Ischemic Heart

Question 1

Coronary artery disease

Answer 1

Pathologic process affecting coronary arteries (atherosclerosis)

Question 2

Coronary heart disease

Answer 2

Includes angina pectoris, MI, silent myocardial ischemia and mortality from CAD

Question 3

Cardiovascular disease

Answer 3

Pathologic process affecting entire arterial circulation

Question 4

Myocardial infarct

Answer 4

Irreversible death of heart muscle due to prolonged lack of oxygen

Question 5

What is the role of nitric oxide?

Answer 5

Inhibits plaque formation, anti-inflammation

Damage leads to development of atherosclerosis

Question 6

Major risk factors of IHD

Answer 6

Diet, HTN, DM, dyslipidemia (high LDL, low HDL, high TAGs), cigarettes
Also can be male, older, FH, obesity, metabolic syndrome

Question 7

When are atypical sxs of IHD more common?

Answer 7

Women, elderly and pts with DM

Question 8

Transient vs prolonged ischemia

Answer 8

Transient may lead to angina pectoris and prolonged cal lead to MI

Question 9

What is another name for stable angina?

Answer 9

Angina pectoris

Question 10

What is the pain like in a stable angina?

Answer 10

Not pain (heaviness, pressure, squeezing, choking)
Substernal so Levine’s sign
Can radiate to arms, neck, jaw, epigastrium, mid-back

Question 11

How long does the pain in a stable angina last?

Answer 11

2-10 min (crescendo-decrescendo)

Usually with rest of sublingual nitro

Question 12

What are atypical sxs of angina?

Answer 12

Dyspnea (common in women), nausea, fatigue or faintness

Question 13

What sxs are not likely to be ischemia or angina?

Answer 13

Sharp, fleeting stabs of chest pain

Prolonged, dull ache in left precordial area

Question 14

What exactly is stable angina?

Answer 14

Exertional or stress-related chest or arm discomfort that resolves with rest or nitro

Question 15

Diagnostic tests done for stable angina

Answer 15

12 lead EKG (may have ST and T wave changes that occur during episodes of chest pain)

Question 16

What is the Bruce protocol?

Answer 16

For exercise stress tests where speed/incline adjusted every 3 min to get HR to 85% of maximum

Question 17

What are we looking for in stress testing?

Answer 17

EKG changes, decreased myocardial perfusion in nuclear imaging, drop in SBP >10 or any other sxs

Question 18

When can exercise stress testing be unreliable?

Answer 18

Women, elderly, obesity, debility, bundle branch block, pacemaker

Question 19

What are the indications for a pharmacologic stress test?

Answer 19

Pt unable to exercise, not able to achieve target HR with exercise or high likelihood of false positive

Question 20

Gold standard for diagnosisng CAD

Answer 20

Angiography

Question 21

What is the focus of IHD tx?

Answer 21

Treat signs and sxs of established IHD, rather than preventing it

Question 22

What is the optimal diet?

Answer 22

Plant based (grains, legumes, veggies, fruits, <15% calories from fat)

Question 23

What types of meds are used for stable angina?

Answer 23

Meds to decrease O2 demand, meds that increase oxygen supply, antiplatelets, statins, revascularization

Question 24

What are meds that decrease O2 demand?

Answer 24

Nitrates (preload reduction), betablockers (afterload reduction) and calcium channel blockers (afterload reduction)

Question 25

First line tx for chronic angina

Answer 25

Beta blockers

Question 26

Meds that increase O2 supply

Answer 26

Nitrates (.3-.6 mg sublingually or spray), CCBs

Question 27

What are the antiplatelet meds?

Answer 27

Aspirin (every pt on this unless contra), clopidogrel or a combo

Question 28

What do statins do?

Answer 28

Stabilize plaques to reduce clinical events, slow progression and induce regression of atherosclerosis

Question 29

What are the acute coronary syndromes?

Answer 29

Unstable angina, non-st segment elevation MI or ST segment elevation MI

Question 30

What is the presentation of ACS?

Answer 30

Ischemic pain, SOB, weakness, nausea, anxiety, sense of doom and may see those atypical sxs

Question 31

Potentially fatal ddx of chest pain

Answer 31

Aortic dissection, PE, pneumothorax, perforated viscous in GI, cocaine abuse

Question 32

Presentation of unstable angina

Answer 32

Ischemic discomfort and 1 of 3: Occurs at rest, >10 min Severe and of new onset (4-6 wks) Occurs with crescendo pattern (gets worse)

Question 33

What is Prinzmetal's angina?

Answer 33

Ischemic sxs secondary to vasospasm Usually younger pts Chest pain at rest with transient ST segment elevation Tx: nitrates and CCBs

Question 34

Possible pathophysiologic processes of UA or NSTEMI

Answer 34

Plaque rupture or erosion with superimposed nonocclusive thrombus (most common) Dynamic obstruction (coronary artery spasm) Progressive mechanical obstruction UA secondary to increased myocardial O2 demand/decreased supply

Question 35

Stress testing in UA/NSTEMI

Answer 35

Only in situations where there is no evidence for infarction (normal enzymes) but diagnosis unclear

Question 36

Clinical features of unstable angina

Answer 36

No elevation of CK-MB or troponin (no myocardial cell necrosis)

Question 37

Clinical features of non-ST elevation MI

Answer 37

Definite elevation of CK-MB and/or troponin (no ST elevation)

Question 38

Txs for UA/NSTEMI

Answer 38

Bedrest with monitoring, MONA, beta blockers, antiplatelets, anticoagulation with heparin, statins, PCI (STEMI is very similar)

Question 39

TIMI variables for risk stratification of UA/NSTEMI

Answer 39

``` Age > 65 >3 risk factors of CHD Prior coronary stenosis >50% ST segment deviation on admitted EKG >2 anginal episodes in 24 hrs Increaesd cardiac biomarkers Aspirin in last 7 days 1 pt for each ```

Question 40

Interpretation of TIMI risk score

Answer 40

As it increases, it increases the number of events that occur over 14 days

Question 41

Who is at an increased risk for STEMI?

Answer 41

Ppl with multiple risk factors or history of UA

Question 42

Identifiable precipitating factors of STEMI

Answer 42

Vigorous exercise, extreme stress, medical/surgical illness

Question 43

Common causes of STEMi

Answer 43

Rupture of vulnerable plaque (complete occlusion of coronary artery) Slowly developing stenosis of coronary artery

Question 44

Diagnostics for STEMI

Answer 44

12 lead EKG, CXR, biomarkers, CBC, lipid panel, cardiac imaging, angiogram

Question 45

EKG changes and cardiac markers for UA, STEMI and NSTEMI

Answer 45

UA: negative biomarkers and either! STEMI: positive markers and ST segment elevation NSTEMI: positive markers and no ST elevation

Question 46

What is MONA?

Answer 46

Management of IHD Oxygen first Then nitro or morphine if that doesn't work Antiplatelet therapy to limit size of infarct

Question 47

When must you start thrombolytic therapy?

Answer 47

Within first 12 hrs of STEMI (so 30 min after dx)

Question 48

Absolute contraindications of thrombolytic therapy

Answer 48

Hx of intracranial hemorrage, stroke in last year, poorly controlled HTN, suspected dissection, active internal bleeding

Question 49

What is revascularization indicated for?

Answer 49

STEMI (can be more effective than thrombolytics if doc is good)

Question 50

Complications post mI

Answer 50

Recurrent ischemia, pump failure, ventricular arrhythmias, pericarditis, mural thrombus, cardiac rupture, depression

Question 51

Management post MI

Answer 51

Risk stratification, treat risk factors, beta blockers/aspirin or ACE/ARB is LV dysfunction