CHD

Question 1

Left main artery

Answer 1

aka left coronary

branches to left anterior descending (LAD) and circumflex

Question 2

right coronary artery

Answer 2

RCA
to base and anterior wall
RA and RV

Question 3

LAD

Answer 3

left anterior descending

LA- front and septum

Question 4

circumflex

Answer 4

from left coronary

LA and LV- back and side

Question 5

CHD

Answer 5

athersclerosis - endothelial injury causes smooth m. proliferation, inflammatory cell recruitment and lipid deposition within the vessel
plaque progressively narross the coronary artery lumen impacting blood flow
unstable plaque ruptures and exposes throbogenic core of lipid and necrotic material to platelets that adhere and aggregate causing ACS

Question 6

10 yr risk of CHD event > 20%

Answer 6

noncoronary artheroscerotic disease - carotid artery disease, PAD, AAA
DM
CKD

Question 7

CHD: risk factors

Answer 7

Fhx - MI/death of 1st degree relative 45 (M), >55 (F)
gender- men, women after menopause
Elevated hs-CRP
metabolic syndome
obesity
elevated blood homocysteine levels
low intake fruit/vegetables/fiber and high intake of red meat/glycemi index foods
physical inactivity
psychosocial factors - stress, depression
estrogen deficiency 
oral contraceptives
cocaine

Question 8

framingham risk calculator

Answer 8

uses age, gender, SBP, cholesterol, HDL, BP meds, smoking status

Question 9

CHD symptoms

Answer 9

often asymptomatic
CP/angina
arm, shoulder, neck, back of jaw pain
dyspnea w/ or w/o exertion
syncope or presyncope
weakness
dizziness/lightheadedness
fatigue
palpatations/ arrhythmias
SCD
HF - dyspnea, orthopnea, wt gain, edema

Question 10

CHD PE

Answer 10

often normal
may have bruits - PVD
abnormal ABI/ weak lower extremity pulses - PAD
HF - peripheral edema, S3, ascites, rales, JVD, HJR

Question 11

Stable angina pectoris

Answer 11

usually causes by CHD, oxygen demand exceeds supply
CP- heavy, pressure, squeezing, burning, fullness, elephant on chest, may radiate to shoulder, arm, neck, jaw
does not change w/ position or inspiration
palpatation causes no additional discomfort
Also - SOB, nausea, diaphoresis, lightheaded, fatigue
discomfort occurs w/ activity and resolves w/ rest
same discomfort every episode
nitroglycerin shortens or aborts attack

Question 12

stable angina pectoris PE

Answer 12

incr. in HR, BP - sympathetic activation
S3, S4, paradoxical splitting of S2
New/changed murmur- papillary m. dysfcn

Question 13

stable angina pectoris tests

Answer 13

Labs - lipid, CMP, CBC, TSH
troponin/ CK-MB
CXR- should be no findings
resting EKG - not sensitive or specific but during anginal episode, characteristic ST depression

Question 14

echocardiogram

Answer 14

ultrasound
ability to evaluate cardiac anatomy and function
evaluate LVEF - +50% normal
can show wall motion abnormalities indicative of S/P MI or active ischemia

Question 15

exercise stress test

Answer 15

evaluate continue EKG w/ exercise
look for ST depression of 1 mm or greater
ability to monitor BP, functional capacity, monitor for exercise-induced symptoms and arrhythmias
cannot use for abnormal resting EKG - ST depression, NSST changes, LBBB or paced
no radiation

Question 16

stress echocardiogram

Answer 16

provides an ultrasound evaluation of cardiac function pre- and post-exercise
normal study - hypercontractility of all walls post exercise
abnormal - one area has poor movement or hypokinetic
difficult on pts with large body habitus
no radiation

Question 17

dobutamine stress echocardiogram

Answer 17

increases contractility of the heart (+ inotropic agent)
ordered only for pts unable to exercise and have significant COPD/ asthma with active wheezing
highly symptomatic - feel like having heart attack - CP, dyspnea, palpitations, HA, nausea

Question 18

Nuclear stress test

Answer 18

visualize radiopharmaceutical pre and post exercise
can calculate LVEF
can tell if viability fixed (post MI) or reversible (active ischemia)
modest radiation exposure, high cost
may see balanced perfusion in 3 vessel disease but generally fairly accurate

Question 19

chemical nuclear stress test

Answer 19

for pts that cannot exercise to target HR, lexiscan used
contraindications - pregnancy, AV blocks (not 1st), sinus node dysfcn, active wheezing, BP <90/60
common SE - bronchoconstriction, hypotension, dyspnea, CP, nausea, flushing, abd pain, HA, dizziness (usually brief)

Question 20

Stress Test contraindications

Answer 20

acute MI, unstable angina pectoris
uncontrolled arrhythmias causing hemodynamic compromise symptoms
symptomatic sever vavlular stenosis - aortic esp.
uncontrolled, symptomatic HF
active endocarditis, acute myocarditis, pericarditis
aortic dissection
PE or systemic emboli
acute disorders that exercise may aggravate
pregnancy - nuclear/pharm only

Question 21

stress test info

Answer 21

exercise to target HR - 85% of max for age (220-age*.85)
LBBB or paced rhythm should be pharm testing only
drop in SBP indicates stenosis including left main disease
be prepared for the worst - staff and equipment
consider radiation exposure if done often

Question 22

CCTA

Answer 22

coronary CT angiogram
non-invasive test to assess coronary artery anatomy and stenosis
irregular heart rhythms, severe coronary artery calcification, stents can interfere with the quality of images
segments with diameter <60
utilized when stress test results inconclusive
radiation exposure, contrast dye and kidneys, insurance

Question 23

Left Heart Catherization

Answer 23

catheter inserted in the femoral/ radial artery, threaded up to coronary arteries
contrast dye injects to allow visualization of stenotic lesion
low risk of complications, substational radiation and risk of contrast-induced nephropathy
gold standard to determine info about atherosclerosis

Question 24

antiplatelets

Answer 24

ASA +/- P2Y12 receptor blockers
P2Y12 - clopidogrel, prasugrel, ticagrelor
all pts w/ CHD should be treated with ASA
dual for post-PCI and ACS only
ASA inhibits thromboxane A2
P2Y12 block ADP binding -> no GP IIb/IIIa binding or aggregation

Question 25

statins

Answer 25

reduce serum LDL atherosclerosis regression, plaque stabilization, inflammation reduction, reverse endothelial dysfunction, decrease thrombogenicity, CRP reduction proven survival benefit -primary and secondary

Question 26

beta blockers

Answer 26

1st line anginal episodes, improve exercise tolerance reduce heart oxygen demand by dec. HR and contractility prevents reinfarct and S/P MI survival SE: fatigue, diziness, sexual dysfcn, bronchoconstriction contraindications: bradycardia, active bronchospasm, >1st degree block, hypotension, pulmonary edema, HF

Question 27

ACEIs/ ARBs

Answer 27

don't reduce angina | improve LV fcn and decrease mortality S/P MI

Question 28

CCBs

Answer 28

decr. contractility coronary and peripheral vasodilation used when BBs contraindicated, SE or not sufficient

Question 29

Nitrates

Answer 29

decrease myocardial oxygen demand- system vasodilation SL nitre - tx of choice in acute anginal episodes chronic tx for recurrent angina nitro tolerance is an issue SE: HA, flushing, hypotension contraindicated: RV infarct, HCM, phosphodiesterase-5 w/in 24 hrs, severe asthma

Question 30

ranolazine

Answer 30

chronic angina reduces angina and incr. exercise capacity late sodium channel blocker minimal effects on BP and HR, can prolong QT many drug interactions

Question 31

PCI

Answer 31

stents, reduces restenosis and acute vessel closure done during diagnostic cath only lesions +70% FFR and IVUS used to asses size of intermediate coronary lesions not done- diffuse disease, chronic total occlusions, left main stent use shoudl be discussed prior to procedue <1% adverse risk - MI, stroke, death complications - contrast nephropathy, retroperitoneal bleed, hematoma, AV fistula, pseudoaneurysma, contract rcn

Question 32

PCI - Bare metal vs. DES

Answer 32

DES - decreased risk of restenosis, require 1 year S/P PCI dual anti-platelet therapy Bare metal - 30 days anti-platelet, vessles >4mm, pts can't afford dual platelet therapy, non-compliance likeley, durg alcohol abuse, needed surgical procedure in <1 yr

Question 33

S/P PCI thrombosis

Answer 33

usually due to discontinuation of antiplatelets - high rate of MI and death never stop post PCI antiplatelets w/o consulting their cardiologist first

Question 34

CABG

Answer 34

coronary artery bypass graft diffuse disease, total chronic occlusion, left main disease, 3 vessel disease, etc. graft patency higher w/ IMA vs. saphenous vein graft elective <1% death, most 2-5% risk of death complications - graft occlusion, perioperative MI, atrial and ventricular arrhythmia, pericarditis, pericardial effusion, tamponade, infection, bleeding, acute kidney injury, DVT, PE, pleural effusion, atelectasis, neuro problems afib in up to 40% of early postoperative period

Question 35

CHD screening

Answer 35

diabetics who want to start exercising multple risk factors for CHD jobs w/ high cardiovascular performance required men over 45, women +55, w/ multiple risks starting vigorous exercise pts at high risk for CHD EBCT w/ >75th percentile

Question 36

ACS

Answer 36

acute coronary syndromes unstable angine, NSTEMI, STEMI sudden, reduced blood flow to the heart plaque disruption, platelet plug, coronary thrombosis CHD signs and symptoms + nausea, diaphoresis, anxiety, incr. angina, symptoms at rest, in early am, brady/tachycardia+ arrythmias, HTN/ hypotension, respiratory distress

Question 37

UA

Answer 37

unstable angina rest angina, new onset, increasing angina - frequency, time, exertion EKG may or may not be suggestive - ST depression, T wave no troponin or CK-MB

Question 38

NSTEMI

Answer 38

troponin or CK-MB+ | EKG - ST depression, T wave, nothing

Question 39

STEMI

Answer 39

ST elevation or new LBBB biomarkers not needed classic evolution - peaked T wave, ST elevation, Q wave development, T-wave inversion

Question 40

ACS: ER management

Answer 40

``` ABC Hx and PE 12-lead EKG CXR resuscitation equipment bedside cardiac monitor, O2 IV + labs - CMP, CBC< cardiac biomarkers, coag indices, lipids bedside echo ```

Question 41

ACS: Rx

Answer 41

ASA: 325 mg chewed STAT Nitro: .4 mg Q5 min until 3 doses given, may be IV Morphine - 2-4 mgs Q15 min for persistant pain PRN BBs Statin dual antiplatelet, angicoagulant, GP IIb/IIIa - cardiologist

Question 42

UA and STEMI revascularization

Answer 42

no fibrinolysis use TIMI Score to determine timing of angiography - age, risks, known CAD, aprin use, sever angina, cardiac markers, ST elevation

Question 43

STEMI tx

Answer 43

PCI - door to balloon time of < 4 hrs, utilized w/in 12 hours contraindications: ICH, known intracracranial issues, strokes, aortic dissection, active bleeding, significant closed-head trauma

Question 44

Post ACS Car

Answer 44

``` dual antiplatelet statin BBs ACEIs aldosterone antagonist Nitro PRN cardiac rehab risk factor modification - include diet and exercise ```

Question 45

Variant angina

Answer 45

aka prinzmetal angina angina pectoris due to coronary artery vasospasn - high grade obstruction w/o CHD normally 50+ yo Japanese women that uses tobacco, cocaine, has other vasospastic disorders recurrent CP - at rest, at night, 5-15 min result - MI, aryrhthmias - palpitations, syncope, SCD - AV block - RCA, Vtach (LAD) transiet ST elevation during discomfort tx: avoid stimulation, nitro, chronic: CCVs, long-acting nitrates, ICD

Question 46

SCD

Answer 46

hemodynamic collapse due to Vfib w/in 1 hr of symptoms usually CHD, HF, cardiomyopathy, LVH, myocarditis, HCM, cogenital anomalies, conduction - Brugada, long QT, Wolff-Parkinson-White, triggers- electolytes, drugs, commotio cordis

Question 47

P2Y12 receptor blockers

Answer 47

clopidogrel, prasugrel and ticagrelor- ACS only

Question 48

BBs

Answer 48

-lol

Question 49

ACEIs

Answer 49

-pril

Question 50

ARBs

Answer 50

-sartan

Question 51

CCBs

Answer 51

-ipine, diltiazem, verapamil

Question 52

nitrates

Answer 52

nitroglycerin, isosorbide

Question 53

anticoagulants

Answer 53

heparin, enoxaprin, bivalirudin, fondaprinux

Question 54

GP IIb/ IIIa

Answer 54

abciximab, eptifibatide, tirofiban