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ICM Exam 3 Cardiology > Chronic Ischemic Heart Disease - Yaacoub > Flashcards

Chronic Ischemic Heart Disease - Yaacoub Flashcards

1
Q

Traditional risk factors for atherosclerotic vascular disease (8)

A
  1. Age (45M, 55F)
  2. Fam Hx (M55, F65)
  3. DM or glucose intolerance
  4. HTN
  5. Smoking
  6. Cholesterol
  7. BMI >30
  8. Sedentary
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2
Q

Serum cholesterol risk increase

A

1.92 per 40 mgDL

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3
Q

Age increase in risk

A

1.63 per six years

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4
Q

High cholesterol is more problematic when…

A

there is CHD

greatly increased risk

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5
Q

Metabolic syndrome diagnosis

A

Any three of:

  • HTN (130/85)
  • Abdominal Obesity (waist circum. >40cm)
  • HDL <40
  • Triglycerides >150
  • Fasting plasma glucose >100
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6
Q

Metabolic syndrome associated with

A

inflammation

coagulation abnormalities

progression to T2DM

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7
Q

Manifestations of CAD

A
  • Chronic stable angina
  • Unstable angina
  • Myocardial infarction
  • Ischemic cardiomyopathy
  • Sudden Cardiac death
  • Silent ischemia
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8
Q

IHD often shows ___ during physical exam

A

S4

during periods of ischemia

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9
Q

Evidence of prior infarction on ECG

A

Q waves

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10
Q

Eval for IHD

A

Stress testing + Measurement of LV function

(BP, lipids, BMI, OGTT, Chemistries, CBC)

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11
Q

Angina pectoris sx

A
  • Visceral discomfort
  • Diffuse and substernal
  • Dyspnea, diaphoresis, nausea, lightheadedness
  • Provoked by exertion, stress, meals, cold temperature

Onset = minutes

Relief = rest and NG

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12
Q

Atypical angina =

A

missing one or more of the features of typical angina

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13
Q

Canadian CVS classification

A

1 = no angina

2 = Angina only with more than usual activity

3 = Angina on less activity

4 = Angina at rest or any activity

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14
Q

DDx for chest pain

A
  • CAD/MI
  • Aortic dissection, ulcer, hematoma
  • pericarditis
  • PE, PNA, Pneumothorax
  • Esoph. Spasm, inflamm, or stricture
  • Musculoskeletal
  • Anxiety
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15
Q

Signs of critical disease

A

postprandial symptoms

Nocturnal angina

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16
Q

Atherosclerosis a systemic disease

A

Obstruction

Aneurysm

Embolization

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17
Q

Sx of PE

A

sudden dyspnea and pleuritic pain

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18
Q

Sx of pericarditis

A
  • variable duration
  • sharp
  • positional
  • pleuritic
  • worse with inspiration
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19
Q

Aortic dissection - check for ____

A

unequal pulses

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20
Q

Musculosk. Sx

A

Fleeting, reproduced by palpation

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21
Q

GERD pain

A

substernal, 10-60 min

22
Q

Non-atherosclerotic CAD

A
  • Vasospasm
  • ANomalous Coronary arteries
  • Coronary arteritis (Kawasaki, TGCA)
  • Coronary dissection
  • Myocardial bridge
  • Coronary embolism
23
Q

6 Novel risk factors for atherosclerotic disease

A
  1. Chronic inflammation
  2. Elevated hsCRP
  3. Homocysteine
  4. Chronic kidney disease
  5. Coagulation abnormalities
  6. Chronic infctn
24
Q

6 secondary causes for Myocardial ischemia

A
  1. Severe anemia
  2. Hypoxemia
  3. Uncontrolled HTN
  4. Severe LVH
  5. Uncontrolled Tachycardia
  6. Thyrotoxicosis
25
Q

Coronary dissection is associated with

A

pregnancy

(young females)

26
Q

ECG may be…

A

normal in 50% of patients

27
Q

Most common finding is _______

A

non-specific ST-T changes

28
Q

Conduction abnormalities =

Associated with…

A

LBBB

LAFB

Associated with LV dysfxn, multivessel disease and poor prognosis

29
Q

Pretest probability determine

A

post-test findings

30
Q

Stress tests

A

Exercise stress ECG

(Stress = treadmill, or pharmacologic - dobut or vasodil.)

31
Q

Echo for

A

Treadmill or dobut

32
Q

Nuclear imaging

A

Treatmill or vasodilators

rarely dobut.

33
Q

Stages of standard bruce protocol

A

1 = 1.7mph, 5METs, light work

2 = 2.5mph, 7 METs

3 = 3.4mph, 10 METs

4 = 4.2mph, 13 METs

34
Q

About 1/3 of patients with angina also

A

experience episodes of silent ischemia (asymp)

35
Q

Stress tests function

A

Confirm grey zone diagnosis (not low-risk)

Assess the limitation in functional capacity

Assess status of modifiable vascular risk factors

Assess the burden of ischemia

Assess LV function

36
Q

CONS of Stress ECG

A

High false positive

Unreliable if resting ECG is abnormal

False negs

37
Q

Target HR

A

85% of age-predicted max

(220-age)

38
Q

METs =

A

functional capacity

39
Q

With ST depression in ischemia, _______ is worse

A

Earlier

Longer

More leads

Higher magnitude

40
Q

ST seg changes in stress ecg

A

>1mm horizontal or downsloping ST depression

>1mm ST elevation (in leads w/o Q waves)

41
Q

Sensitivity and specificity of Exercise ECG

A

68%

77%

42
Q

High risk groups for CAD

A
  1. Left main stenosis >50%
  2. 3 vessel disease especially with LV dysfunction
  3. 2 vessel disease involving proximal LAD
  4. Multi-vessel disease in diabetics
  5. Impaired LV function
43
Q

Stress test findings suggestive of high risk

A

Inability to complete stage 2

Angina at low workload (<6MET’s)

Can’t reach 80% HR OR >120bpm

Fall in BP >10mmHg with progressive exercise

ST elevation >1mm

Sustained ventricular tach

44
Q

Oxygen consumption can be…

A

estimated for various activity levels (METs)

45
Q

<6 METs =

A

Low functional capacity

46
Q

>10 METs =

A

Good functional capacity

47
Q

Indications for stress imaging

A
  1. Unable to exercise
  2. Abnormal baseline ECG (LBBB, LVH, WPW, digoxin)
  3. Known CAD
48
Q

Agents for Stress imaging

A

Regadenoson

Adenosine

Dipyridamole

(coronary vasodil. in normal segments, diseased segments unable to dilate leading to relative hypoperfusion)

49
Q

Stress imaging findings suggestive of high risk

A
  1. Pefusion defects in multiple regions
  2. Large reversible defect in single region
  3. Transient ischemic LV dilatation
  4. Increased lung uptake
  5. Abnormal LV (EF below 40%)
50
Q

Stress echo findings suggestive of high risk

A

Wall motion abnormal in multiple regions

Large inducible wall motion abnormalities in one region

LV dysfunction (EF <35%)

51
Q

Indications for coronary angiography in stable CAD

A
  • Persistent Sx
  • Non-invasive tests suggest high risk CAD, or non-diagnostic
  • High risk occupation
52
Q

Initial management of IHD

A
  • Aspirin 81mg
  • Sublingual NG
  • Lipid lowering therapy

Instructions on healthy lifestyle (diet, smoking, wt.)

Activity dictated by Sx

ICM Exam 3 Cardiology (8 decks)

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