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Flashcards in 3: Chronic Ischemic Heart Disease Deck (55)
1

traditional risk factors for atherosclerotic vascular disease

-age (men > 45; women > 55)
-family history (first degree relative) - males 30)
-sedentary lifestyle

2

before exam look at this slide

graphs and relative risk increases based on risk factors

3

what two risk factors, if had together, significantly increase risk of fatal or non-fatal MI?

DM + previous MI

4

what is metabolic syndrome?

any 3 of the following:
-HTN (>/= 130/85)
-abdominal obesity (waist circumference > 40cm men; >35 cm women)
-HDL /= 150
-fasting plasma glucose >/= 100

5

what is metabolic syndrome associated with?

inflammation (vasculitis)
coagulation abnormalities
progression to T2DM

6

manifestations of CAD

-chronic stable angina
-unstable angina
-MI
-ischemic cardiomyopathy (CHF)
-sudden cardiac death
-silent ischemia

7

what physical findings may appear during periods of ischemia?

an S4 heart sound (not always though)

also may show an S3 if they have CHF/dilated cardiomyopathy

8

what tests do you get for eval of ischemic heart disease in the office?

-office and ambulatory BP
-fasting lipid profile
-BMI calculation
-fasting plasma glucose (OGTT)
-chemistries
-CBC
-stress testing
-measure of LV function (important prognostic value; tells you how to treat patient)

9

questions you need to ask for chest pain history

-location
-character
-radiation
-intensity
-duration
-frequency
-associated symptoms
-exacerbating/relieving factors
-pattern over time

10

presentation of stable angina pectoris (6 things)

-visceral discomfort
-diffuse and sub-sternal pain
-dyspnea, diaphoresis, nausea, light-headed
-provoked by physical exertion, emotional upset, rarely heavy meals, working in cold
-onset over several minutes
-relieved by rest, sublingual NTG

11

difference between atypical angina and typical angina

missing one of the following:
-substernal pain
-brought on by exertion
-relieved by rest or NTG

12

less common sites of pain with MI

-right side
-epigastrium
-jaw
-back

13

where might you see pain referred in angina?

lower jaw (not upper jaw)

14

Canadian CV society classification of angina

Class I: no angina
Class II: angina on more than usual activity
Class III: angina on less than usual activity
Class IV: angina at rest or on any activity

15

angina equivalents

-arm/back/lower jaw pain
-dyspnea on exertion
-postprandial symptoms
-nocturnal angina
-nausea
-diaphoresis
-fatigue

16

why is nocturnal angina really bad?

at night is when the body has the lowest metabolic demand and blood flow should be best - if angina still occurs then, means the patient is critically ill

17

what other options are there for a chest pain ddx?

-CAD/MI
-aortic: dissection, ulcer, hematoma
-pericarditis
-pulm: embolism, pneumonia, pleurisy
-esophageal: spasm, inflam, stricture, GERD, achalasia
-musculoskeletal
-anxiety

18

in what group of people is it more common to see TIA sx or claudication pain?

smokers

19

ddx: how does pericarditis differ?

variable duration
sharp
positional (relieved by sit up + lean forward)
pleuritic
worse with inspiration

20

ddx: how does aortic dissection differ?

excruciating, ripping, sudden pain
anterior
radiates to back
unequal pulse?

21

ddx: how does PE differ?

sudden onset dyspnea and pleuritic pain

22

ddx: how does musculoskeletal pain differ?

sudden onset
fleeting
reproduced by palpation

23

ddx: how does GERD differ?

burning
substernal
epigastric 10-60minutes
related to meals

24

ddx: how does psychological differ?

tightness
aching
with dyspnea
non-exertional
lasts more than 30 min

25

when do we feel chest pain? aka pathophysiology of ischemia

imbalance between supply and demand:

supply:
-stenosis
-spasm
-anomaly
-anemia

demand:
-tachycardia
-aortic stenosis
-HTN urgency
-LVH

26

causes of non-atherosclerotic CAD

-coronary vasospasm
-anomalous coronary arteries
-coronary arteritis (Kawasaki)
-coronary dissection
-myocardial bridge
-coronary embolization

27

what is myocardial bridge?

piece of myocardium over a coronary artery
-incidental finding
-doesn't normally cause angina
-don't do anything about it

28

novel risk factors for atherosclerotic disease

-chronic inflammation (RA)
-elevated hsCRP
-homocys
-chronic kidney disease
-coagulation abnormalities
-chronic infection?

29

myocardial ischemia: secondary causes

-severe anemia
-hypoxemia
-uncontrolled HTN
-severe LVH
-uncontrolled tachycardia (SVT, WPW)
-thyrotoxicosis

30

resting EKG in ischemic heart disease

-may be normal in 50%
-most common finding is non-specific ST-T changes
-conduction abnormalities such as LBBB, LAFB (marker for poor prognosis)

31

importance of pretest probability: what groups do you do stress tests for and which do you not?

-asymptomatic patients with or w/o some risk factors: don't do
-opposite end of spectrum- already diagnosed CAD: don't do
-DON'T DO FOR UNSTABLE SYMPTOMS

-only use it for patients in the middle ground gray zone - medium risk category w/ some clinical sx and some risk factors

32

stress test modalities

-exercise stress EKG
-stress imaging modalities

33

how is the stress provided in a stress test?

treadmill
pharmacologic (dobutamine, vasodilators)

34

whenever you do a pharmacological stress test, what do you also always have to add?

imaging- chances to see things on EKG with this type of test is low

35

what imaging modalities are used for stress test?

-echo (treadmill, dobutamine)
-nuclear (treadmill, vasodilators, or rarely dobutamine)
-MRI

36

stage I of standard Bruce protocol for stress test

-office work
-light housework
-golf (walking with bag)

37

stage II of standard Bruce protocol for stress test

-light factory work
-stairs
-bicycle riding (10 mph)

38

stage III of standard Bruce protocol for stress test

-heavy factory work
-running (10min/mile)

39

stage IV of standard Bruce protocol for stress test

-running (8min/mile)
-stairs with heavy weight
-boxing

40

at what percent stenosis does a person with CAD get symptoms?

70% occluded- this is when you get a drop in flow

41

what is the evolution of abnormalities in ischemia?

1. decreased relaxation (diastolic dysfxn)
2. systolic dysfxn
3. decreased filling
4. decreased ST
5. angina

42

approximately what percent of patients with angina also experience episodes of silent ischemia?

50%

43

what do you do in evaluating IHD

-confirm diagnosis of CAD
-assess functional limitations
-assess status of modifiable risk factors
-assess burden of ischemia:
-how much muscle is at risk?
-how many vessels involved?
-how severe is ischemia?
-assess LV function

44

pros and cons of exercise stress EKG

pros:
-low cost, versatility, validated, no need for IV access, fairly sensitive and specific

cons:
-high false positive in females, unreliable with abnormal resting EKG, false negative (failure to achieve HR)

45

stress EKG: what counts as ST segment changes

greater than 1mm horizontal or down-sloping ST depression is diagnostic of ischemia
-magnitude: more is worse
-duration: longer is worse
-timing: earlier is worse
-number of leads: more is worse
-associated angina, drop in BP, arrhythmia

greater than 1mm ST elevation

46

coronary artery disease: high risk groups?

-left main stenosis > 50%
-3 vessel disease, especially with LV dysfxn
-2 vessel disease involving proximal LAD
-multi-vessel disease in diabetics
-impaired LV function

47

stress test findings suggestive of high risk

-inability to complete stage II of Bruce protocol
-angina at a low workload (less than 6 METs)
-failure to achieve 80% of target HR or HR>120
-fall in BP > 10 with progressive exercise (accompanied by other evidences of ischemia)
-ischemic ST depression
-ST elevation more than 1mm (non infarct lead)
-sustained ventricular tachycardia

48

findings with ischemic ST depression

-greater than or = 2mm (esp downsloping)
-occurring at a low workload or HR (5 min into recovery

49

grading functional capacity with METs

10 - good capacity

50

what is 1 MET?

oxygen consumption of a 40 y/o, 70kg man in resting state

51

indications for stress imaging

-unable to exercise
-abnormal baseline EKG
-known CAD (prior infarct, revascularized/cath)

52

describe the regadenosan, adenosine or dipyridamole

coronary vasodilatation in normal segments, diseased segment (s) unable to dilate leading to relative hypoperfusion

53

stress imaging findings suggestive of high risk

-perfusion defects in multiple coronary territories
-large reversible perfusion defect in single territory (LAD)
-transient ischemic LV dilatation
-increased lung uptake (with abnormal perfusion)
-abnormal LV function (EF

54

indications for coronary angiography in stable CAD

-persistent sx despite medical therapy (min 2)
-non-invasive test results suggesting high risk
-equivocal or non-diagnostic non-invasive test results
-high risk occupation

55

initial management of IHD

-aspirin 81 mg daily
-sublingual NTG as needed
-lipid lowering therapy
-instructions on healthy lifestyle
-activity dictated by symptoms
-report any change in symptoms immediately