Exam 1 - Ischemic Heart Disease

Question 1

Who die more suddenly of ACS?

Answer 1

Women

Question 2

Low risk unstable angina (5)

Answer 2

1. <70
2. Exertion also pain lasting <20min
3. Pain not rapidly accelerating
4. Normal/unchanged ECG
5. No elevation of cardiac markers

Question 3

Normal % Cardiac event:

Answer 3

20-25%

Question 4

Mildly Abnormal % Cardiac Events:

Answer 4

25-30%

Question 5

Severely Abnormal % Cardiac events:

Answer 5

45-50%

Question 6

3 things of O2 demand:

Answer 6

1. HR
2. Contractility
3. Wall tension (afterload/preload)

Question 7

2 things of O2 supply:

Answer 7

1. Coronary BF

2. Arterial O2 content

Question 8

When does ischemia occurs with balance?

Answer 8

O2 demand > O2 supply

Question 9

6 things that increase myocardial oxygen demand:

Answer 9

1. Tachycardia
2. HTN
3. Thyrotoxicosis
4. HF
5. Valvular heart disease
6. Catecholamine analogues (bronchodilators, tricyclic antidepressants, cocaine)

Question 10

5 things that reduce myocardial oxygen supply:

Answer 10

1. Anemia
2. Hypoxia
3. Carbon monoxide poisoning
4. Hypotension
5. Tachycardia

Question 11

Chronic narrowing of coronary arteries due to:

Answer 11

Atherosclerosis

Question 12

With atherosclerosis, can resistance coronary vessels dilate?

Answer 12

No

Question 13

With atherosclerosis, when you increase O2 demand with exercise, can you increase O2 supply?

Answer 13

No and thats when you get ischemia and angina

Question 14

2 treatment goals of stable ischemic heart disease:

Answer 14

1. Prevent MI and death

2. Reduce symptoms of angina and occurrence of ischemia

Question 15

6 things to reduce ischemia and anginal symptoms:

Answer 15

1. Sublingual nitroglycerin
2. Beta blockers
3. Calcium channel blockers
4. Long-acting nitrates
5. Ranolazine
6. Non-pharmacological treatments (PCI/CABG)

Question 16

What increase capacitance and decrease preload; venous?

Answer 16

Nitrates

Question 17

What decrease resistance, pressure, and afterload; arterial?

Answer 17

Calcium channel blockers

Question 18

What decrease HR and inotropy; heart?

Answer 18

Beat blockers

Question 19

What 5 things prevent MI and death?

Answer 19

1. Aspirin (consider adding P2Y12 inhibitor or rivaroxaban)
2. Statins
3. BP control (goal <130/80; BB/ACE-I/ARB)
4. Control DM
5. Non-pharmacological (diet, exercise, wt loss, stop smoking)

Question 20

4 different acute causes of myocardial O2 supply-demand mismatch:

Answer 20

1. Plaque rupture/erosion with occlusive thrombus
2. Vasospasm or coronary micro vascular dysfunction
3. Atherosclerosis & O2 supply/demand imbalance
4. O2 supply/demand imbalance alone

Question 21

FINAL DIAGNOSIS: 
Ischemic discomfort
Acute coronary syndrome (atherothrombotic)
ST elevation 
\+ bio markers

Answer 21

ST elevation MI (type 1)

Question 22

FINAL DIAGNOSIS: 
Ischemic discomfort
Acute coronary syndrome (atherothrombotic)
No ST elevation 
\+ bio markers

Answer 22

Non-ST elevation MI (type 1)

Question 23

FINAL DIAGNOSIS: 
Ischemic discomfort
Acute coronary syndrome (atherothrombotic)
No ST elevation 
- bio markers

Answer 23

Unstable angina (thrombotic mediated)

Question 24

FINAL DIAGNOSIS: 
Ischemic discomfort 
Supply-demand imbalance (nonthrombotic)
No ST elevation 
\+ bio markers

Answer 24

Non-ST elevation MI (type 2)

Question 25

``` FINAL DIAGNOSIS: Ischemic discomfort Supply-demand imbalance (nonthrombotic) No ST elevation - bio markers ```

Answer 25

Unstable angina (demand related)

Question 26

5 Non-ST Elevation-acute coronary syndrome treatments:

Answer 26

1. Aspirin 2. Nitroglycerin (NTG) 3. Anti-thrombotic regimen (aspirin+P2Y12 inhibitor) 4. Statins 5. BB

Question 27

What does short term statins do?

Answer 27

Reduce inflammation and improve endothelial function

Question 28

What does long term statins do?

Answer 28

Cholesterol reduction

Question 29

Which stent has chance to cause stent thrombosis (platelets adhere to exposed stent struts and initiate thrombus formation)

Answer 29

Bare metal stent

Question 30

When does bare metal stents re-endothelialization compete?

Answer 30

1-3months

Question 31

Which stent require shorter courses of anti platelets?

Answer 31

Bare metal stents

Question 32

Which stent delays re-endothelialization by several months?

Answer 32

Drug-eluting stents

Question 33

Which stent prolong duration of stent thrombosis risk and require longer courses of anti platelets?

Answer 33

Drug-eluting stents

Question 34

What 2 considerations in patients for CABG?

Answer 34

1. Significant disease in L main coronary artery | 2. Disease in 3 or more coronary vessels + LV dysfunction (EF<40%)

Question 35

Critical time-dependent period (myocardial salvage)

Answer 35

0-3 hrs

Question 36

Time-independent period (open infarct-related artery)

Answer 36

6-12 hrs

Question 37

Mortality in 1st yr post ACS averages:

Answer 37

10%

Question 38

Percent of deaths due to CAD:

Answer 38

85%

Question 39

Percent of sudden deaths due to CAD and within first 3mths:

Answer 39

50%

Question 40

Percent of deaths due to CAD within first 3wks:

Answer 40

33%

Question 41

Big 5 Post ACS pharmacotherapy:

Answer 41

1. Aspirin 2. ACE-I/ARB 3. BB 4. Clopidogrel/prasugrel/ticagrelor 5. Statins

Question 42

4 things to treat preop unstable CAD:

Answer 42

1. IV nitrates 2. IV heparin 3. Treat arrhythmias 4. Intra-aortic balloon pump

Question 43

8 operative myocardial protection:

Answer 43

1. Hypothermia 2. Hemodynamic modulation 3. Cardioplegia 4. Ischemic preconditioning 5. Anesthetic preconditioning 6. Remote ischemic preconditioning 7. Ischemic post-conditioning 8. Pharmacotherapy

Question 44

2 pharmacotherapy for operative myocardial protection:

Answer 44

1. BB | 2. Statins

Question 45

How does BB provide myocardial protection (3):

Answer 45

Decrease: 1. HR 2. Contractility 3. O2 consumption

Question 46

What are the 3 ‘pleotropic effects’ of statin:

Answer 46

1. Increased plaque stability 2. Decreased platelet activity 3. Decreased inflammatory markers

Question 47

4 postop myocardial protection:

Answer 47

1. Control HR 2. Reduce afterload 3. Max O2 delivery 4. Minimize O2 consumption

Question 48

Can symptoms of ischemia be absent in period setting due to anesthesia and analgesia?

Answer 48

Yes

Question 49

What does acute increase in cardiac troponin indicate?

Answer 49

MI

Question 50

3 other signs of ischemia:

Answer 50

1. Tachycardia 2. Hemodynamic instability 3. Pulmonary congestion (reduce O2 sat/lung compliance/wheeze)

Question 51

3 medications to manage periop MI?

Answer 51

1. Nitroglycerin 2. BB 3. Aspirin