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Flashcards in 4: Ischemic Heart Disease Deck (22):
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Ischemic Heart disease

Mismatch between demand and supply

1

Affected coronary vessels

LAD>RCA>LCA

RCA: posterior, inferior wall
LCA: lateral wall
LAD: anterior wall

2

MC congenital anomaly on coronary artery causing IHD

LAD is originating from Pulmonary artery

3

MCC of IHD

Atherosclerosis

4

Risk

Male: over 45
Female: over 50 postmenopausal
Diabetes
HTN
Smoking (takes 15yrs for risk to come down)
Inflammation (vasculitis)*- it makes thrombus dangerous, makes it easier to rupture
Hyperhomocystinimia

5

IHD- spectrum

Angina (ischemia)
MI (permanent damage to cardiac muscle)

6

Stable angina- info

Substernal pain (can present as squeeze, pressure, weight on chest)
Pain lasts for few mins (up to 5 mins), crescendo, decrescendo
Any stress in life will bring up the pain (anger, sex, etc)
Rest makes it better
Nitrates (reduce the pain for angina, might not for MI)
Subendocardial damage
Raveen's sign

7

Angina decubitus

lying down causes pain
1: increased intrathoracic pressure and heart needs to pump harder, higher demand for O2
2: Sleep
3: Respiratory system dysfunction during sleep

8

Unstable angina- UA/NSTEMI (non-ST elevated MI)

1: Accelerating (Diabetic. with less and less activity)
2: New onset (suddenly started. Faster pathogenesis than atherosclerosis)
3: Resting
Thrombus formation or Ruptured plaque (non-occlusive)
Subendocardial damage

9

Prinzmetal angina

No previous history
Younger pts (30-40)
While they are sleeping
Vaso-spasm (hyper-responsive smooth muscle and some chemical causes it)
Transmural damage
MC in RCA (LCA is more affected by ischemia)

10

Investigation- angina

EKG (show nothing)*
Stress induced EKG changes (let pts exercise while on EKG-> ST depression more than 1mm over 0.8 sec on more than one LEAD)- stop with more than 2mm depression or arrhythmia!! (MC done test)
Coronary angiography (GOLD STANDARD)- done in 4 cases;
1: tx dont improve the angina
2: stress test is unconclusive
3: pts keep coming back with typical angina sx but stress test is negative
4: if the pts is in charge of ppl's lives (i.e. airplane pilot, surgeon etc)
Lipids
TL 50
HTN retinopathy (AV nicking)
Xanthoma

11

ST depression

due to Injury current caused by subendocardial ischemia.
Current going away from the LEAD, thus depression

12

ST elevation

in case of MI/ Prinzmetal
Intramural ischemia sending the current toward LEAD thus elevation.

13

Pts unable to exercise for stress test

Pharmacologic stress test
Decrease the supply of blood to heart
Dipyridamole, Dopamine

14

Treatment- angina

Reassurance (angina is better than MI)
Encourage to stop smoking
Sx management
Reduce stress
MONA;**
Morphene
Oxygen (dont give if O2 saturation is good)
Nitrate (give pulsating headache, reflex tachycardia, tolerance development [nitrate free window keeps efficacy]) +Beta blocker (on on asthma, COPD, AV block. in that case, give Cachannel blocker [beta blocker is better since it increase the diastolic time which increase the time for coronary vessels to receive more blood)
Aspirin (or other anti-platelet drugs like clopidogrel, anti-coagulation like Heparin, fundaperinux which do not cause HIT)

15

Prinzmetal- tx

Nitrate
Cachannel blocker
PCI (percutaneous intervention)- drug eluting stent (Saerolimus, Paclitaxil), stent (for a year, clopidogrel and aspirin, and life time of aspirin afterward) [restenosis can happen, temporary]
Cabbage (coronary artery bipass graft) [permanent, risk of stroke]
DO Cabbage if:**
-3 or more vessels involved
-Left main vessel involved
-Diabetics
-Ejection fraction <50%

16

MI-sx

Chest pain lasts more than 30mins**
Pain- Nitrates and rest wont cure it
Sympathetic stimulation (anterior wall)- tachycardia
Parasympathetic stimulation (inferior wall)- bradycardia

17

MI- Investigation

1: Chest pain more than 30 mins
2: ST elevation (in more than 2 LEADs)
3: Bio-markers (Troponin the most reliable)

EKG:
1: ST elevation on certain LEADs (left bundle block-> anterior cause)
2: Q wave develops (hr to days)
3: T wave inversion
4: ST elevation on opposite LEADs

Akinesia or Dyskinesia can be seen

18

LEADs

Lateral: V5, V6, I, aVL
Anterior: V1, V2, V3, V4
Inferior: aVF, II, III

19

MI- tx

Nitrate
Oxygen
Aspirin
Thrombo-lytic (p-TA, alte-plas) [any chance of bleeding contraindicate it]

20

MI- tx; timeline

Thrombo-lytic (30mins-2hrs)* efficacy goes down after 2hrs and ineffective after 12hrs
PCI: door to surgery in 90mins*

21

MI- complication

V-fibrillation
Dressler's syndrome (many weeks later)
Necrosis; Mitral regurgitation, interseptal rupture, lateral free wall rupture (cardiac tamponade)