IHD Patho 2012_Student Version (1)

Coronary angiography significant blockage consider

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Coronary angiography Significant blockage Consider balloon angioplasty or stent implantation Significant blockage Consider balloon angioplasty or stent implantation
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Percutaneous  Intervention  (PCI) Photo adopted from: http://medical-surgical-nursing.blogspot.com/ Goal time within presentation to hospital: ≤ 30 minutes for fibrinolytics ≤ 90 minutes for primary PCI
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Stress Testing Not diagnostic for CHD Often used to determine prognosis or probability of CHD in patients with chronic stable angina Types Exercise tolerance testing (ETT) Pharmacologic Dipyridamole Adenosine Dobutamine
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Stress Testing Monitor blood pressure and ECG pattern during test, sometimes with an echocardiogram Can predict risk for future cardiac events and mortality Insensitive for predicting location of obstruction Commonly used in conjunction with nuclear imaging
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Exercise Tolerance Testing Patients walk on treadmill with progressive elevation and speed Trying to elicit imbalance between myocardial oxygen demand and supply which leads to ischemia that is detected on ECG or on imaging Adverse Predictors Poor exercise capacity Exercise-induced angina ECG finding ≥1 mm ST-segment depression Ventricular arrhythmias Photo adopted from: http://www.texasheart.org/HIC/Topics/Diag/distress.cfm
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Pharmacologic Stress Testing Used in patients who cannot exercise on a treadmill Pharmacologic agents used to induce “stress” to the heart Dipyridamole or adenosine Cause vasodilation supply Dobutamine HR, contractility demand
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Nuclear Imaging Used with stress testing to help localize the area of ischemia Patients injected with radionuclide tracers (sestamibi or thallium) to isolate the area of ischemia Imaging then performed on 2 occasions After exercise At rest (usually 4 hours after exercise on treadmill) Looking for “cold spots” Areas of myocardium that are not being perfused If appear after exercise and then disappear with rest Reversible ischemia If appear after exercise and at rest Irreversible ischemia
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Echocardiography Can be done in combination with stress testing Ultrasound of the heart Two types: Transesophogeal echocardiography (TEE) More sensitive and specific than TTE Transthoracic echocardiography (TTE) Determine EF, wall motion abnormalities
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Patient Case ST is a 65 y/o WM who presents to the ED complaining of substernal crushing chest pain An ECG reveals the following: CK-MB and troponins are negative x 2 within the first 12 hours What type of ACS is ST likely experiencing?
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Questions??
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Coronary angiography Significant blockage Consider balloon...

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