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MOHD KEYSTONE Exam 1 (Jordan) > #10 - Ischemic Heart Disease (Brown) > Flashcards

#10 - Ischemic Heart Disease (Brown) Flashcards

1
Q

List the 4 ways ischemic heart disease can manifest clinically

A
  • chest discomfort
  • heart failure / shortness of breath
  • abnormal EKG/ stress test
  • arrhythmia
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2
Q

What percentage of death due to cardiac disease are “sudden deaths”?

A

60%

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3
Q

How many sudden deaths are instantaneous?

A

1/3

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4
Q

How many sudden deaths occur outside the hospital?

A

70%

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5
Q

Most sudden cardiac deaths are due to which type of arrhythmia?

A

ventricular fibrillation

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6
Q

T/F: Most sudden cardiac deaths are caused by acute MIs.

A

False. Most are associated with atherosclerosis and remote MI’s but the majority are due to arrhythmias, NOT caused by acute MIs.

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7
Q

T/F Most deaths due to MI are “sudden death” but most sudden deaths are not due to MI

A

True.

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8
Q

What are the 4 direct determinants of myocardial oxygen DEMAND?

A
  • intraventricular systolic pressure.
  • ventricular cavity radius
  • heart rate
  • contractility in the muscle (more actin/myosin units- more energy)

NOTE: stroke volume is not a determinant of oxygen demand!

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9
Q

T/F diastolic pressure is more important than systolic pressure for coronary artery blood flow.

A

True.
(Why?? during systole, when the ventricle contracts, it squeezes the arteries, closing them. Therefore they fill during diastole)

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10
Q

What are the 3 main determinants of myocardial blood flow.

A
  • perfusing pressure (diastolic more important than systolic)
  • resistance to flow (arterioles, atheroclerosis,)
  • right atrial pressure
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11
Q

What are the 3 ways resistance in the coronary arteries can change?

A
  • arterioles - they are in charge of normal autoregulation
  • obstructions (atherosclerotic plaques/ coronary artery spasm
  • myocardial wall tension compresses the intramural portion of the arteries during systole, occluding flow
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12
Q

What are the 2 categories of causes of IHD?

A
  • disease of increased oxygen demands

- diseases of the coronary arteries (atherosclerosis/spasm)

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13
Q

Which diseases cause ischemic heart disease through increased oxygen demands.

A

aortic valve disease (stenosis/insufficiency) –> hypertrophy of the LV wall, with inadequate capillary growth to supply blood to new tissue –> ischemia.

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14
Q

T/F- the diagnosis of ischemic heart disease depends on the coronary angiogram

A

FALSE. Diagnosis is based on the history.

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15
Q

Describe the type of pain in angina

A

tightness, aching, squeezing, pressure or weight, or burning.

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16
Q

List 5 things that can increase heart rate/BP and help to provoke a heart attack. (Hint: remember Netter picture).

A
  • heavy meal
  • cold temperature
  • activity early in the day (higher HR)
  • activity involving arms
  • cigarrettes.

netter picture from the ppt: guy leaving restaurant in the cold, carrying heavy briefcase. he was also smoking.

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17
Q

How long does angina last?

A

usually 3-5 minutes.
sometimes 5-15 min
rarely 15-20 min

Never more than 30 min after rest or nitroglycerin.

18
Q

What are the 3 criteria for clinical diagnosis of angina? How do tthey relate to typical angina, atypical angina, and noncardiac chest pain?

A

1) substernal chast discomfort with a characteristic quality and duration.
2) chest discomfort is provoked by exertion or emotional stress\
3) relieved by rest or nitroglycerin

Typical angina = all 3
Atypical (probable) angina = 2/3
noncardiac chest pain = 1 or none /3

19
Q

T/F: Physical exam is very useful for diagnosing stable angina.

A

False. It is often unrevealing, especially if the angina is not presently occurring. This is why they make people do the stress test.

20
Q

What are the 3 main tests used for diagnosis of ischemic heart disease?

A
  • EKG (during rest doesn’t show much)
  • Treadmill test (along with concurrent testing)
  • coronary angiography (remember angiography doesn’t make the diagnosis by itself)
21
Q

When should (and shouldn’t) a treadmill test be used in the evaluation of ischemic heart disease?

A

It should be used for patients with stable, typical angina, or probable angina.

DO NOT order this test for someone with unstable angina or an acute MI - that person needs to be hospitalized!!

22
Q

What are the advantages of a treadmill test?

A
  • it is most practical (most available and cheapest)

- correlates patient’s BP/HR with symptoms and ST depression on EKG

23
Q

Coronary angiography shows a patient with angina has vessels that are 40% occluded. What is the conclusion? Does this person have severe or mild disease?

A

Mild. This is likely not causing severe disease. Coronary arteries are twice as wide as they need to be, so the lumen must be

24
Q

Definition of MI

A

a more prolonged imbalance between blood flow and oxygen demand, which is documented to have produced myocardial necrosis.

25
Q

How do you make a diagnosis of MI?

A

Almost always, associated with angina.

However, EKG changes or biochemical changes (troponin) is necessary to make the diagnosis.

26
Q

How long does angina from an MI last?

A

usually 1/2 hour to several hours.

27
Q

Clinical presentation of an MI

A

BP and HR vary
Fever may be present (reaction to necrosis)
-angina, often accompanied by sweating nausea vomiting or weakness
-almost all patients will have S4 gallop.
S3 may be present
-pericardial friction rub - 24 hrs after onset of pain

28
Q

What heart sound is almost always heard in an acute MI patient?

A

S4 gallop

29
Q

T/F: physical exam is very important in an Mi patient.

A

True.

30
Q

Which EKG changes are diagnostic of MI?

A
  • pathological Q waves

- ST-T changes.

31
Q

What is the window for testing troponin for an MI?

A

it peaks at 6-8 hours but may remain normal for 1-2 weeks.

32
Q

What are the major complications of acute MIs?

A

1) arrhythmias of all types (PVCs, tachycardia, ventricular fibrillation) - remember that ventricular fibrillation is major cause of death from acute MI)

2) Heart failure.
3) hypotension

33
Q

How might heart failure due to an acute MI manifest?

A

at first, only the finding of an S3 gallow and persistent relative sinus tachycardia at rest.

34
Q

T/F: If there is no ST elevation in an MI (but positive troponin), there is likely a pathological Q wave present.

A

FALSE. Q waves tend to accompany ST changes. If ST elevation present, Q wave likely (not always) present. And vice-versa.

35
Q

Definition of unstable angina?

A

angina without stable, exertional pattern, without ST elevation on EKG or elevated troponin.
This includes
-new onset angina (even if exertional)
-exertional angina but occurring with increasing frequency or with preipitation by lesser degrees of exertion
-angina at rest or during sleep
-prolonged angina of >20 -30 min duration

36
Q

Definition of stable angina

A

angina with a predictable exertional pattern which has been present for >1 month.

37
Q

What is the major mechanism for all the acute coronary syndromes?

A

unstable/ruptured atherosclerotic plaque.

38
Q

Which is NOT a determinant of myocardial oxygen demand?

  • intraventricular systolic pressure.
  • ventricular cavity radius
  • stroke volume
  • heart rate
  • contractility in the muscl
A

Stroke volume.

Think of it this way: lowering your blood pressure means your heart would have a larger stroke volume with the same amount of energy output/o2 requirements. Stroke volume is dependent on more than the energy the heart is expending. On the contrary, the heart could be working its ass off, but b/c of atrial valve stenosis, get low stroke volume.

39
Q

What is a determinant of all 3: oxygen delivery, blood pressure, and myocardial demands?

A

Heart rate

40
Q

You see a patient who has angina at rest. Is this sufficient for a diagnosis of atypical angina?

A

Yes. Hospitalize that shit!

MOHD KEYSTONE Exam 1 (Jordan) (7 decks)

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