
|
|
Term
|
Definition
Drug of choice in acute angina attack.
Prinzmetals angina – relief of coronary artery vasospasm
CHF refractory to standard therapy |
|
|
Term
Nitroglycerin tablets – o.4 mg
Once opened the tablets have shelf-life of 6 months |
|
Definition
|
|
Term
| Nitrovasodilators long acting: |
|
Definition
NTG
2% ointment
slow release – transdermal patch
Isosorbide dinitrate- given twice
Isosorbide mononitrate- given once/day |
|
|
Term
| important note with nitro patch: |
|
Definition
| Have to take a break at night to recover to avoid tachyphylaxis- no matter how much more you give you always get a diminishiing response. |
|
|
Term
|
Definition
First tablet (or spray) sublingual. Wait 5 minutes and if pain remains
Take second tablet (or spray). Wait 5 minutes and if pain remains
Take third tablet (or spray). Wait 5 minutes and if pain remains – go to hospital!
(One spray = one tablet, do not shake the spray prior to using.) |
|
|
Term
|
Definition
- headache
- postural hypotension> syncope
- interaction with drugs for erectile dysfunction |
|
|
Term
| NTG has adverse effects iwth __ __ __ which are used for __ __ or __ __. |
|
Definition
- phosphodiesterase 5 inhibitors (PDE 5 inhibitors)
- erectile dysfunction
- pulmonary HTN
-- sildenafil, tadalafil & vardenafil (the “afil” class) |
|
|
Term
| β-blockers reduce heart rate and increase duration of diastole, which allows more coronary perfusion. |
|
Definition
|
|
Term
β-blockers decrease the frequency of anginal episodes and raise the anginal threshold.
β- blockers reduce mortality and re-infarction in post-MI patients
Abrupt withdrawal of β-blockers can precipitate unstable angina and MI in patients with chronic CAD. |
|
Definition
|
|
Term
| B-1 blockers are primarily used for ACS and angina and include: |
|
Definition
- Atenolol
- Metropolol tartrate/succinate
- Nebivolol |
|
|
Term
| Abrupt withdrawal of β-blockers can precipitate unstable angina and MI in patients with chronic CAD. |
|
Definition
|
|
Term
| 3 therapeutic uses for Beta blockers: |
|
Definition
- angina pectoris
- acute MI
- post MI |
|
|
Term
|
Definition
Propranolol
Atenolol
Metoprolol tartrate
Metoprolol succinate
Nadolol
Nebivolol |
|
|
Term
| Beta blocker side effects: |
|
Definition
- bronchospasm
- diminished exercise capacity
- decreased contractility
- sexual dysfunction
- bradycardia
- masked hypoglycemia
- fatigue |
|
|
Term
| Calcium channel blockers that have primarily cardiac effects: |
|
Definition
| - Non-dihydropyridines: Verapimil and Diltiazem |
|
|
Term
| Calcium channel blockers with primarily vascular effects; |
|
Definition
| Dihydropyridines: Nifedipine, Amlodipine |
|
|
Term
|
Definition
- arterial dilation> afterload reduction
- coronary artery dilation
- prevention of coronary vasoconstriction
- enhancement of coronary collateral flow
- improved subendocardial perfusion
- slowing of heart rate with non-dihydropyridines |
|
|
Term
| CCB mechanism of action in angina: |
|
Definition
- decrease excitablity of vascular smooth muscle
- decrease propensity of arteries to spasm
- decrease tone of vascular smooth muscle
- decrease afterload |
|
|
Term
| Additional effects of non-dihydropyridine CCB Verapimil and Diltiazem: |
|
Definition
- decrease SA and AV node function
- decrease contractility
both of these decrease cardiac work |
|
|
Term
nondihyro CCB best for heart.
dihydro CCB best for bp. |
|
Definition
|
|
Term
|
Definition
- peripheral edema- worse with dihydro
- headache
- flushing
- palpitation
- gingival hyperplasia- espec Verapimil
- constipation |
|
|
Term
| Antiplatelet agents in tmt of ACS: |
|
Definition
|
|
Term
Aspirin
Decreased platelet aggregation dramatically decreases probability of M.I.
clearly demonstrated to ¯ mortality in patients with unstable angina, reducing incidence of MI and death
¯ incidence of MI in chronic stable angina due to inhibition of platelet aggregation |
|
Definition
Tmt benefits of ASA:
Subsequent MI’s are reduced by ¼.
Deaths are reduced by 1/5.
NNT - For every 15 patients with suspected AMI, who are treated promptly with ASA and rapid intervention, one early vascular death will be prevented. |
|
|
Term
Clopidogrel
Alternate to, or additive with, aspirin
Inhibits ADP pathway in platelets
Reduces platelet aggregation
NO EFFECT ON PROSTAGLANDINS – preferred over aspirin
Particularly useful in unstable angina |
|
Definition
|
|
Term
ASA/Aspirin ( clopidigrel – 81 mg ASA)
Clopidigrel –
9-12 months
non-coated stent – 1 month
(sirilimus) coated stent – 3 months |
|
Definition
|
|
Term
| Beta-Blockers - Beta-blockers reduce mortality, readmission, and reinfarction for both CAD and CHF. |
|
Definition
| Reduce contractility, HR, increase diastolic interval so more time for coronary flow |
|
|
Term
| ACE inhibitors - ACE inhibitors (ACEI) are indicated (angiotensin receptor blockers [ARBs] if ACEI aren't tolerated; in addition to beta-blockers, when possible) for most patients following AMI. |
|
Definition
| ACE inhibitors reduce mortality and morbidity associated with large infarcts |
|
|
Term
| leading cause of death in women in United States: |
|
Definition
|
|
Term
1 in 5 women has some form of CVD
38% of women who have a heart attack die within 1 year
40% of coronary events in women are fatal
Most occur without prior warning |
|
Definition
|
|
Term
Heart Attack Symptoms:
Typical in both sexes
Pain, pressure, squeezing, or stabbing pain in the chest
Pain radiating to neck, shoulder, back, arm, or jaw
Pounding heart, change in rhythm
Difficulty breathing
Heartburn, nausea, vomiting, abdominal pain
Cold sweats or clammy skin
Dizziness |
|
Definition
Typical in women
Milder symptoms (without chest pain)
Sudden onset of weakness, shortness of breath, fatigue, body aches, or overall feeling of illness (without chest pain)
Unusual feeling or mild discomfort in the back, chest, arm, neck, or jaw (without chest pain) |
|
|
Term
|
Definition
Abdominal obesity
Men >88 cm (>40 in)
Women >80 cm (>35 in)
Triglycerides (TG) >150 mg/dL
HDL cholesterol
Women <50 mg/dL
Men <40 mg/dL
Blood pressure >130/>85 mm Hg
Fasting glucose >100 mg/dL |
|
|
Term
| Women and CAD risk factors: |
|
Definition
Higher prevalence of avoidable risk factors1
↑ blood cholesterol, ↑ TG
↑ physical inactivity
↑ overweight (body mass index, 25.0-29.9)
Diabetes is a more powerful risk factor for CAD2
3- to 7-fold in women vs 2- to 3-fold in men
↓ HDL cholesterol levels more predictive of CAD2
Women counseled less about nutrition, exercise, and weight control2 |
|
|
Term
|
Definition
Exercise Treadmill: best in younger, low-risk males; not as sensitive in women
Radionuclide imaging (rest/stress): high sensitivity and specificity
Stress Echocardiogram: operator dependent, use in low-risk women
High resolution CT scan: excellent assessment of lesion in coronary arteries but unclear from trials if it relates to functional ischemia
Angiography: still gold standard
Newman, David. Annals of Emergency Medicine. 2009 Mar; 53(3): 305-8
Cameron, Peter et al. Textbook of Adult Emergency Medicine, 3rd Edition. Section 5.1 and 5.2. |
|
|
Term
Murmur> Echo
Murmur radiating to left axilla: mitral regurg, but don’t put that on SOAP just describe it systolic ejection murmur blah blah blah consistent with mitral regurg, but don’t say its mitral regurg until the ECHO comes back. |
|
Definition
|
|
Term
| Thrombolysis in Myocardial Infarction Risk Score (TIMI): |
|
Definition
1 point each for presence of :
Age > 65 years
Documented prior coronary artery stenosis > 50%
Three or more conventional cardiac risk factors (e.g. age, sex, family history, hyperlipidemia, diabetes, smoking, obesity)
Use of aspirin in the preceding 7 days
Two or more anginal events in the preceding 24h
ST-segment deviation (transient elevation or persistent depression)
Increased cardiac biomarkers
0-2= low risk
3-4= intermediate risk
5-7= high risk |
|
|
