Edited, memorised or added to reading list

on 20-Apr-2016 (Wed)

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Flashcard 1334347173132

Tags
#cardiology
Question
How do physiological mechanisms act to maintain arterial pressure and organ perfusion in CHF (failure of the cardiac pump)?
Answer
 Frank-Starling Mechanism: increase in end-diastolic ventricular volume increases tension in wall and enhances contractility

 Activation of the sympathetic nervous system
- Increase heart rate
- Increase myocardial contractility

 Activation of the renin-angiotensin system

 Myocardial adaptations, including hypertrophy and ventricular remodeling


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Flashcard 1334349008140

Tags
#cardiology #exam
Question
The hypertrophied heart is vulnerable to [...]
Answer
decompensation

d/t:
 Increase in size of cardiac myocytes
 No proportional increase in capillary number!
 Oxygen consumption increased in hypertrophied heart but supply of oxygen and nutrients potentially more restricted


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Flashcard 1334350843148

Tags
#cardiology
Question
Differential Diagnosis of Cardiac Hypertrophy
Answer
Cardiomyopathic processes e.g. Hypertrophic cardiomyopathy
Volume overload processes e.g. Aortic insufficiency
Pressure overload processes e.g. Essential hypertension
Compensatory processes e.g. Atherosclerotic heart disease
Interstitial infiltrative processes e.g Amyloidosis
Storage disease processes e.g. Pompe Disease
Drugs e.g. Anabolic steroids


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Flashcard 1334352678156

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#cardiology
Question
Physiological hypertrophy is:
Answer
increased size of cardiomyocytes without significant end organ damage (i.e. fibrosis)


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Flashcard 1334354513164

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#cardiology
Question
Pathological hypertrophy is:
Answer
cardiomyocyte hypertrophy associated with both structural changes and molecular changes


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Flashcard 1334356348172

Tags
#cardiology
Question
Cardiac hypertrophy initially [...] but ultimately leads to [...]
Answer
decreases wall stress
decreased myocardial performance


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Flashcard 1334358183180

Tags
#cardiology
Question
What increases cardiac work? (4 things)
Answer
1) MI (regional dysfn w/ volume overload)
2) valvular ds (pressure and/or volume overload)
3) HTN (pressure overload)
4) cardiomyopathy (cellular contraction defect or myocarditis)


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Flashcard 1334360018188

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#cardiology
Question
[...] → ↑ wall stress → cell stretch → hypertrophy and/or dilatation → systolic/diastolic dysfn
Answer
↑ cardiac work → ↑ wall stress → cell stretch → hypertrophy and/or dilatation → systolic/diastolic dysfn


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Flashcard 1334361853196

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#cardiology
Question
↑ cardiac work → [...] → cell stretch → hypertrophy and/or dilatation → systolic/diastolic dysfn
Answer
↑ cardiac work → ↑ wall stress → cell stretch → hypertrophy and/or dilatation → systolic/diastolic dysfn


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Flashcard 1334363688204

Tags
#cardiology
Question
↑ cardiac work → ↑ wall stress → [...] → hypertrophy and/or dilatation → systolic/diastolic dysfn
Answer
↑ cardiac work → ↑ wall stress → cell stretch → hypertrophy and/or dilatation → systolic/diastolic dysfn


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Flashcard 1334365523212

Tags
#cardiology
Question
↑ cardiac work → ↑ wall stress → cell stretch → [...] → systolic/diastolic dysfn
Answer
↑ cardiac work → ↑ wall stress → cell stretch → hypertrophy and/or dilatation → systolic/diastolic dysfn


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Flashcard 1334367358220

Tags
#cardiology
Question
↑ cardiac work → ↑ wall stress → cell stretch → hypertrophy and/or dilatation → [...]
Answer
systolic/diastolic dysfn


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Flashcard 1334369193228

Tags
#cardiology
Question
Cardiomyopathy is:
Answer
a term used to describe heart disease resulting from an abnormality in the myocardium


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Flashcard 1334371028236

Tags
#cardiology
Question
Cardiac myopathy has multiple different etiologies:
Answer
 Primary cardiomyopathies represent diseases of the myocardium itself

 Secondary cardiomyopathies are other systemic disorders that also cause damage to the myocardium (e.g. Alcoholism, infectious myocarditis, thiamine deficiency, etc.)


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Flashcard 1334372863244

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#cardiology
Question
What are the patterns of cardiomyopathy?
Answer
 Dilated cardiomyopathy (including arrhythmogenic right ventricular cardiomyopathy) - mix of genetic & acquired
 Hypertrophic cardiomyopathy - usually genetic (beta myosin chain)
 Restrictive cardiomyopathy - usually acquired (something causing stiffening of myocardium e.g. amyloid)


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Flashcard 1334374698252

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#cardiology
Question
What are other causes of myocardial dysfunction or damage?
Answer
 Myocarditis - Infectious, Immune-mediated
 Cardiotoxic drugs - Cancer chemotherapy drugs, lithium, etc.
 Amyloidosis - Cardiac restricted (transthyretin), Systemic amyloidosis


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Flashcard 1334376533260

Tags
#cardiology
Question
fluid hemodynamics:
The capillary bed is the site of [...]
Answer
hemodynamic control

NB:
Arteriolar end – hydrostatic pressure predominates
Venular end – oncotic pressure predominates


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Flashcard 1334379154700

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#cardiology
Question
fluid hemodynamics:
Exit of fluid at the [...] end is nearly balanced by influx of fluid at the venular end
Answer
arteriolar
venular


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Flashcard 1334380989708

Tags
#cardiology
Question
fluid hemodynamics:
Excess interstitial fluid is drained via [...]
Answer
lymphatics


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Flashcard 1334382824716

Tags
#cardiology
Question
CAUSES OF EDEMA
Answer
 Increased hydrostatic pressure: - Venous obstruction, congestive heart failure, arteriolar dilatation
 Reduced plasma oncotic pressure: - Cirrhosis, malnutrition, nephrotic syndrome
 Lymphatic obstruction
 Sodium Retention
 Inflammation


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Flashcard 1334384659724

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#cardiology
Question
In Subcutaneous edema, Distribution is influenced by [...] and is most pronounced in the [...] parts of the body
Answer
gravity
dependant

NB: it may be the first clue to heart failure


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Flashcard 1334386494732

Tags
#cardiology
Question
pulmonary edema is Most commonly seen with [...]
Answer
left ventricular failure


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Flashcard 1334388329740

Tags
#cardiology
Question
Brain edema May be [...] or generalized (e.g. encephalitis, CSF outflow obstruction)
Answer
localized (e.g. with abscess or neoplasm)


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Flashcard 1334390164748

Tags
#cardiology
Question
Brain edema May be localized (e.g. with abscess or neoplasm) or [...]
Answer
generalized (e.g. encephalitis, CSF outflow obstruction)


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Flashcard 1334391999756

Tags
#cardiology #exam
Question
CLINICAL CONSEQUENCES OF EDEMA
Answer
Effects range from merely annoying to fatal

 Subcutaneous edema most significant as a marker of an underlying problem with fluid hemodynamics
 Pulmonary edema can interfere with normal ventilatory function
 Severe brain edema can result in herniation and compression of critical structures


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Flashcard 1334393834764

Tags
#cardiology
Question
Obstruction to blood flow can take two forms:
Answer
 Obstruction to flow of blood through the heart (e.g. obstruction of a valve or great vessel)
 Obstruction to flow of blood to the heart (i.e. obstruction of a coronary vessel) - reducing blood supply to the heart when it needs it the most


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Flashcard 1334395669772

Tags
#cardiology #exam
Question
Obstruction to blood flow through the heart is frequently due to problems with [...]
Answer
heart valves

E.g. Aortic valve stenosis, Congenital heart valve problems (e.g. Tricuspid atresia, bicuspid aortic valve), Endocarditis


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Flashcard 1334397504780

Tags
#cardiology
Question
A stenotic valve cannot open completely, thus hindering [...]
Answer
forward flow of blood


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Flashcard 1334399339788

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#cardiology
Question
Valve stenosis can lead to [...] and can also lead to cardiac hypertrophy or potentially pump failure if untreated
Answer
increased work for the heart (pressure overload)


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Flashcard 1334401699084

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#cardiology
Question
Valve stenosis can lead to increased work for the heart (pressure overload) and can also lead to [...] or potentially pump failure if untreated
Answer
cardiac hypertrophy


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Flashcard 1334403534092

Tags
#cardiology
Question
Valve stenosis can lead to increased work for the heart (pressure overload) and can also lead to cardiac hypertrophy or potentially [...] if untreated
Answer
pump failure


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Flashcard 1334405369100

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#cardiology
Question
Obstruction to blood flow through coronary aa → MI
why?
Answer
Development of atherosclerotic plaque +/- thrombus (fixed or variable obstruction)

Occlusive thrombus on plaque (complete obstruction)


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Flashcard 1334407466252

Tags
#cardiology
Question
What is the triad of thrombosis?
Answer
hypercoagulability

abnormal blood flow

endothelial injury


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Flashcard 1334409301260

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#cardiology
Question
What is the predominant cause of thrombosis?
Answer
Endothelial injury

-Particularly important for arterial or cardiac thrombus formation
-Frequently occurs over atherosclerotic plaques, or at sites of trauma or inflammatory vascular injury (vasculitis)
-May be due to physical disruption of endothelium with exposure of underlying collagen, or endothelial dysfunction


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Flashcard 1334411136268

Tags
#cardiology #exam
Question
What types of abn blood flow can lead to thrombosis?
Answer
turbulence
-Contributes to arterial/cardiac thrombosis by promoting endothelial injury/dysfunction
-Also forms countercurrents and local pockets of static blood

stasis
-Major factor in the development of venous thrombi
-hyperviscosity

Turbulence and Stasis:
 Disrupt laminar blood flow
 Allow platelets to come into close contact with endothelium
 Prevent dilution of activated clotting factors
 Promote endothelial cell activation


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Flashcard 1334412971276

Tags
#cardiology
Question
Hypercoagulability is
Answer
Any alteration of the coagulation pathways that predisposes to thrombosis


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Flashcard 1334414806284

Tags
#cardiology
Question
What are causes of hypercoagulability?
Answer
Primary (genetic)
 Factor V Leiden
 Prothrombin mutation
 Homocysteinemia
 Protein C, S deficiency

Secondary (acquired)
 OCP, Pregnancy
 Smoking
 Prolonged immobilization
 Cancer


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Flashcard 1334416641292

Tags
#cardiology
Question
What is the fate of the thrombus?
Answer
Propagation
 Extension and growth of thrombus
 May eventually lead to vessel occlusion (bad with coronary aa)

Embolization
 Arterial vs. venous

Dissolution

Organization and recanalization (so thrombus may not cause much problem)


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Flashcard 1334418476300

Tags
#cardiology
Question
What is regurgitant blood flow?
Answer
Failure to maintain unidirectional flow of blood through the heart


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Flashcard 1334420311308

Tags
#cardiology
Question
[...] and [...] of blood flow through damaged valves may coexist
Answer
Obstruction
Regurgitation


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Flashcard 1334422146316

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#cardiology
Question
Shunted blood flow is typically a ft of:
Answer
congenital cardiac anomalies, involving the heart and/or great vessels


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Flashcard 1334423981324

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#cardiology
Question
Cardiac anomalies arise during gestational weeks [#] when major cardiovascular structures begin to form
Answer
3 - 8


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Flashcard 1334425816332

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#cardiology
Question
Defects compatible with embryological development and maturation usually only affect [...] or [...]
Answer
one chamber
discrete region of the heart


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Flashcard 1334427651340

Tags
#cardiology
Question
What are different types of congenital cardiac anomalies?
Answer
 Malformations causing left-to-right shunt (more load on RV)
 Malformations causing right-to-left shunt (shunting de-O2 blood into systemic)
 Malformations causing an obstruction (e.g. coarctation of aorta w/ R to L shunt)


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Flashcard 1334431321356

Tags
#cardiology
Question
Type of arrhythmia depends on [...] to the conduction system and/or presence of [...]
Answer
location of disruption
ectopic foci of excitation


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Flashcard 1334433156364

Tags
#cardiology
Question
[...] is often a result of trauma, leading to massive loss of blood into body cavities, and shock
Answer
Rupture of the heart/great vessels


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Flashcard 1334434991372

Tags
#cardiology
Question
Rupture of the heart/great vessels is often a result of [...] , leading to massive loss of blood into body cavities, and shock
Answer
trauma


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Flashcard 1334436826380

Tags
#cardiology
Question
A smaller cardiac rupture may result in [...] into the [...]
Answer
leakage of blood
pericardial space

NB: can cause cardiac tamponade = mechanical restriction


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Flashcard 1334438661388

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#cardiology
Question
Rupture of the great vessels may be seen with [2-3 things]
Answer
severe atherosclerotic or aneurysmal disease, diseases of collagen synthesis (i.e. Marfan syndrome, Ehlers-Danlos syndrome), etc.


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Flashcard 1334440496396

Tags
#cardiology
Question
What is shock?
Answer
Systemic hypoperfusion caused by reduction in effective circulating blood volume or cardiac output, resulting in impaired tissue perfusion and cellular hypoxia


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Flashcard 1334442331404

Tags
#cardiology
Question
What are causes of shock?
Answer
 Cardiogenic Shock (acute versions)
- Myocardial infarction, ventricular rupture, arrhythmia, cardiac tamponade, pulmonary embolism
 Hypovolemic Shock
- Hemorrhage, fluid loss, trauma, etc.
 (Septic Shock)
 (Neurogenic Shock)
 (Anaphylactic Shock)


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Flashcard 1334444166412

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#cardiology
Question
What are the stages of shock?
Answer
1) initial non-progressive phase (compensatory mechanisms)
-Neurohumoral mechanisms act to maintain cardiac output and blood pressure
-Ex. Release of catecholamines, ADH, activation of reninangiotensin-aldosterone pathway, generalized sympathetic stimulation
-Net effect: tachycardia, peripheral vasoconstriction, renal conservation of fluid

2) progressive phase
-Widespread tissue hypoxia commences:
  • ↓ pH due to lactic acid production (anaerobic glycolysis)
  • ↓ vasomotor response with arteriolar dilatation and blood pooling in the peripheral circulation
  • Vital organs begin to fail (AKI)
-clinically confused, urine output ↓

3) irreversible stage
-Widespread anoxic cellular injury occurs
 Leakage of lysosomal enzymes
 Marked electrolyte disturbances
 ↓ Myocardial contractility
 Complete renal shutdown due to acute tubular necrosis
 Multi-organ system failure ensues
 May develop disseminated intravascular coagulation


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Flashcard 1334449933580

Tags
#cardiology #pathology
Question
What are the 3 pathological distribution of atherosclerosis?
Answer
1) branch points
2) curvatures
3) regions of complex blood flow


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Flashcard 1334451768588

Tags
#cardiology #pathology
Question
Pathological Consequences of Atherosclerosis
Answer
1.Coronary artery disease
2.Abdominal aortic aneurysms
3.Cerebrovascular disease – stroke syndromes
4.Peripheral vascular disease
5.Mesenteric disease
6.Renovascular disease


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Flashcard 1334453603596

Tags
#cardiology #pathology
Question
the [...] is the master vascular regulator
Answer
endothelial cell


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Flashcard 1334457273612

Tags
#cardiology #pathology
Question
Pathophysiology of atherosclerosis:

[...] → endothelial dysfn → inflm cell recruitment → foam cell formation & fatty streaks (cycles w/ inflm cell recruitment) → intermediate lesion → fibrous plaque → thrombus formation
Answer
Pathophysiology of atherosclerosis:

toxic insult → endothelial dysfn → inflm cell recruitment → foam cell formation & fatty streaks (cycles w/ inflm cell recruitment) → intermediate lesion → fibrous plaque → thrombus formation


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Flashcard 1334459108620

Tags
#cardiology #pathology
Question
Pathophysiology of atherosclerosis:

toxic insult → [...] → inflm cell recruitment → foam cell formation & fatty streaks (cycles w/ inflm cell recruitment) → intermediate lesion → fibrous plaque → thrombus formation
Answer
Pathophysiology of atherosclerosis:

toxic insult → endothelial dysfn → inflm cell recruitment → foam cell formation & fatty streaks (cycles w/ inflm cell recruitment) → intermediate lesion → fibrous plaque → thrombus formation


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Flashcard 1334460943628

Tags
#cardiology #pathology
Question
Pathophysiology of atherosclerosis:

toxic insult → endothelial dysfn → [...] → foam cell formation & fatty streaks (cycles w/ inflm cell recruitment) → intermediate lesion → fibrous plaque → thrombus formation
Answer
Pathophysiology of atherosclerosis:

toxic insult → endothelial dysfn → inflm cell recruitment → foam cell formation & fatty streaks (cycles w/ inflm cell recruitment) → intermediate lesion → fibrous plaque → thrombus formation


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Flashcard 1334462778636

Tags
#cardiology #pathology
Question
Pathophysiology of atherosclerosis:

toxic insult → endothelial dysfn → inflm cell recruitment → [...] → intermediate lesion → fibrous plaque → thrombus formation
Answer
Pathophysiology of atherosclerosis:

toxic insult → endothelial dysfn → inflm cell recruitment → foam cell formation & fatty streaks (cycles w/ inflm cell recruitment) → intermediate lesion → fibrous plaque → thrombus formation


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Flashcard 1334464613644

Tags
#cardiology #pathology
Question
Pathophysiology of atherosclerosis:

toxic insult → endothelial dysfn → inflm cell recruitment → foam cell formation & fatty streaks (cycles w/ inflm cell recruitment) → [...] → fibrous plaque → thrombus formation
Answer
Pathophysiology of atherosclerosis:

toxic insult → endothelial dysfn → inflm cell recruitment → foam cell formation & fatty streaks (cycles w/ inflm cell recruitment) → intermediate lesion → fibrous plaque → thrombus formation


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Flashcard 1334467759372

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Question
Pathophysiology of atherosclerosis:

toxic insult → endothelial dysfn → inflm cell recruitment → foam cell formation & fatty streaks (cycles w/ inflm cell recruitment) → intermediate lesion → fibrous plaque → [...]
Answer
thrombus formation


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Flashcard 1334469594380

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Question
What is the spectrum of lesions in atherosclerosis?
Answer
1.Stable eccentric atheroma, with:
a. Thin fibrous cap overlying necrotic lipid core (vulnerable plaque)
b. Stable fibromuscular plaque
c. Stable fibrocalcific plaque
2.Acute plaque hemorrhage with rapid expansion of plaque
3.Atherosclerosis with non‐occlusive luminal thrombus
4.Atherosclerosis with occlusive luminal thrombus
5.Atherosclerosis with recanalized, organized thrombus
6.Atherosclerosis with obliterated lumen


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Flashcard 1334471429388

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Question
What are the typical ft's of atheresclerosis?
Answer
  • Typical eccentric plaque
  • Necrotic core (outgrow blood supply)
  • May have thin fibrous cap
  • Chronic inflammation common
  • Remodelling of vessel wall common
  • Luminal stenosis (here severe)
  • Calcification common


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Flashcard 1334473264396

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Question
What is an acute myocardial infarction?
Answer
  • kills by causing heart failure or arrhythmia (via ischemia)
  • acute coagulative necrosis
  • Usually localizes to vascular territory perfused by occluded artery
  • Left ventricle most often effected
  • Starts in subendocardial zone and may become transmural


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Flashcard 1334475099404

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Question
Early myocardial ischemia / infarction shows [...] on histology
Answer
contraction bands
-takes 6h to develop


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Flashcard 1334476934412

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Question
When do you start to see acute inflm in early MI?
Answer
>12-16 hours


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Flashcard 1334478769420

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Question
Early healing myocardial infarction shows [...] and [...] on histology
Answer
macrophages
loss of cardiomyocytes

-takes place after >1 day
-moving in of chr inflm cells
-fibroplasia to stabilize wall (can cause arrhythmia)


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Flashcard 1334480604428

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Question
Complications of an Acute Myocardial Infarction
Answer
Arrhythmia / sudden death (~20%)
Free wall or septal rupture / hemopericardium (tamponade)
Mitral insufficiency / acute heart failure
Papillary muscle rupture (→ acute valvular insufficiency - can kill you quickly)
Aneurysm / mural thrombus / embolism
Congestive heart failure (long term)


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Flashcard 1334482439436

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Question
With chr ischemia, there is [...] and [...] without history of myocardial infarction
Answer
Myocardial fibrosis
degeneration

-myocardium in survival mode; no fn


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Flashcard 1334484274444

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Question
Any coronary artery luminal stenosis of [...] % significantly increases the risk of sudden and unexpected death at any time
Answer
> 70‐75


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Flashcard 1334486109452

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Question
Any coronary artery luminal stenosis of > 70‐75% significantly increases the risk of [...]
Answer
sudden and unexpected death at any time


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Flashcard 1334487944460

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Question
Any coronary artery luminal stenosis of > 70‐75% significantly increases the risk of sudden and unexpected death at any time – especially when..
Answer
there exists a supply vs. demand mismatch such as with exercise, emotional stress, etc


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Flashcard 1334491614476

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Question
What are 3 atherosclerotic aortic ds's?
Answer
aortic dissection (most d/t HTN)
intramural hematoma
penetrating aortic ulcer


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Flashcard 1334493449484

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Question
What is atheroembolic ds?
Answer
bits of plaque get released and occlude little vessels down stream (can → acute renal failure)


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Flashcard 1334495284492

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Question
What is "trash foot"?
Answer
Ulcerations & gangrene on the feet d/t atheroemboli occluding small vessels after catherization


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Flashcard 1334497643788

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Question
What is a coronary atheroma?
Answer
Buildup of cholesterol, calcium, and inflammatory cells

Results in coronary artery narrowing


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Flashcard 1334499478796

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Question
The largest risk factor of coronary artery ds is [...]
Answer
Age


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Flashcard 1334501313804

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Question
What are the big 5 risk factors for CAD ?
Answer
1. cigarette smoking
2. hyperlipidemia
3. diabetes
4. hypertension
5. family history of premature CAD


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Flashcard 1334503148812

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Question
Smoking is associated w/ [2 things]
Answer
acute plaque rupture (d/t accelerated plaque progression) and heart attack
-very important risk factor @ young age


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Flashcard 1334505245964

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Question
What is angina?
Answer
symptom due to myocardial ischemia from myocardial oxygen demand exceeding supply


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Flashcard 1334508653836

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Question
What are ft's not characteristic of angina?
Answer
• Location: solely middle/lower abdomen, radiates into lower extremities, localized to one finger tip
• Character: reproduced by movement or palpation, pleuritic (sharp brought on by respiration)
• Duration: very brief (few seconds or less), constant for many hours


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Flashcard 1334510488844

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Question
Aggravating and alleviating factors of angina?
Answer
precipitants:
• Exercise
• Emotion
• Eating
• Cold
• Sexual activity

relievers:
• Rest
• Nitroglycerin (vasodilator)


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Flashcard 1334512323852

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Question
How is severity of angina classified?
Answer
I
No limitation to ordinary activity.
Angina with strenuous, rapid or prolonged exertion

II
Slight limitation to ordinary activity
Angina walking > 2 level blocks or > 1 flight of stairs

III
Marked limitation to ordinary activity
Angina walking < 2 level blocks or < 1 flight

IV
Inability to carry out any activity.
Angina may be present at rest


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Flashcard 1334514158860

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Question
What are the classifications of angina?
Answer
Typical angina (definite) - needs to meet all 3 criteria
1) substernal chest discomfort - burning, tightness, squeezing
2) provoked by exertion or emotional stress and
3) relieved by rest or nitroglycerin

Atypical angina (probable)
-meets 2 of the of characteristics

Noncardiac chest pain
-meets ≤ 1 of the typical angina characteristics


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Flashcard 1334515993868

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Question
The pre-test probability is based on [3 things]
Answer
age
sex
classification of angina (typical, etc)


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Flashcard 1334517828876

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Question
What types of diagnostic testing do we do for angina?
Answer
functional
-exercise stress test
-nuclear test
-stress ECHO

structural
-coronary angiogram
-CT coronary angiogram


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Flashcard 1334519663884

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Question
What 2 components do all functional tests (for angina) have?
Answer
Stress – some method of increasing myocardial demand (by dropping resistance)
Test – some measure of adequacy of blood supply (ECG, Nuclear, ECHO - imaging the resulting flow)


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Flashcard 1334521498892

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Question
How can we induce stress for functional tests?
Answer
Exercise (most common)

Pharmacologic stresses (if can't exercise)
– Dobutamine (beta agonist) - causes HR to go up, and causes heart to contract more vigorously -> higher demand (checks can epicardial aa supply enough)

Vasodilators
– Persantine
– Adenosine


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Flashcard 1334523858188

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Question
Coronary flow is autoregulated by [...]
Answer
arteriolar smooth muscle tone


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Flashcard 1334525693196

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Question
How much stenosis is required to bring on exercise & rest chest pain?
Answer
exercise pain @ 70%
rest pain @ 90%


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Flashcard 1334527528204

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Question
What is the ischemic cascade?
Answer
Different things you can measure as ischemia progresses over time:
1) blood flow changes (Nuclear)
2) wall motion abnormalities (ECHO)
3) ECG changes (ECG)
4) pain (symptomatic) - very last


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Flashcard 1334529363212

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Question
Describe the 3 functional tests for angina
Answer
Exercise treadmill stress test
-Treadmill protocol (most common: Bruce) - speed & incline gradually increases every few min
- 65% accurate for severely narrowed arteries (so not very good)
-Assess for symptoms, and changes in blood pressure and ECG

Nuclear testing
-IV radioactive tracers (don't want to do too many in esp young women)
-Taken up by myocardium proportional to blood flow
-Emits radiation which can be measured
-85% accuracy (more accurate, more expensive)
-if change at rest vs stress, reversible defect = ischemia
-if no change at rest/stress, fixed defect = prior infarct

ECHO (u/s) testing
-Normal heart muscle thickens 50% when it contracts
-Abnormal heart thickening referred to as “wall motion abnormality”
-Wall motion abnormalities during stress but not at rest suggest ischemia
-90% accuracy, also expensive


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Flashcard 1334531198220

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Question
What are the 2 structural tests for angina?
Answer
Coronary angiography
-Gold standard (100% accuracy)
-Invasive
-1:1000 risk of serious complications

CT coronary angiogram
-CT scan with contrast opacification of coronary arteries
-95-98% accurate


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Flashcard 1334533033228

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Question
Bayes theorem:
A tests predictive value is dependent on [...]
Answer
pretest probability

NB:
pre-test probability - 10% -> 50% (w/ +ve test) or 1% (w/ -ve test)
- 50% -> 90% (+ve) or 10% (-ve)
- 90% -> 99% (+ve) or 50% (-ve)


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Flashcard 1334534868236

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Question
Non‐pharmacologic treatment of Stable CAD
Answer
• Exercise
• Weight loss
• Mediterranean diet (fruits, vegetables, olive oil, nuts, fish)
• Smoking cessation


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Flashcard 1334536703244

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Question
Pharmacologic treatment of Stable CAD
Answer
• Risk factor modification: Treat diabetes, hypertension, dyslipidemia (statins) - rx these aggressively
• Antiplatelet: aspirin - to prevent acute events from plaques
• Anti‐anginals
– Beta‐blockers (e.g. bisoprolol) - first line
– Nitrates (sublingual spray, patch, pills) - vasodilators
– Calcium channel blockers (e.g. amlodipine) - also vasodilates


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Flashcard 1334538538252

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Question
What are 2 ways of revascularization in CAD?
Answer
Percutaneous Coronary Intervention - stents
• Bare metal stents
– Stainless steel
• Drug eluting stents
– Stainless steel/Platinum chromium
– Drugs (anticancer drugs to prevent cell growth into stents)
• Everolimus
• Zotarolimus

Coronary Artery Bypass Grafting
• Internal mammary and saphenous vein grafts used to bypass blockages


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Flashcard 1334547713292

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Question
What are the 2 classes of acute coronary syndromes (ACS)?
Answer
Unstable angina

MI
-STEMI
-non-STEMI


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Flashcard 1334549548300

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Question
What is unstable angina?
Answer
Clinical syndrome characterized by new or worsened coronary ischemia


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Flashcard 1334551383308

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Question
What is an MI?
Answer
Myocardial necrosis due to coronary artery occlusion


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Flashcard 1334553218316

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Question
What shows ST-elevation?
Answer
STEMI


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Flashcard 1334555053324

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Question
What shows no ST-elevation?
Answer
non-STEMI
unstable angina


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Flashcard 1334556888332

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Question
In general, [...] imply more loss of myocardium
Answer
Q waves


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Flashcard 1334558723340

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Question
In general, Q waves imply [...]
Answer
more loss of myocardium


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Flashcard 1334560558348

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Question
Central mechanism of ACS is [...]
Answer
Plaque Rupture


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Flashcard 1334562393356

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Question
[...] is pathognomonic of infarction
Answer
Acute ST elevation is pathognomonic of infarction


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Flashcard 1334564490508

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Question
Acute ST elevation is pathognomonic of [...]
Answer
Acute ST elevation is pathognomonic of infarction


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Flashcard 1334566325516

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Question
Chest pain [how long] suggests infarction
Answer
> 20 min to hours


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Flashcard 1334568160524

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Question
What falls under unstable angina?
Answer
• New onset angina
• Accelerated angina (classic)
– Decreasing exercise capacity
– Increased duration, frequency
– Crescendo angina
• Rest angina
• Post-MI

NB: these pt's likely have ruptured plaque


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Flashcard 1334569995532

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Question
What ECG findings would you see with unstable angina/non-STEMI?
Answer
• Normal
• T inversion
• ST depression


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Flashcard 1334571830540

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Question
What ECG findings would you see with STEMI?
Answer
• ST elevation
• New LBBB


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Flashcard 1334573665548

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Question
Which ECG leads measure what wall of the heart and function of which vessel?
Answer
V1 – V4Anterior WallLAD
II, III, aVFInferior WallRCA
V5 – V6Lateral WallCircumflex


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Flashcard 1334575500556

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Question
What cardiac enzymes are Reasonably specific for myocardial damage?
Answer
• Creatine Kinase; CK-MB (myocardial)
• Troponin: T and I

Elevated within 4 – 6 hours if necrosis


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Flashcard 1334577335564

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Question
What are symptomatic therapies for ACS?
Answer
• Rest
• O2
• Pain control
– Nitroglycerine
– morphine


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Flashcard 1334579170572

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Question
What therapies improve survival in ACS?
Answer
Thrombus: Heparin

Platelets (dual-antiplt therapy):
1) ASA
2) clopidogrel/Prasugel/Ticagrelor (some 2nd agent)
3) IIb/IIIa inhibitors (not used much)

Beta-blockers

CAD (long term improvement): statins, ACE-inhibitors

Education

Regular exercise


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Flashcard 1334581005580

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Question
What are important mimics of MI?
Answer
pulmonary embolus (most common)
pericarditis (assc w/ ST elevation)
aortic dissection (get chest pain)
NB: heparin is contraindicated in the above 2


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Flashcard 1334582840588

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Question
What are complications of MI?
Answer
tachyarrhythmia
bradyarrhythmia
LV failure
myocardial rupture (3-7days)
pericarditis
RV failure
stroke


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Flashcard 1334584675596

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Question
What is the STEMI therapy?
Answer
• Principles of non-ST elevation ACS apply

• Reperfusion is the goal

• Anti-platelet therapy
• Heparin
• Beta-blockers

• Treat underlying CAD


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Flashcard 1334586510604

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Question
How can you provide reperfusion in STEMI?
Answer
thrombolytic therapy (being replaced by primary angioplasty)
– TNK (tenectaplase)
– t-PA (tissue plasminogen activator)
– Streptokinase

Coronary Angioplasty
• Provides prompt anatomic information
• Establish patency mechanically
• Most reliable vessel patency if prompt


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