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104 Cards in this Set
- Front
- Back
what are the other names for CAD? |
ischemic heart disease IHD or coronary artery disease CHD |
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what disease does CAD include? |
stable/unstable angina and MI |
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define atherosclerosis. how is it related to CAD? |
a disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls...CAD is caused by the narrowing of arteries by atherosclerosis |
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define chronic stable angina |
chronic occurrence of chest discomfort due to transient myocardial ischemia with physical exertion or other conditions that increase oxygen demand |
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what can CAD cause? |
chronic stable angina or acute coronary syndrome |
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what consists of acute coronary syndrome? how does it all start |
unstable angina and MI, comes form the rupture of atherosclerosic plaque |
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Describe how patients find out they have CAD? |
Half have chronic stable angina the other half will have an MI |
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What are the main coronary arteries? what do they break up into? |
left main and right coronary artery. the left main splits into the left anterior descending and the circumflex |
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what is prinzmetals angina? |
vasospasm that causes a narrowing of the coronary arteries, not caused by atherosclerosis |
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what are the modifiable risk factors for CAD? |
smoking, dyslipidemia, diabetes, HTN, physical activity, obesity, low consumption of fruit and veggies, alchohol |
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what are the non modifiable risk factors for CAD? |
age greater than 45 for men, age greater than 55 for women, men or postmenopausal women, family history of premature CAD (aka first degree relative had it if male was less than 55 or female was less than 65) |
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what determines oxygen supply to the heart? |
arterial P02, diastolic filling time (shorter), plaques vasospasm or thrombus |
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what determines oxygen demand/consumption |
HR, contractility, ventricular wall tension (and this depends on BP, volume, wall thickness) |
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when exactly will you experience the symptoms of chronic stable angina? |
during exercise or when atherosclerotic plaque occludes 50-70% of coronary artery |
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how much do unstable plaques occlude an artery? |
asymptomatic, occlude less than 50% |
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Describe the quality, location, duration of CAD? |
pressure/tightness/pain, anterior or chest (neck jaw shoulder and back of arm), several minutes |
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what can accompany CAD pain? what can make it worse? |
dyspepsia, nausea, vomiting, diaphoresis big meals or cold |
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how would cardiac enzymes appear for a chronic stable angina patient? |
normal |
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what does a stress test, test for? what do you do if it is positive? what does that test look for? |
monitor EKG for signs of ischemia during exercise undergo coronary angiography visualize coronary anatomy to identify narrowing of coronary arteries due to atherosclerotic plaques |
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how can you determine between chronic stable angina and acute coronary syndrome? |
CSA is experienced in a pattern and is reproducible with exertion ACS has prolonged symptoms that are unexpected and unrelieved by NTG |
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what are the 6 treatment goals of treatment? |
prevent ACS/death, alleviate acute symptoms, prevent progression, reduce complications, minimize adverse treatment effects, prevent recurrent symptoms |
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what drugs are used to treat chronic stable angina and reduce oxygen demand of the heart? |
short acting nitrates, BB, CCB, LA nitrates |
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what are the treatments that increase oxygen supply of CSA? |
PCI which is subcutaneous coronary intervention or angioplasty CABG which is coronary artery bypass grafting |
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describe PCI surgery |
catheter into blood vessel into coronary artery, balloon inflation which is usually followed by stent placement |
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three disease states that are major risk factors for CAD? |
htn, dm, dyslipedmia |
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what drugs are used for acute coronary syndrome? |
anti-platelet agents, statins, acei/arb, SA NTG |
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what should you give if a patient cannot not take ASA? |
clopidegrel |
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when is dual antiplatelet therapy used? |
following acute coronary syndrome or PCI with stent placement |
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when can you use anti-platelet agents for primary prevention? |
if they have a history of CAD |
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who should receive a statin? what else should all these patients get? |
all patients with CAD regardless of baseline LDL a ACE or ARB |
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what should all patients with angina be prescribed? |
NTG |
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should patients take NTG before exercise? |
not recommended, no studies and may cause more dizziness |
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what should be used for patients that have frequent angina? |
BB, CCb, or LA nitrates |
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what happens when a nitrate is combined with a PDE inhibiotr? |
severe hypotension which can reduce blood flow to vital organs |
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what are the SL NTG counseling points? |
use in seated position, call 911 if symptoms do not improve/worsen after 5 minutes of the dose, store in glass container, do not store in the same container as other meds, no long term S/E do not hesitate to use, do not sue if sidenafil/vardenafil in 24 hours or tadalafil in 48 hours |
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do BB prevent cardiac arrhythmias? |
yes but only during the time around an acute coronary syndrome event |
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are BB good for long term? |
no there is no mortality benefit |
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what are the contraindications for BB |
bradycardia less than 50bpm, asthma/copd, depression |
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can BB be abruptly stopped? |
no, taper if they are hemodyamically stable, but you can d/c completely if they have hypotension or bradycardia |
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what CCB's are best to use? |
verapamil and diltiazem |
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what drug can be combined with a DHP CCB to prevent reflex tachycardia? |
BB |
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what should be used first, a BB or a CCB? |
use a BB first unless intolerable, then go for the CCB |
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a patient is using a BB but still has angina symptoms, what should you do? |
add a LA DHP CCB |
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what should be used to treat prinzmetals angina? |
CCB's over BB |
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what are the better CCB's to use if you have HF? |
ammlodipinde or felodipine, they have less negative inotropic effects |
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what should never be used to treat angina? |
short acting nifepidine or nicardipine |
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how do you avoid tolerance of nitrates? |
do not use them for 8-12 hours during the day |
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why do we avoid nitrate monotherapy? |
reflex tachycardia and increase o2 consumption, and you will not be protecting during the off time |
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can you use monotherapy nitrates in those with low BP? |
yes |
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why is ranolazine last line? |
excessive cost and can cause QT prolongnation |
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should a women with acute coronary syndrome recieve HRT? |
no, can increase thromboembolic events |
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what NSaid should a patient with CAD use for a headache? |
naproxen only for shortest duration possible |
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how should you administer aspirin and an nsaid? |
nsaid at least 30 mins after the aspirin or 8 hours before the aspirin |
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what should be avoided in variant angina? what should be used? |
BB b/c it can worsen vasospasm use CCB or nitrate |
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what should you monitor for CSA patients? |
symptoms, BP, HR, risk factors, kidney function, adherence, drug therapy |
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what is essential in patient education? |
what to do if anginal symptoms occur and when to seek emergent care |
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what is the underlying cause of acute coronary syndrome? |
the rupture of an atherscelortic plaque and eventual clot formation |
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what is a STEMI? what is usually done if a patient has one? |
it is an MI characterized by ST elevation (flat part) on an EKG reperfusion therapy with PCI within 12 hours of symptom onset |
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what drugs should a STEMI patient receive? Anything else if they undergo PCI? |
intranasal O2, SL NTG, ASA, P2Y inhibitor (clopidorgrel, prasugrel, ticagrelor), and an anticoagulation add a GPIIb/IIIa inhibitor(abciximab or tirofiban) and UFH if undergoing PCI |
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are the drugs used for the treatment of NSTEMI any different? |
initial therapy is the same but P2Y inhibitor is not used until later |
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what drugs should all STEMI/NSTEMI patients receive indefinitely? |
ASA, BB ACEI and may add statin |
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Under what conditions do you use PY2 inhibitor for a year? |
if patient undergoes PCI, or had a NSTEMI |
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Under what condiitions would you use PY2 inhibitor for 14 days? |
non-PCI treatments and STEMI |
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what proteins cause platelet adhesion and activation? |
Tissue factor and collagen on exposed smooth muscle |
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Why is ventricular remodeling bad? What drugs can slow it? |
can lead to HF, ACEI, ARBS, B and aldosterone antagonists can work |
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What may indicate ACS on an EKG? |
ST elevation, ST depression or t-wave inversion |
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what are the two cardiac biomarker? which one is preferred? |
troponin and CK-MB Troponin is preferred |
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How should be troponin be checked? |
once in ED, then 6-9 hours later, and again 12-24 hours later if negative on the first two |
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What should be done as soon as ST elevation is observed? How long can you wait for the treatments/ |
fibrinolytics within 30 mins or PCI within 90 mins? |
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Short term goals for ACS? long term |
restore blood flow, prevent further cardiac injury, prevent death , relieve chest discomfort reduce modifiable risk factors, prevent CV events, improve QOL |
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General approach of treating an ACS? |
oxygen, avoid valsalva maneuver, pain management, chew ASA, anticoagulant, continuous EKG monitoring, and vital signs |
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what are the anticoagulants used? |
UFH, enoxaparin, or bivalirudin |
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when do you call a PCI secondary? |
after 12 hours since symptom onset |
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what is the goal door to balloon time for STEMI? |
less than or equal to 90 minutes |
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what is different about PCI in NSTEMI? |
usually do angiography first |
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what is the other term for PY2 inhibitors? |
thienopyridine |
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the contraindications of fibrinolytics are? |
acute internal bleeding, previous intracranial hemorrhage or ischemic stroke in the last 3 months, intracranial neoplasm, vascular lesions, aortic dissection, closed head or facial trama in the last 3 months |
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what is the treatment option if PCI is not done for STEMI? how quickly should this be done? |
use fibriolytic, door to needle time is less than or equal to 30 minutes |
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what are the fibrinolytics? Of these, which one is not preferred? |
alteplase, reteplase, tenecteplase, and streptokinase streptokinase, has worse outcomes |
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what P2Y inhibitors are prodrugs |
clopidogrel and ticagrelor |
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For patient who do not undergo PCI and could get a fibrinolyti, what is the door to needle time? |
less than 30 mins |
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what are the indications for ASA? |
prevent stent thrombosis, reduce risk of death, recurrent MI and stroke |
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How soon should patient with ACS get ASA? |
within 24 hours of hospital admission |
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what are common drug interactions of with the thienopyridines? |
NSAIDs and Warfarin |
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What is prasugrel contraindicated in? why? |
patients with prior CVA or TIA due to increased risk of intracranial hemorrhage |
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how long should clopedigrel be used for if ACS and noninvasive strategy (thrombolysis)? |
1 month but should go for a whole year |
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how long should clopedigrel be used for if STEMI and treated with thrombolytic? |
14 days but should go for 28 days |
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what kind of stent should you use if there is a good chance the patient wont be compliant? |
use a bare metal for low adherent patients |
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how long should you wait to have surgery if you had a bare metal stent placed? what about a drug eluting stent? |
delay surgery for 4-6 weeks after BMS Delay surgery 12 months after DES |
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If you have a CABG coming up and you are on clopidogrel, how long before surgery should you stop using it? what if you were on prasugrel? |
5 days pre op 7 days pre op |
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what thienpydrodine is dose twice a day? |
ticagrelor is BID all other are QD |
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what are the glyoprotein IIB/IIIa receptor inhibitors? what is the MOA? |
abciximab, eptifbatide, and tirofiban prevent cross linking between the IIb/IIIa receptors on platelets |
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what gp IIb/IIIa receptor inhibitors get redosed based on kidney function? |
eptifibatide and tirofiban |
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when are the gp IIa/IIIb inhibtors most commonly used? |
in combo with UFH following PCI |
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What are the anticoagulants? which ones do you need to watch kidney function? |
UFH, enoxaparin, bivalirudin, and fondaparinux (not used in stemi) enox, biva, fonda |
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what may be better than the UFH gp IIb/IIIa inhibitor combo for post PCI? |
bivalirudin, and it is cheaper |
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when are anticoagulants usually discontinued? |
following PCI, may use 2-3 days if ACS w/o reperfusion |
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common side effect of nitrates? what is done to combat this? |
headache, use APAP |
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when should a patient call 911 when refering to NTG use? |
if their angina/discomfort is not resolved within 5 minutes after the first dose |
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do ACS patients usually get CCB's? When do they? |
no, only if discomfort persists despite nitrate use and contraindication of BB aka use BB first |
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when should you use an aldosterone antagonist? |
when patient is on ACE and BB and LVEF (left ventricular ejection fraction) is less than or equal to 40 percent |
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what is the main difference in treating Stemi versus nstemi? |
nstemi acs do not get fibrinolytics |
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what are the long term goals following MI? |
control modifable risk factors, prevent HF, recurrent MI or stroke, death, stent thrombosis after PCI |
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what should all these patients get |
statin, asa, bb, acei |