EXAM #1: ISCHEMIC HEART DISEASE

Question 1

What is the definition of Coronary Atherosclerosis?

Answer 1

Fatty infiltration of the tunica intima of a coronary artery

*Remember, if you have atherosclerosis is one location, you probably have it in many

Question 2

What are the modifiable risk factors for CAD?

Answer 2

HTN
Hypercholesteroloemia
Smoking
DM

Question 3

What are the non-modifiable risk factors for CAD?

Answer 3

Major:

• Age (45 men/ 55 women)
• Gender
• Genetics/ family hx.

Minor:

• Chronic renal disease
• Obesity
• CRP
• Sedentary lifestyle
• Psychology

Question 4

Outline the response to injury model for ASCVD?

Answer 4

1) Endothelial injury–>lipids leak into the tunica intima
2) Monocytes/ macrophages oxidize lipids and consume them and form foam cells
3) Growth factors cause smooth muscle cell infiltration into the intima and form foam cells
4) Healing and inflammation occurs forming the plaque

*Note that smooth muscle and macrophages can form “foam cells”

Question 5

What are the four cell types the participate in forming the atherosclerotic plaque?

Answer 5

1) Endothelium
2) Smooth muscle cells
3) Macrophages
4) Platelets

Question 6

What are the morphologic stages of atherosclerosis?

Answer 6

1) Fatty streak
2) Intimal thickening
3) Fibrous plaque

Question 7

What are the complications associated with atherosclerotic plaques?

Answer 7

1) Calcification
2) Ulceration
3) Hemorrhage into the plaque
4) Thrombosis

Question 8

What is the most common cause of death in DM?

Answer 8

Consequences of atherosclerosis

Question 9

What is the definition of a positive family history of CAD?

Answer 9

• Male, first degree relative under 55

- Female, first degree relative under 65

Question 10

How much does DM increase the risk of a hard CVD event?

Answer 10

20%

Question 11

What is the definition of diabetic dyslipidemia?

Answer 11

• Smaller denser LDL particles with LDL near normal (worse than elevated LDL)
• Low HDL
• Elevated TG

Question 12

What are the possible markers of metabolic syndrome?

Answer 12

1) Diabetic dyslipidemia
2) PAH
3) Central abdominal obesity
4) Insulin resistance

Question 13

How much does cigarette smoking increase the risk of CAD?

Answer 13

2x

This is the leading cause of preventable death in the US

Question 14

How much does stopping smoking reduce the risk of CAD?

Answer 14

• 1/2 the risk after 1 year

- Same as non-smoker after 5 years

Question 15

How does smoking enhance atherosclerosis?

Answer 15

1) Hemodynamic stress
2) Endothelial injury
3) Lipid changes
4) Enhanced coagulability
5) Arrhythmogenesis
6) Hypoxia

Question 16

How are the risk factors for atherosclerosis described?

Answer 16

Synergistic i.e. the total effect is more than simply the sum

Question 17

What are the complications of CAD?

Answer 17

1) ACS
2) Sudden cardiac death
3) Dilated cardiomyopathy
4) A-fib/flutter

Question 18

List the primary prevention practices for CAD.

Answer 18

1) Diet
2) Exercise
3) Weight-loss
4) Smoking cessation

Question 19

List the secondary prevention practices for CAD?

Answer 19

In the patient WITH ASCVD, treat risk factors e.g.

• HTN
• Dyslipidemia
• DM
• Smoking cessation
• Exercise
• Weight
• Diet

Question 20

What is the “sign” of prinzmetal angina on ECG?

Answer 20

ST elevation at rest

Question 21

What are the three major determinants of myocardial oxygen demand?

Answer 21

1) HR
2) Contractility
3) Systolic wall tension

Question 22

What is the differential diagnosis for chest pain?

Answer 22

1) Costochondritis
2) GI
3) Aortic dissection
4) Pericarditis

Question 23

What is stable angina?

Answer 23

Chest pain that arises with exertion or emotional stress

Question 24

What is unstable angina?

Answer 24

Chest pain that occurs at rest i.e. “angina decubitus”

or

• New onset
• Subjectively worse discomfort

Question 25

If chest pressure lasts a few seconds, is this angina? What if onset is abrupt?

Answer 25

No - Angina lasts minutes - Onset is gradual, not acute

Question 26

What are the classic mitigating and exacerbating factors for angina?

Answer 26

Exacerbating: - Increased work - Lying down* Mitigating: - Cessation of activity - Medication (nitro) *Increased preload= increased wall tension

Question 27

What labs are part of the work-up for angina?

Answer 27

1) Lipid panel 2) CBC 3) Blood chemistry panel with electrolytes, BUN, creatinine 3) UA for protein, glucose...etc.

Question 28

What is the utility of a stress test?

Answer 28

1) Diagnosis of atypical angina | 2) Prognosis in patient with stable angina

Question 29

When is a stress test NOT indicated?

Answer 29

Asymptomatic patient under 40

Question 30

What drugs are used for a pharmacologic stress test?

Answer 30

1) Adenosine* 2) Dipyridamole* 3) Dobutamine *Vasodilators, heart works harder to fill the dilated vessels

Question 31

What are the indications of a positive stress test?

Answer 31

1) ST changes 2) Development of angina 3) VT

Question 32

When is the diagnosis of angina certain with a stress test?

Answer 32

ST depression greater than 2mm

Question 33

What causes irreversible injury to the myocardium?

Answer 33

- Depletion of high-energy phosphate bonds | - Catabolite accumulation

Question 34

How do you reduce MI injury?

Answer 34

1) Increase supply - Reperfusion - Coronary vasodilation 2) Decreased demand - Beta blockers - Decrease BP - Reduce preload - Reduce circulating catecholamines

Question 35

What is the MOA of nitrates in treating MI?

Answer 35

Venodilators that: - Decrease preload - Decrease LV size and LV wall tension Coronary dilation

Question 36

What is the MOA of beta-blockers in MI?

Answer 36

Decrease heart rate and contractility to decrease oxygen demand

Question 37

Do beta-blockers have any effect on oxygen supply?

Answer 37

NO

Question 38

What is the major MOA of Ca++ antagonists in MI?

Answer 38

Decreased afterload by vasodilating effect