Term
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Definition
• Progression of a fatty streak to an advanced lesion and can be associated with endothelial injury that activates an inflammatory response
• Limitation of blood flow causes myocardial ischemia
– O2 supply vs demand
• Rupture of plaque surface occurs frequently during growth of plaque and is probably the most significant mechanism causing progression of coronary lesions |
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Term
| progression of coronary artery disease and pathophys |
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Definition
• Plaques can become unstable and rupture which promotes formation of a blood clot which can partially or completely occlude the artery
• Can occur in minutes and if severe enough can lead to downstream myocardial necrosis- MI
• This triggers a process called the ischemic cascade
– Cell death > tissues necrosis > myocardial scarring (collagen)
• Can be caused by formation of atherosclerotic plaque, rupture of plaque with thrombus formation, vasospasm, embolic occlusion, coronary artery dissection |
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Term
| coronary artery disease and occulsion |
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Definition
-asymptomatic atherosclerotic plaque- little buildup
-stable angina- atherosclerosis, only issues w physical exertion
-unstable angina- more plaque and platelets aggregate (acute coronary syndrome)
-non-ST-segment elevation MI- atherosclerosis, plt aggregation and thrombus (acute coronary syndrome_
-st-segment elevation MI- thrombus, fully occluded (acute coronary syndromes) |
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Term
| unstable angina main points |
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Definition
-non occlusive thrombus
-non specific on 12-lead ECG
-normal cardiac enzymes |
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Term
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Definition
-non-occlusive thrombus sufficient to cause tissue damage and mild myocardial necrosis
-st depression +/- t wave inversion on 12-lead ecg
-elevated cardiac enzymes |
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Term
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Definition
-complete thrombus occulustion
-ST elevation on 12-lead ECG or new LBBB
-elevated cardiac enzymes
-more severe symptoms
-high risk for cardiac arrest |
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Term
| evaluation/testing for coronary artery disease |
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Definition
• ECG stat
• Troponin (cardiac biomarkers) – Very sensitive and specific >90% – Rises fast
• CK-MB +/- (going out of favor) • CXR |
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Term
| ECK results and likelihood of MI |
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Definition
WNL 0-20%
ST depression 50%
ST elevation 60%
Q 75%
ST elevation and reciprical cahnges or ST elevation and Q waves 90%
ST elevation reciprocal changes and Q waves 90-95% |
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Term
| risk factors for coronary artery disease |
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Definition
• Hypertension
• Hyperlipidemia
• Diabetes
• ASCVD- Coronary artery disease, peripheral vascular disease, CVA
• Tobacco Use
• Family History of Premature CAD
• Gender- Male
• Age
• Sedentary Lifestyle |
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Term
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Definition
Just remember that the two coronary openings actually come off what's called the sinuses of Valsalva just above the aortic valve. You can see them right there.
The left coronary divides into the left anterior descending and the circumflex. This supplies the lateral and anterior walls of the left ventricle and the anterior 2/3 of the intraventricular septum. And then the right coronary supplies the right ventricle, posterior wall of the left ventricle, and posterior third of the septum. And then these will divide into smaller and smaller vessels. I just wanted to talk about the major vessels. So it all comes off right after those-- that's the first break off the aorta.
Because remember, you want the first bifurcation off, the most blood, the richest, oxygentated blood to go to the heart first. So the first thing that comes off when that oxygenated blood leaves the heart through the aorta is these little ostia that feed the right and left coronary arteries. The next branch off is the carotids, which go to perfuse the brain. So you want to perfuse the heart first and then the brain.
[image] |
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Term
| stable angina signs and symptoms |
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Definition
– Paroxysmal substernal chest pain, often described as squeezing or pressure sensation
– Associated symptoms: shortness of breath, nausea, vomiting, light- headedness, dizziness, palpitations, diaphoresis
– Can radiate to left neck, arm or jaw.
– Atypical symptoms in females, diabetics, and elderly
– Symptoms relieved with rest, nitroglycerin. Exacerbated by physical activity
– Levine’s sign
– No classical physical exam findings, however, signs of heart failure or cardiogenic shock may be present on exam if myocardial infarction present. |
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Term
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Definition
• Made by history and physical exam
• No significant electrocardiogram changes
• Normal cardiac enzymes |
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Term
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Definition
• Modification of Risk Factors: beta-blocker if hypertensive, statin if dyslipidemia, blood sugar control in diabetics, etc
• ASA recommended for all adults > 50 for primary prevention.
• Consider stress testing or echocardiography. |
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Term
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Definition
• Angina that is increasing in frequency or severity brought on by less exertion or not relieved by pharmacological treatment or rest.
• Usually lasts greater than 20 minutes
• May be associated with shortness of breath, nausea, diaphoresis, weakness, dizziness, or near syncope |
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Term
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Definition
– Cardiac biomarkers negative
– EKG- non specific ST segment and T wave changes
– Stress test or Myocardial perfusion imaging to evaluate severity of coronary artery disease.
• May then proceed with cardiac catheterization if indicated.
– Diagnostic Imaging that may be useful: chest radiography or echocardiography |
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Term
| unstable angina treatments |
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Definition
• Maximize medical therapy
– Aspirin
– Beta Blocker
– Nitrates- Sublingual, Nitropaste, or IV nitroglycerin – Opiates
– Oxygen- if hypoxic (SpO2 <92%)
– Heparin- ?
• Revascularization if indicated
• Refractory Angina
– Consider Ranolazine (Ranexa)
– Long acting oral nitrates (ex. Isosorbide mononitrate)
– Calcium Channel Blockers |
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Term
| 'NSTEMI causes and data interpretation/testing |
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Definition
• Caused by subendocardial AMI
• Data Interpretation/Testing
– Myocardial ischemia present with cell death leading to elevated biomarkers (CK, CK-MB, troponin)
– EKG ST depressions and T wave changes : NEW horizontal or down- sloping ST depression > 0.05mV in two contiguous leads and/or T wave inversion > 0.1mV in two contiguous leads with prominent R wave or R/S ratio > 1
– Chest radiography
– Echocardiography- evaluation of LV function and for wall motion abnormality
– Myocardial Perfusion Imaging
– CT Coronary angiography
– CoronaryAngiography |
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Term
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Definition
AMI NSTEMI
This is just an EKG of a person having an acute MRI, a non-ST-elevated MI. You see that you don't see any elevations. You actually see ST depression. I've highlighted them with the red arrows. You see ST depression and T wave changes. So no ST elevations here |
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Term
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Definition
• Initial therapy:
– Stabilizing the patient’s condition
– Relieving ischemic pain- nitrates or opiates – Providing antithrombotic therapy
• Pharmacologic anti-ischemic therapy:
– Nitrates (for symptomatic relief) SL, Topical, or IV
– Beta blockers (e.g., metoprolol): These are indicated in all patients unless contraindicated
• Pharmacologic antithrombotic:
– Aspirin
– Heparin or LMWH
– Clopidogrel, Prasugrel, or Ticagrelor
– Glycoprotein IIb/IIIa receptor antagonists (abciximab, eptifibatide, tirofiban)
• May be dependent on TIMI Score (helps determine high risk patients) |
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Term
| AMI NSTEMI additional measures and guidelines |
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Definition
• Additionaltherapeuticmeasuresthatmaybe indicated include the following:
– Thrombolysis
– Percutaneous coronary intervention (preferred treatment for ST-elevation MI)
– Coronary Artery Bypass and Grafting for severe multi- vessel disease
• Currentguidelinesforpatientswithmoderateor high-risk ACS include the following:
– Early invasive approach (urgent <24 hours vs early <72 hours)
– Concomitant antithrombotic therapy, including aspirin and clopidogrel, as well as UFH or LMWH |
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Term
| TIMI score calculation points |
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Definition
• TIMI Score Calculation (1 point for each):
– Age≥65
– Aspirinuseinthelast7days(patientexperienceschestpaindespite ASA use in past 7 days)
– Atleast2anginaepisodeswithinthelast24hrs
– STchangesofatleast0.5mmincontiguousleads
– Elevatedserumcardiacbiomarkers
– KnownCoronaryArteryDisease(CAD)(coronarystenosis≥50%)
– Atleast3riskfactorsforCAD,suchas:
• Hypertension -> 140/90 or on anti-hypertensives
• Current cigarette smoker
• Low HDL cholesterol (< 40 mg/dL)
• Diabetes mellitus
– FamilyhistoryofprematureCAD
• Male first-degree relative or father younger than 55
• Female first-degree relative or mother younger than 65 |
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Term
| TIMI score interpretation |
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Definition
– % risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization.
– Score of 0-1 = 4.7% risk
– Scoreof2=8.3%risk
– Score of 3 = 13.2% risk
– Score of 4 = 19.9% risk
– Score of 5 = 26.2% risk
– Score of 6-7 = at least 40.9% risk |
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Term
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Definition
• STelevation– persistent complete occlusion of an artery supplying a significant area of myocardium without adequate collateral circulation- transmural AMI
• 80%ofheartdamage occurs within the first 2 hours
[image] |
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Term
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Definition
• STelevationduetoAMI usually demonstrates regional or territorial pattern
• PrecordialLeads:V1-V6 subdivided
– Septal V1-V2 – Anterior V3-V4 – Lateral V5-V6
• LimbLeads
– Lateral I, aVL
– Inferior II, III, aVF
[image] |
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Term
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Definition
• ST elevations defined as elevation at the J point (point where the ST takes off from the QRS) in two contiguous leads > 0.1mV in limb leads and > 0.2 mV in precordial leads or new LBBB on EKG, will see reciprocal changes.
• Regions
– Anterolateral (LAD, LCx): I, aVL, V4- V6
– Lateral (LCx): I, aVL, V5, V6
– Apical (LAD or RCA): V3-V6
– Inferior (RCA): II,III,aVF
– Anteroseptal (LAD): V1-V3 |
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Term
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Definition
• Morphine, Oxygen, Nitroglycerin(SL,IV), ASA 325mg, Beta-blocker if no contraindication
– Caution nitroglycerin in inferior MI- decrease in preload leading to hypotension, caused by RV involvement
– Beta blocker- caution in large anterior MI with signs of CHF or shock and with inferior MI (bradycardia and CHB)
• Adjunctive treatment: heparin, clopidogrel, IIb/IIIa inhibitors
• EMERGENT REVASCULARIZATION
– PCI with goal door-to-balloon time 90 minutes
– If facility unable to do PCI, fibrinolytic therapy with goal door-to- needle time 30 minutes if onset of symptoms < 12 hours.
– Contraindications to fibrinolytic therapy |
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Term
| AMI thrombolytic therapy absolute and relative contraindicaitons |
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Definition
absolute: • Active bleeding/bleeding disorders
• Prior hemorrhagic stroke/other
stroke within 1 year
• Intracranial or spinal cord cancer
• Suspected/known aortic dissection
Relative:
• Severe/uncontrolled hypertension
• Anticoagulation (elevated INR)
• Old ischemic stroke
• Recent major surgery/trauma
• Pregnancy |
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Term
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Definition
STEMI
• There is progressive ST elevation and Q wave formation in V2-5
• ST elevation is now present in I and aVL.
• There is some reciprocal ST depression in lead III.
• This is an acute anterior STEMI – this patient needs urgent reperfusion! |
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Term
| post STEMI revascularization recommendations |
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Definition
• Recommended Dual Anti-platelet therapy (ASA, Plavix)- post stent- up to 12 months then aspirin for indefinitely.
– TicagrelorwasfoundtobesuperiortoPlavix
– PrasugrelwasfoundtobesuperiortoPlavix
• Continue O2 therapy as needed
• Statins- high intensity
• Beta-Blockers
• ACEi for patients with LV dysfunction (ARB if ACEi not tolerated)
• Glycemic & BP optimization
• Modify lifestyle as necessary
• Follow up- important, may have other critical or noncritical disease that needs to be staged
• Secondary Prevention- prevent further MI events, CHF, and strokes |
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Term
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Definition
• Arrhythmias–Atrial Fibrillation,Ventricular Tachycardia or Fibrillation (most common cause of death)
• Heart Failure
– New left ventricular dysfunction/Cardiomyopathy
– Papillary muscle rupture causing new mitral regurgitation
• Left Ventricular wall rupture or aneurysm
• RV failure
• Cardiogenic Shock
• Cardiac Arrest |
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Term
|
Definition
• Varies depending on person’s health, extent of heart damage, and treatment
– 5-6%diebeforeleavingthehospital,7-18%diewithin1year
• Risk factors
– Age
– Hemodynamicvariables-lowsystolicBP
– STsegmentdeviation
– Diabetes
– AKI
– Heartfailure-causedbydecreasedLVfunction
• Symptoms include pulmonary edema, S3 gallop, elevated JVD, etc
• 5 year survival for newly diagnosed CHF- 50%
• Mechanical complication-papillary muscle rupture, free wall rupture, etc
• Morbidity and mortality has improved with improvement in treatment and PCI techniques |
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