Coronary artery disease (CAD)

Question 1

The RCA supplies most of right atria and ventricle; these areas are best seen in what leads?

Answer 1

Inferior and posterior

Question 2

The RCA runs in the coronary sulcus; list and describe its 4 branches

Answer 2

1) SA nodal artery br. – SA node
2) Right marginal br. – RV, apex
3) AV nodal br. – AV node
4) Posterior IV br. (anastomoses with LAD): Posterior 1/3 of septum, R&LV

Question 3

What are the EKG leads of the right heart?

Answer 3

II, III, aVF and “posterior” leads - reciprocal of the anterior leads V2,3,4

Question 4

What are the EKG leads of the left heart?

Answer 4

I, aVL, V5,6 and anterior leads V2-4

Question 5

What does the Frank-Starling law address the relationship between?

Answer 5

SV vs. Preload (end diastolic volume)

Question 6

Describe the pathophys of CAD

Answer 6

Visceral Sensory nerves of the heart enter spinal cord DRG at C3-T7
Referred pain: Shoulders, left arm; Back; Jaws; Neck

Question 7

What 2 things are req. to Dx CAD?

Answer 7

Reversible ischemia (angina)
H/o MI, or documented presence of plaque
AND
+/- symptoms controlled with Rx or revascularization

Question 8

Describe Tx for CAD

Answer 8

Risk factor mitigation: Lifestyle changes
Optimal treatment of comorbidities: HTN, Lipids, & DM (all risk for ACS)
Rx: antiplatelet, statin, antianginals
Selected patients may benefit from revascularization – PCI or CABG

Question 9

Describe lifestyle modifications for risk factor modification of CAD

Answer 9

1) Exercise – 30-60 minutes moderate intensity (3-6 METS), 5-7 days a week
Safe
GXT not needed prior to start low-moderate program
High risk patients can be enrolled in supervised exercise program
2) Weight loss – dietary, medical, surgical
3) Smoking cessation – 5 As
Similar risks as non-smokers 10 years after quitting

Question 10

Describe 3 comorbidities of CAD

Answer 10

1) Lipids: statin intensity
2) HTN: goal BP < 130/80 in most patients
3) Diabetes: AIC goals

Question 11

What should you Rx for stable CAD?

Answer 11

1) Antiplatelet: daily low dose ASA for most
2) Antianginals: NTG PRN, scheduled B-blockers or CCB (no HF)
3) Statin: high intensity for most

Question 12

Describe the 2 antiplatelets used for CAD

Answer 12

1) ASA (81 mg daily): Decrease GI risk, low cost
2) Clopidogrel (Plavix): Similar effects, more cost

Question 13

What is the initial antianginal Tx for CAD?

Answer 13

1) SL Nitroglycerin for immediate symptom relief
-Vasodilator
2) B-blockers for long term relief – unless contraindicated
-Negative chronotrope
3) CCB
-Negative chronotrope and negative inotrope – not in HF
4) Nitrates
-SL NTG 0.4 mg PRN angina = Shorting acting drug of choice for immediate relief from anginal symptoms
-Long acting = when BB or CCB don’t work
5) Ranolazine
-Inhibits sodium & calcium current decreasing ventricular diastolic tension and myocardial oxygen demand

Question 14

Which antianginal for CAD should not be used in HF?

Answer 14

CCBs

Question 15

What is primarily used when BB or CCB do not adequately relieve symptoms of CAD?

Answer 15

Nitrates (SL NTG 0.4 mg PRN angina)

Question 16

Describe nitrates for CAD

Answer 16

1) SL NTG 0.4 mg PRN angina - Shorting acting drug of choice for immediate relief from anginal symptoms
2) Long acting are primarily used when BB or CCB do not adequately relieve symptoms

Question 17

Describe Ranolazine as an antianginal for CAD

Answer 17

1) Ranolazine – inhibits sodium & calcium current decreasing ventricular diastolic tension and myocardial oxygen demand
2) No effect on BP or HR , thus alternative to BB or CCB in patients with anginal and hypotension or bradycardia
3) May also be used as adjunct to BB or CCB

Question 18

BLUF:
1) How do you Tx [stable] angina?
2) What abt persistent angina?

Answer 18

1) SLN 0.4mg acute, and BB long term (unless contraindicated)
If symptoms not controlled consider CCB, long-acting nitrate, Ranolazine
2) Consider PCI or CABG

Question 19

BLUF: Describe how to Tx HF stages C&D

Answer 19

Life-style changes
GDMT for comorbid HTN, DM, Cholesterol
Routine use of BB, ACEi or ARB or ARB/ARNI, aldosterone inhibitor, & SGLT-2i
PRN or scheduled loop diuretics for volume overload
Add on hydralazine/long-acting nitrates in select patients

Question 20

Describe a healthy diet

Answer 20

Example: Mediterranean diet
Fruits and vegetables
Fiber, including cereals
Foods with a low glycemic index and low glycemic load
Monounsaturated fat rather than trans fatty acids or saturated fats
Omega-3 fatty acids (from fish, plant sources, or supplements)

Question 21

The leading avoidable cause of premature death is what?

Answer 21

Cigarette smoking

Question 22

Describe smoking avoidance and cessation

Answer 22

1) Cigarette smoking - leading avoidable cause of premature death
2) Benefits of cessation begin to appear after only a few months and reach that of the nonsmoker in several years
-For CVD: never too late to quit
-For cancer: never too early to quit
3) Risks relate largely to duration rather than quantity

Question 23

Describe HTN control for CVD

Answer 23

1) Well-established MAJOR risk factor for CVD
-Stroke, CAD, HF, PVD
2) Thresholds and goal blood pressures
3) Nonpharmacologic measures –TLCs
4) Pharmacologic therapy - 3 classes for initial therapy

Question 24

Describe the effects of lipids/ antilipid drugs on CAD risk

Answer 24

1) Statins - demonstrated clinical benefits
4 statin groups
2) Adjunctive Rx – benefit when added to statins
Ezetimibe
PCSK9i

Question 25

List 2 lipid related CAD risk enhancers

Answer 25

Hyper triglycerides and metabolic syndrome

Question 26

Describe metabolic syndrome

Answer 26

1) 40 y/o + ~ 40% 2) Risk enhancing feature 3) 3 or more of the following: Elevated: abdominal obesity hyper triglycerides ≥150 mg/dL systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥85 fasting glucose ≥100 mg/dL 4) Low HDL-C

Question 27

Describe the use of aspirin for CAD prevention

Answer 27

1) Secondary prevention: yes 2) Primary prevention: depends -aspirin decreases the risk of nonfatal myocardial infarction (MI) but increases the risk of major bleeding select patients may benefit – calculated 10-year risk >10%

Question 28

Give the BLUF for CAD risks

Answer 28

Assess ASCVD risk using AHA/ACC calculator or other pooled Cohort equation Consider and implement ASCVD risk reduction strategies No single intervention does it all Selectively move away from ASA for primary prevention