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Describe the pathophysiology of Coronary Artery Disease
Injury to epithelial cells in intima > platelet aggregation, monocyte migration, lipoproteins enter > monocytes develop into macrophages > Macrophages eat LDL forming foam cells > accumulation of foam cells form fatty streak > fibrotic plaque > collagen cap > ruptured plaque > collagen cascade > thrombus >possible infarct and occlusion
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What two drugs are administered to stop process of platelet aggregation and thrombus formation caused by CAD
- aspirin
- glycoprotein inhibitors
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PQRST exam of chest pain
- Provocation
- Quality
- Radiation/Region
- Severity
- Timing
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Risk factors for CAD
- men >55
- Women >65
- High LDL, Low HDL
- Smoking
- HTN
- Obesity/Inactivity
- Diabetes
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What things should u ask about the persons HX when diagnosing/treating CAD
- prior hospitilizations
- SOB/CP
- Meds: NO nitro if on sildenifil
- Stressors
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What is the Holter monitor used for
- detect dysrhythmias,
- pt wears 24-48 hrs and logs activity & symptoms
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What is held the morning before a patient goes for an exercise stress test
Beta Blockers
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What meds may be given to help stimulate response to exercise stress test
- adenosine
- regadenoson
- dipyridamole
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What test is noninvasive ultrasound that visualizes cardiac structures, motion, and function of heart valves and chambers
ECHO
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What do u instruct patients to do before TEE exam
NPO 6-8 hours before except meds
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When can a patient eat after TEE
when gag reflex returns
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What is a rare complication of TEE
esophageal perforation
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Difference between cardiac catheterization and arteriography
- C: heart pressures and CO
- A: visualize blood vessels
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Name some interventions post cardiac-cath
- bed rest 6-8 hours till discharge
- immobilize extremity used
- Look at site for bleeding/hematoma
- HOB <30
- Pulses q 15x4, q 30x4, q 1x2
- Encourage fluids
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When can CK total be seen on diagnostics? Peaks?
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When can CK-MB be seen on diagnostics? Peaks?
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When can troponin I & T be seen? Peaks?
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When can myoglobin be seen?
30-60 min
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What medication acts to treat cholesterol by inhibiting HMG-COA reductase resulting in lowering LDL
Statins
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When should Statins be taken
in the evening because body makes more cholesterol at night
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Major side effect of statins
rhabdomylosis, liver damage
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How do u instruct pt to take cholestyramine or colestipol
- mix with fluid or applesauce
- wait 1 hour before or 4 hrs after other meds
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Initial interventions of high cholesterol
life-style changes (exercise, low-cholesterol diet, wt loss, smoking cessation)
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How long after life-style modifications are made will a physician start a pt on anti-lipid meds if target cholesterol levels are not met
6 months
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Target levels for LDL:
- No CHD and <2 risk factors: 160
- No CHD >2 risk factors: <130
- CAD <100
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Side effects of nicotinic acid
LOTS: flushing, metallic taste in mouth, gout, hyperglycemia
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How to instruct pt to take nicotinic acid
- after meals
- take with aspirin to reduce flushing
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How to instruct pt to take Gemfibrozil
before bfast and dinner with milk or meals
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What condition is bile salts contraindicated in
billiary obstruction
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How do bile salts work to reduce cholesterol
combine with cholesterol containing bile acids in intestines to be eliminated through feces
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How does ezetimibe reduce cholesterol?
blocks absorption of cholesterol from food
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Drugs prescribed to CAD people to prevent platelet aggregation
- Aspirin
- clopidogril
- Dipyridimine
- Ticlopidine
- prasugrel
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Difference between stable and unstable angina
- stable: with exertion, relieved by rest
- unstable: pain at rest, more nitro therapy
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How long till a person with diagnosed unstable angina is at risk for MI
18 months
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What type of angina is caused by coronary artery spasms
Variant (Prinzmetal)
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What does unstable angina look like on EKG
ST depression
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What does EKG look like for variant angina
marked ST elevation that returns to normal after episode
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3 places in chest pain is felt during angina
- retrosternal
- left pectoral
- epigastric
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3 associated symptoms of angina
- dyspnea
- light-headedness
- diaphoresis
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how long does angina pain last
1-5 min
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3 precipitating factors of angina
- physical/emotional stress
- temp extremes
- ingestion of heavy meal
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What causes angina
- myocardial ischemia
- demand higher than supply
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how does fibric acid derivatives help lower cholesterol
increase VLDL clearance
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treatment of variant angina
CCB
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Name 3 conditions/med that affect afterload
- HTN
- Aortic stenosis
- Vasopressors
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What can caused too much increased preload
volume overload
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What type of cardiac meds can mask hypoglycemia
BB
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What to teach pt taking Verapamil
DO NOT CRUSH/CHEW
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MOA of glycoprotein Abciximab
antiplatelet
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What lab should be monitored with heparin and what should u not do if u inject it
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Most common meds given for angina
nitrates
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Instructions regarding nitoglycerin
- take before strenuous exercise
- tightly capped, away from heat/moisture
- Replace q 6 months
- Patch: rotate sites, 12-14 hours/day
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two classifications of MI
- STEMI (Q wave)
- NONSTEMI (no Q wave)
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What causes most AMIs
atherosclerosis
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How long can cardiac cells withstand ischemia
20 min
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What usually causes STEMI? NONSTEMI?
- S: plaque rupture
- NS: partial occlusion
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Treatment of RV infarct
fluids
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Paramount symptom of MI
chest pain
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What is the window for thrombolytic therapy following MI
6 hrs
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3 Thrombolytic meds
- t-PA
- Streptokinase
- Reteplase
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3 criteria for PTCA
- uncompromised collateral flow
- noncalcified lesions
- lesions not on bifurcations of vessels
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Initial pain relief of AMI
morphine
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MONA
- Oxygen
- Nitroglycerin
- Aspirin
- Morphine
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Criteria for thrombolytic therapy
- <6 hours from onset
- pain >20 min unrelieved by nitro
- ST elevation >1 of depression <0.5
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When is fibrinolysis not effective
NONSTEMI or unstable angina
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Worst complication of thrombolytics
intracranial hemorrhage
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When should PCI be performed
within 90 min of hospital, target less than 60 min
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How soon should ACE be started to prevent ventricular remodeling
24 hrs
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What has to be started and continued for individuals receiving intrcoronary stent
anticoagulates
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What 3 vessels can be used for CABG
- mammory
- saphenous vein
- radial
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What artery is most commonly used for CABG and what are some benefits
- Mammary
- better long term patency
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What is the goal of MIDCAB? When it is used
- avoid cardiopulmonary bypass
- when only 1-2 arteries will be bypassed
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3 indications for CABG
- Unstable angina
- MI
- Failed percutaneous interventions
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What are ICD used for
treat survivors of sudden cardiac arrest
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When is BNP released
secreted by ventricular myocytes in response to wall stretch
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BNP high indicated?
decompensated HF
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What is a good marker to differientiate between pulmonary and cardiac dyspnea
BNP
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4 drugs to improve pump function in HF
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What helps lower BNP
Natrecor
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3 things pericarditis can lead to
- Infusion
- Tamponade
- scarring
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3 hallmarks of pericarditis
- friction rub
- Pulsus paradoxus
- Initial ST elevation
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how long are pacemakers good for? how r they powered
- 7-10 years
- lithium batteries
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What is the primary underlying cause of HF
CAD
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Most common type of HF
Left systolic dysfunction
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Most important test to diagnose HF
ECHO
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what is the most common method of diagnosing pericarditis
detection of pericardial friction rub
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Symptoms of pericarditis
precordial pain radiating to shoulder, neck, arm, back intensified by inspiration, movement, coughing
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Treatment of pericarditis
- pain
- pericardiocentesis/or window
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Most common valve to be affected for endocarditis
mitral
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3 types of endocarditis
- Native
- Prostetic valve
- IV drug user
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name 4 skin lesions associated with septic emboli following endocarditis
- Janeway: hemorrhagic palms/soles
- Olser: red/purple fingers/toes
- Roth: retinal
- Splinter
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false verse true aneurysm
- F: complete tear in arterial wall
- T: fusiform, saccular, dissecting
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most common aneurysm? Where is it found
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