Term
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Definition
| sense of suffocation or suffocating pain |
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Term
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Definition
| pain in center of chest induced by exercise and relieved by rest; may spread to jaws and arms; occurs when demand for bloody by the heart exceeds supply from the coronary arteries & usually results from coronary artery atheroma |
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Term
| Acute Coronary Syndrome (ACS) |
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Definition
| clinical syndrome resulting from imbalance between myocardial oxygen supply & demand, includes unstable angina & acute myocardial infarction |
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Term
| Pathophysiology of Ischemic Heart Disease = Coronary Artery Dx (CAD) = Coronary Heart Dx |
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Definition
2ndary to atherosclerosis of coronary arteries;
occurs when myocardial O2 demand exceeds myocardia O2 supply |
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Term
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Definition
2ndary to atherosclerosis;
symptoms have been stable for a long period of time;
pain occurs only w/ exertion;
pain is relieved with rest or nitroglycerin (NTG);
ECG:
- normal in 90% of pts;
- T-wave inversion or flattening; |
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Term
| Prinzmetal's or Variant Angina |
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Definition
2ndary to coronary artery vasospam;
spasm can occur at any time: not exertion-related and not relieved by rest; |
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Term
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Definition
pt is assymptomatic;
painless;
detected on ECG only! |
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Term
| Determinants of Myocardial O2 Supply |
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Definition
oxygen carrying capacity;
coronary blood flow - occurs during diastolic phase, originates in aorta (factors that limit coronary blood flow: extent of cross-sectional obstruction, length of lesion, geometry of obstructing lesion), tightly coupled to O2 demand (autoregulation, adenosine, EDRF or NO); |
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Term
| Determinants of Myocardial O2 Demand (MVO2) |
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Definition
Heart Rate;
Contractility;
Intramyocardial wall tension during systole;
Double Product (DP) |
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Term
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Definition
| inadequate flow of blood to a part of body (particularly the heart), caused by constriction or blockage of blood vessels supplying it |
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Term
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Definition
death of part or whole organ which occurs when artery carrying its blood supply is obstructed by a blood clot, it causes a small localized area of dead tissue produced as a result of an inadequate blood supply;
essentially, it is an infarction of heart muscle following coronary thrombosis |
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Term
| Patient Assessment of IHD |
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Definition
1) symptoms;
2) electrocardiogram;
3) biochemical medical markers;
4) stress test; |
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Term
| Past Medical History for Pt Assessment of IHD |
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Definition
angina;
IHD;
revascularization - PTCA +/- stenting or CABG (coronary artery bypass graft) |
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Term
| IHD Risk Factors for Pt Assessment |
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Definition
Age: males >45, females >55 yrs;
Family Hx: 1st degree relative (males <55 yr, females <65 yrs);
HTN: BP >140/90 or on antiHTNsive meds;
Diabetes Mellitus (DM);
Dyslipidemia;
Current Cigarette Smoking; |
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Term
| Duration & Quality of Pain associated with IHD |
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Definition
Duration: 0.5 - 30 min;
Quality: "heavy weight" on chest, burning sensation, tightness, SOB, deep, heavy, aching, squeezing, gradual increase in intensity followed by gradual fading away; |
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Term
| Location of Pain associated with IHD |
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Definition
over sternum or near to it;
between epigastrium & pharynx;
may be limited to left shoulder & left arm;
RARELY limited to right arm;
limited to lower jaw;
lower cervical or upper thoracic pain;
left interscapular or suprascapular area; |
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Term
| Radiation of Pain associated w/ IHD |
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Definition
| medial aspect of left arm; left shoulder; jaw; occasionally right arm; |
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Term
| Precipitating Factors for Pain associated with IHD |
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Definition
relationship to exercise;
effort that involves use of arms above head;
cold environment;
walking against wind;
walking after a large meal;
emotional factors involved w/ physical exercise;
fright, anger;
coitus (sex);
Relief of pain within 45 sec-5 min of taking NTG |
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Term
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Definition
substernal chest pain w/ characteristic quality & duration;
provoked by exertion or emotional stress;
relieved by rest or NTG |
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Term
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Definition
| meets 2 characteristics of typical angina |
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Term
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Definition
Meets < or = 1 characteristic;
Differential Diagnosis: musculoskeletal, GERD/PUD, pulmonary embolism (PE); |
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Term
| Classic EKG Changes of MI |
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Definition
1) ST-segment elevation = injury;
2) T-wave inversions = ischemia;
3) Q-wave changes = necrosis; |
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Term
| Troponins I & T (TnI, TnT) (normal range: <1.5 ng/ml) |
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Definition
protein complex that regulates Ca-mediated interaction b/w actin & myosin for cardiac contraction;
highly specific for MIs;
may be inaccurate (elevated) in renal insufficiency;
Values:
< 0.6 ng/ml - normal;
< 1.5 ng/ml >0.6 ng/ml - may be associated w/ myocardial damage, but has limited specificity;
> or = 1.5 ng/mL - consistent w/ myocardial damage; |
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Term
| Creatinine Kinase (CK) (normal range: <12 IU/L or <3-6% of total CK) |
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Definition
enzyme responsible for transferring high-energy phosphate groups;
found in skeletal, mycardial muscle, & brain;
directly related to muscle mass;
high sensitivity, low specificity;
CK-MB >10 IU/L or >5% of total CK is highly indicative of acute MI |
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Term
| Myoglobin (normal range: 0-85 ng/mL) |
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Definition
heme protein found in cardiac & skeletal muscle;
high sensitivity, low specificity;
fast rise & fall post-MI;
Normal range: 0-85 ng/mL |
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Term
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Definition
| biochemical marker(s) that present within 6 hrs of symptom onset |
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Term
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Definition
| biochemical marker(s) that presents AFTER 6 hrs of symptoms onset; |
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Term
| High-sensitivity c-reactive protein (hs-CRP) |
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Definition
an acute phase inflammatory reactant with <10% interpersonal variability;
measure it among intermediate risk for CHD (10-20% Framingham 10-yr CHD risk) --> aids in evaluating therapy for primary prevention of CVD;
Helpful in those w/ CHD to determine recurrence of events;
Risk Categorization:
Low - <1 mg/L;
Average - 1-3 mg/L;
High - >3 mg/L; |
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Term
| Increased hs-CRP (>1 mg/L) Levels |
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Definition
| HTN, high BMI, cigarette smoking, DM/metabolic syndrome, low HDL/high TG, estrogen/progesterone hormone use, chronic infections, chronic inflammation |
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Term
| Decreased hs-CRP (<1 mg/L) Levels |
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Definition
| moderate EtOH consumption, exercise, weight loss, medications (statins, fibrates, niacin) |
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Term
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Definition
used to assess prognosis & aid in management decisions;
Endpts assessed: anginal symptoms, BP/HR response, exercise capacity, EKG changes;
D/C Beta-blockers or CCBs if performing exercise stress test for diagnosis or risk stratification |
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Term
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Definition
preferred form of stress test;
typically performed on treadmill or supine bicycle;
provides more accurate functional capacity |
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Term
| Pharmacologic Stress Test |
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Definition
alternative to those unable to undergo exercise stress test;
agents used:
- dipyrimadole/adenosine/regadenoson;
- dobutamine |
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Term
| dipyridamole/adenosine/regadenoson (Lexiscan) |
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Definition
vasodilation via activation of adenosine receptors on vascular smooth muscle;
selective for A2A adenosine receptor;
increase coronary blood flow 3-5x baseline w/ little to no increase in blood flow in stenotic arteries;
Caution: hypotension, COPD, theophylline/caffeine w/in 24 hrs; |
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Term
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Definition
synthetic catecholamine, mostly beta-1 agonist;
increase coronary blood flow 2-3x baseline;
primarily used in those intolerant/C-I'd to vasodilators;
used with echocardiography |
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Term
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Definition
immediate relieft of ischemia & pain;
halt progression of dx;
prevent serious adverse outcomes; |
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Term
| Cardiovascular Risk Reductions |
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Definition
Smoking cessation;
blood pressure control;
lipid management;
physical activity/weight management;
diabetes management;
antiplatelet therapy;
RAAS system blockers;
Beta-blockers;
Influenza vaccination;
chelation therapy; |
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Term
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Definition
cardiovascular risk reduction strategy;
Ask: Identify pts willing to quit;
Advise: strongly suggest to quit;
Assess: inquire user's willingness to quit;
Assist: provide assistance;
Arrange: schedule follow-up;
Avoid exposure to environmental tobacco smoke; |
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Term
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Definition
General CAD prevention: BP target <140/90 - use any effective antiHTNsive or combo;
High CAD risk: <130/80 - ACE-I or ARB or CCB or thiazide diuretic or combination;
CAD (angina): <130/80 - BB and ACE-I or ARB;
Initiate &/or maintain lifestyle modifications |
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Term
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Definition
cardiovascular risk reductions;
diet modification - reduce intake of saturated fats (<7% of total cals), trans-fatty acids, & cholesterol (<200 mg/day);
Add plant stanols/sterols &/or viscous fiber to decrease LDL;
Daily physical activity & weight management;
Omega-3 fatty acids, higher doses to treat hypertriglyceridemia;
Target LDL<100 mg/dl;
If TGs are 200-499 mg/dL, target non-HDL <130 mg/dL;
If TG >500 mg/dL, therapy to reduce TG should be initiated prior to LDL reduction; |
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Term
| Physical Activity/Weight Management |
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Definition
30-60 min, 7 days/wk (min of 5 days/wk);
moderate-intensity aerobic activity;
resistance training 2 days/wk in addition to physical activity;
target BMI between 18.5-24.9 kg/m^2;
initiate lifestyle mods. if wt circumference is >35 in. in women or >40 in. in males;
gradual weight loss of 10% from baseline; |
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Term
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Definition
cardiovascular risk reduction;
lifestyle modifications & pharmacotherapy to achieve target HbA1C;
initiate & maintain risk factor modificaitons; |
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Term
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Definition
cardiovascular risk reductions;
aspirin 75-162 mg/day for all pts unless C/I'd;
reduces risk for adverse cardiovascular events by 33%; |
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Term
| Renin-Angiotensin-Aldosterone System Blockers |
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Definition
ACE-Is: initiate in ALL pts w/ LVEF <40% w/ HTN, DM, or CKD; consider in lower risk pts w/ mildly reduced or normal LVEF;
ARBs: alternative to ACE-Is for those w/ HF, or post-MI w/ LVEF <40%;
Aldosterone Antagonist: post-MI pts w/out significant renal dysfunction or hyperkalemia on therapeutic dose of ACE-I + BB, & have LVEF <40% + either DM or HF; |
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Term
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Definition
cardiovascular risk reduction;
all pts who had an MI, ACS, or LV dysfunction with or without heart failure symptoms; |
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Term
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Definition
annual influenza vaccination in pts w/ cardiovascular dx;
recommend INACTIVATED form; |
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Term
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Definition
| IV EDTA is NOT recommended for treatment of chronic angina or arteriosclerotic CVD |
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Term
| Pharmacological Therapy to Control Anginal Symptoms |
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Definition
1) beta-blockers;
2) CCBs;
3) nitrates;
4) ranolazine; |
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Term
| Beta-blockers - atenolol [Tenormin], carvedilol [Coreg], metoprolol [Toprol XL, Lopressor] |
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Definition
MoA: decrease HR, contractility, BP;
Beta-1 selectivity preferred, ISA NOT RECOMMENDED;
1st line for stable exertional angina for ALL pts;
Absolute C/I's: severe bradycardia, severe unstable HF in pts w/ LVEF <40%;
ADRs: bradycardia, hypotension, dizziness, worsening HF symptoms, bronchospasm, glucose intolerance/mask symptoms of hypoglycemia, fatigue, lethargy, depression;
Monitoring Parameters: Anginal Symptoms, HR, BP, Adverse Effects |
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Term
| CCBs - non-dihydropyridines - verapamil [Calan, Isoptin, Veralan, Covera], diltiazem [Cardizem, Dilacor] |
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Definition
MoA: decreases HR, decreases contractility, increases O2 supply;
Role: 1st line for Prinzmetal's angina, 2nd line for stable exertional angina;
Dihydropyridines NOT used for angina;
NON-dihydropyridines USED for angina;
IR formulations --> reflex increase in sympathetic activity, potential precipitation of myocardial ischemia;
C/Is: decompensated systolic HF, severe bradycardia (HR<50 bpm);
ADRs: bradycardia, hypotension, flushing, HA, worsening systolic HF, peripheral edema, constipation;
Monitoring Parameters: anginal symptoms, HR, BP, adverse effects; |
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Term
| nitrates - nitroglycerin, isosorbide dinitrate, isosorbide mononitrate |
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Definition
MoA: decrease myocardial O2 demand, dilate coronary arteries;
Role: acute anginal attacks - SL NTG, chronic prophylaxis - long-acting NTG;
Nitrate tolerance/tachyphylaxis: intracellular depletion of sulfhydryl groups, avoid by 10-12 hr nitrate-free period per day, use lowest effective dose;
C/I's: co-administered w/ phosphodiesterase V inhibitors (sildenafil, vardenafil, tadalafil) - excessive hypotension (irreversible);
ADRs: hypotension, flushing, HEADACHES, reflex tachycardia;
Monitoring Parameters: anginal symptoms, BP, adverse effects; |
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Term
| sublingual nitroglycerin (NTG) |
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Definition
Indications: all pts w/ IHD - treatment of accute attacks, prevention of exercise-induced pain;
Patient Education:
- if anginal discomfort lasts >2-3 min, D/c activity or remove from event;
- if pain does not subside immediately once removed from event, take NTG;
- if 1st tab does not provide relief w/in 5 min, seek medical attention by calling 911, then take a 2nd & 3rd dose at 5 min intervals;
- Should sense tingling sensation on tongue --> no tingling means no Nitric Oxide (NO) left; |
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Term
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Definition
MoA: inhibits late phase of [Na+]inward in ischemic cardiac myocytes during cardiac repolarization, decreasing intracellulr Ca which reduces ventricular tension & myocardial O2 consumption;
NO EFFECT on: HR, BP, or contractiliy;
Indications: tx of chronic angina, ADJUNCT to combo w/ amlodipine, beta-blockers, or nitrates - last-line therapy; reserved for those unresponsive to other anti-anginal medications;
Role: increases total exercise endurance & time to angina onset;
DO NOT give wi/ grapefruit juice;
ADRs: relatively well-tolerated but dizziness, HA, constipation, nausea, & QT-prolongation;
Monitoring Parameters: anginal symptoms, EKG, BP, HR, Adverse effects;
C/I's: pre-existing QT prolongation, hepatic impairment, pts receiving QT-prolonging drugs; |
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Term
| Therapy Choices for Stable Exertional Angina |
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Definition
Acute: nitrates;
Chronic prophylaxis: BBs +/- non-dihydropyridine CCBs +/- nitrates (patch, longer-acting tabs) +/- ranolazine (last line) |
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Term
| therapy choices for Prinzmetal's Angina |
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Definition
Acute: nitrates (SL, spray);
Chronic prophylaxis: 1) non-dihydropyridine CCBs, 2) nitrates (patch, longer-acting tabs);
AVOID: beta-blockers |
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Term
| Therapy Choices for Silent MI |
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Definition
NO acute tx;
Chronic Prophylaxis: 1) Beta-blocker, 2) CCB, 3) nitrates, 4) ranolazine (last-line) |
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Term
| Therapy Choices for IHD with HTN, DM |
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Definition
Recommended: 1) Beta-blocker
2) CCB; |
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Term
| Therapy Choices for Sinus bradycardia, A-V block; |
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Definition
Recommended: 1) dihydropyridine CCBs, 2) nitrates, 3) ranolazine (last-line);
Avoid:
1) beta-blockers;
2) non-dihydropyridine CCBs (verapamil, diltiazem; |
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Term
| therapy Choices for pts w/ Sinus tachycardia, rapid atrial fibrillation |
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Definition
Recommended: 1) beta-blockers;
2) non-dihydropyridine CCBs;
3) ranolazine (last-line); |
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Term
| Therapy Choices for pts w/ IHD & severe symptoms of HF (LVEF <40%) |
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Definition
Recommended:
1) amlodipine, felodipine;
2) nitrates;
AVOID:
1) non-dihydropyridine CCBs;
2) beta-blockers |
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Term
| Therapy Choices for Pts w/ IHD & Stable, Euvolemic HF (LVEF <40%) |
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Definition
Recommend:
1) beta-blockers;
2) amlodipine, felodipine;
3) nitrates;
AVOID:
1) non-dihydropyridine CCBs |
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