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87 Cards in this Set
- Front
- Back
*What is ischemic heart disease?
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insufficient oxygen supply to the myocardium most often caused by narrowing or occlusion of the coronary arteries
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What does myocardial ischemia result in?
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angina pectoris
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What is angina pectoris characterized by?
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chest squeezing, tightness, pressure
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What is the leading cause of death in the US?
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-coronary artery disease (CAD)
-1:5 deaths in the US |
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What are 9 risk factors for atherosclerosis?
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age
HTN elevated lipids tobacco use DM family hx gender (male) sedentary lifestyle post-menopausal state |
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What is chronic stable angina?
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-angina of effort
-frequency of angina can be related to effort expended (also psych/emotional upset) -when supply < demand=angina |
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If a patient has an occluded coronary artery, will they always have angina?
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-no, only when supply < demand
-if supply=demand, they feel ok |
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How do we describe angina?
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-substernal chest discomfort
-provoked by exertion -relieved with rest -lasts less than 3 minutes -relieved by sublingual nitro |
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Manifestations of angina
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-jaw pain
-arm pain -back pain -toothache |
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What are the various manifestations of angina also known as?
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angina equivalents
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What can patients with CSA be managed effectively with?
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-medical therapy and lifestyle modification as outpatients
-don't need to be hospitalized as long as they are 'stable' |
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Will all patients with CSA develop unstable angina or a MI?
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no
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What is CSA not the same as?
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acute coronary syndrome (ACS)
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What are the 3 entities covered by ACS?
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-unstable angina
-NSTEMI -STEMI |
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What does CSA share with ACS?
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-atherosclerosis as their underlying etiology
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What can be seen on an EKG?
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-ischemic changes, ST segment depressed/sagged with ischemia
-may appear normal under normal circumstances (i.e. at rest) |
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Does a normal EKG exclude ischemia/CAD?
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no
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Does MI get better with rest?
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NO
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When approaching a patient with angina, what is crucial?
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detailed history! OPQRST
-change in pain? -similar to heartburn? -is pain predictable with activity? -awaken at night/pain @ rest? -associated symptoms (i.e. dyspnea, diaphoresis) |
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Patient with angina: pt assessment
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-risk factor profile (does the patient have multiple risk factors?
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Patient with angina: PE clues
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-vital signs
-xanthomas -bruits -diminished peripheral pulses -venous stasis changes -murmurs -GET A 12 LEAD EKG! -possibly refer to cardiologist/specialist |
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What are some medical interventions for a patient with coronary artery disease?
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-beta blocker
-calcium channel blocker -aspirin -statin -sublingual nitro |
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What are 2 non-invasive tests for pt with angina?
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-cardiac US
-stress test (stress echo, nuclear perfusion study, other imaging modality i.e. 64 slice CT angiography) |
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What are 2 invasive tests for pt with angina?
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-cardiac catheterization
-coronary angioplasty or stenting |
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What can cardiac US (echocardiogram) assess?
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-structure and function of the heart
-left ventricular ejection fraction -integrity/function of the valves |
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What can stress tests with imaging show?
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-modality to screen for ischemic burden
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What is a normal EF?
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55-65%
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Stress ECHO
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-US images of the heart are taken before and after exertion
-if heart appears hypocontractile after exertion, ischemia is suspect |
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Nuclear stress test
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-2 sets of pictures taken of the heart (at rest and after exercise)
-shows how well blood flows to the heart by creating/comparing images |
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On a nuclear stress test, what will inadequate coronary circulation appear as?
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light areas (b/c radioisotope not reaching that area of myocardium under physiologic stress)
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What does a nuclear stress test NOT show?
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where blockage actually is...only suggest heart is devoid of oxygen (stress echo also does not show where blockage is)
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What is the gold standard to define the coronary anatomy?
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-cardiac cath
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What is an angiogram?
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study that looks at arteries within the body
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64 slice angiogram
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-new, non-invasive technology
-excellent imaging quality -provides detailed anatomic pics of the coronary arteries |
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Angina treated with drugs that...
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-improve blood supply to heart muscle
-decrease myocardial oxygen demand -lower BP |
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What is an example of a vasodilator used for angina pectoris?
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-nitroglycerin (sub-lingual is best route)
-also, nitro patch applied daily or oral isosorbide |
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What are drugs that slow the heart rate down?
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-Ca channel blockers (Diltiazem)
-Beta blockers (Metoprolol) |
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What are 6 drugs for use in patients with chronic stable angina?
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-anti-platelet tx (aspirin)
-lipid lowering therapy (statin) -beta blocker -calcium channel blocker -nitrates -ace inhibitor or ARB (for left ventricular dysfunction) |
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What is a side effect of nitrates?
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-hypotension,headache (headache is most ominous side effect b/c vessels in the head are dilated too)
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What is a side effect of beta blockers?
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-fatigue, erectile dysfunction
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CSA lifestyle changes
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-stop smoking
-lose weight -medication compliance -dietary modification -exercise -glycemic control -positive attitude |
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Prinzmetal's/Variant Angina
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-symptoms of angina are experienced due to coronary vasospasm
-often occurs at rest -pts can develop ischemic EKG changes during periods of vasospasm -NORMAL arteries |
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What are 2 meds for Prinzmetal's Angina?
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-calcium channel blockers i.e. Verapamil, Amlodipine
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What is an MI?
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AKA acute coronary syndrome - death of or damage to part of the heart b/c blood supply stopped or severely reduced
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What is included in ACS?
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MI and unstable angina (NOT stable angina)
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Aside from ischemia, what else can cause ACS?
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-cocaine (b/c vasoconstrictor)
-embolic is not a common cause |
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Roughly what percent of people who experience an MI die from it?
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37%
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What is the leading cause of cardiac death and disability?
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atherosclerosis
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For every 10% increase in adherence to treatment guidelines, what results?
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10% decrease in mortality
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What is myocardial ischemia most often secondary to?
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ahterosclerosis
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What do patients with a STEMI often have?
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a thrombus occluding the infarcted artery
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What is the common theme in all acut coronary syndromes?
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-plaque and/or thrombus obstructing blood flow within the coronary circulation
-degree of obstruction is determining factor of clinical presentations and consequences |
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NSTEMI
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-subendocardial or non-Q wave MI
-EKG often non-diagnostic -clinical hx difficult to distinguish from unstable angina |
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What is a useful distinction b/w unstable angina and NSTEMI?
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cardiac biomarkers
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STEMI
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-most dangerous condition in the spectrum of ACS
-leading cause of cardiac death -TOTAL occlusion of a coronary artery leading to myocardial injury and necrosis -ST elevation |
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NSTEMI vs unstable angina (very simply)
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NSTEMI is severe reduction of blood flow, unstable angina is significant reduction of blood flow
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Risk factors for ACS
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-HTN
-high cholestrol -tobacco -familial history -age -obesity -DM -sedentary lifestyle |
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Who often presents with atypical symptoms?
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women and the elderly
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Can ACS diagnosis be made on PE alone?
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no
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Who can sometimes have "painless angina"?
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-patients with diabetes (neuropathy) b/c have defective anginal warning mechanisms
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Clinical features of angina/ACS
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-chest pain (not always severe)
-sweating -dyspnea -weakness -anxiety -nausea -back/arm pain -feeling of "impending doom" |
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What is an important distinction b/w stable and unstable angina?
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-stable angina is relieved with rest, unstable is not
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Suspected MI/ACS/Cardiac Arrest action plan
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-early access (911)
-EKG -defibrillation for VF then ACLS -ST elevation? -rapid transport to med facility |
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PE of MI
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-exam may be normal!
-vital signs -JVD -wheezes, rales, rhonchi -murmurs, rubs, gallops -exam does NOT make diagnosis |
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What are 4 things someone with an MI can develop?
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-hyper/hypotension
-brady/tachycardia -arrhythmias -cardiogenic shock |
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4 special considerations in PE of MI
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-new murmurs
-mitral regurgitation in inferoposterior infarct -rales due to large myocardial infarct -cardiogenic shock/poor urine output |
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What is TIMI?
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-thrombolysis in MI
-rating system used to risk stratify your patients and assist in determining a triage and management plan |
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TIMI score
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-age greater than 65
-3 or more risk factors for CAD -use of aspirin within the past 7 days -known CAD (50% stenosis in a vessel) -rest angina (more than 1x in past 24 hrs) -abnormal ST segments -abnormal cardiac enzymes |
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What is considered high risk TIMI score?
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greater than 3
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MI/ACS simplified tx plan (first 6 steps)
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-rapid hospital transport for reperfusion
-labs/EKG -antiplatelet tx: heparin/aspirin -nitrates -morphine -oxygen |
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MI/ACS simplified tx plan (2nd 6 steps)
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-establish large bore IV access
-beta blocker -cardiac cath or thrombolysis -intravenous heparin (if appropriate) -glycoprotein 2B3A inhibitors if appropriate -statins |
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What do statins help do?
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stabilize plaques
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If there is STE on EKG, what should be done next?
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cath lab!
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If EKG is low risk, what should be done next?
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compare to prior EKG to screen for new ST/T wave changes
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What does ST segment depression suggest?
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myocardial ischemia
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Whta does ST segment elevation suggest?
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myocardial injury or infarction
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What does T wave inversion suggest?
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ischemia
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What do Q waves help with?
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make the diagnosis of prior infarction
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What is the most sensitive and specific marker for cardiac injury?
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troponins
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What can location of changes on EKG determine?
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location of insult
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In terms of cardiac enzymes, what has yet to be identified?
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-a specific, sensitive marker that is present within one hour after the onset or a cardiac event
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What are the 3 enzymes predominantly used?
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troponins (I and T)
CK CK-MB |
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What are elevated enzymes strongly suggestive of?
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ACS
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What can a triathlete have after a triathlon?
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elevated CK-MB (doesn't mean they're having a heart attack)
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CK is typically increased in MI, but what else can cause it to increase?
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-trauma, post-op, extreme exertion
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Troponins
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-rises 2-6 hours after injury
-peaks in 12-16 hours -stays elevated for 7-12 days |
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CK
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-rises 6 hours after injury
-peaks at 24 hrs -stays elevated for 3-5 days |