Ischemic Heart Disease Flashcards
(40 cards)
What are the clinical stages of coronary artery disesase?
Endothelial dysfunction
positive remodeling
exertional angina
unstable angina
What is the relationship severity of pain & degree of oxygen supply?
weak relationship
there can be severe pain with minimal disruptionof oxygen supply or no pain in severe cases
What are the 4 types of angina?
- Stable angina
- pain resolves at rest
- Unstable angina (ACS)
- continues at rest
- Microvascular angina
- no epicardial disease
- Prinzmetal’s angina
- vasoconstrictive disease - arteries are constricting down causing a stenosis
What are the characteristics of stable angina?
What is another name for stable angina?
- “Effort Angina” - think man showeling show after inactive fall
- Discomfort is precipitated by activity
- minimal or no symptoms at rest
- symptoms disappear after rest/cessation of activity
What are the characteristics of unstable angina?
What is another name for unstable angina?
- “Crescendo or Preinfarction angina”
- acute coronary syndrom spectrum
- may occur at rest or progressively less exertion
- stable to unstable
- severe & of acute onset or longer duration
- Crescendo pain- pain increases over time
- Nocturnal episodes
What are the characteristics of microvascular angina?
What is another name for microvascular angina?
What demographics are most affected by this disease?
- Syndrome X
- Angiographically normal epicardial arteries
- “small vessel disease” with high resistance
- diabetics, women more than men
- unstable angina, objective evidence of ischemia (such as ischemic ST-T deviation), elevated biomarkers, Echo wall motion abnormalities during pain
- Decreased coronary flow reserve
What are the characteristics of Prinzmetal’s angina?
What is another name for Prinzmetal’s angina?
What demographics are most affected by this disease?
- Variant Angina
- normal coronary vessels or minimal atherosclerosis
- ST segment elevation (injury pattern) during pain
- May have transient Q waves
- Angiographic hallmark is coronary spasm with ST elevation during chest pain
- history of migraines
- Provocative testing
- injecting directly into the coronary arteris & watching this occur & can reverse with nitrates
What are the causes of ischemia?
How is this related to the coronary vessels?
- Either an increased oxygen demand or a decrease in oxygen supply
- inadequate blood supply & decreased oxygen supply are directly related to obstructed or stenotic vessels
What are the 3 components of an typical anginal diagnosis?
What if you only have 2/3?
What if you only have 1/3?
- Substernal Chest pain
- usually described as heaviness/pressure/squeezing
- sometimes radiates jaw/LUE/back
- worse with exertion
- better with rest/nitroglycerin
- 3/3 = typical angina
- 2/3 = atypical angina
- 1/3 = likely noncardiac
What are the classic symptom describtors & localization of angina?
- Pressure, tightness, heaviness, squeezing, aching… “PAIN” may not even be described
- Elephant on chest
- Tight bnd around chest, like bra is too tight
- Levine’s Sign (clenched fist)
- retrosternal, eithe ror both sides of the chest, up to throat, down to epigastrium, medial sides of upper arms down to mid forearm
- Women: frequently in jaw, lower teeth ears and sides of neck as well as interscapular (men, too)
What are the associated signs & symptoms with angina?
- Dyspnea on exertion or at rest
- Diaphoresis (women may describe “cold sweat”)
- profound fatigue of sudden onset (may be the only symptom in some women)
- palpitations with or without lightheadedness
- nausea or “indigestion”
- comiting
- Tenesmus
- Dizziness
- Feeling of “Impending Doom”
You have a patient with suspected ischemic heart disease – what symptoms suggest this?
What do you do if they are intermediate or high risk?
What if they are stable?
- Symptoms
- Angina - ie. everytime I mow, my chest hurts, then I sit down & it gets better
- or female specific symptoms
- Intermediate/High Risk (Unstable Angina)
- straight to unstable chart
- Stable
- comprehensive clinical assessment of risk including personal characteristics, coexisting cardiac & medical conditions, and health status
- high risk lestion, prior sudden death or ventricular arrhythmia, prior stent in unprotected left main coronary artery
- straight to guideline-directed medical therapy
- for a patient where this is unknown, go down the algorithm
- high risk lestion, prior sudden death or ventricular arrhythmia, prior stent in unprotected left main coronary artery
- comprehensive clinical assessment of risk including personal characteristics, coexisting cardiac & medical conditions, and health status
What procedures do you follow if you have a patient with stable angina who does not have a high-risk lesion, prior sudden death, ventricular arrhythmia or a prior stent in unprotected left main coronary artery?
Have they had a recent exercise or cardiac imaging study?
- Yes
- techincally adequate?
- Yes -determine if they have any contraindications to stress testing
- No- Test results indicated high-ris coronary lesion?
- Yes- initiate guideline-directed medical therapy; consider coronary revascularization to improve survival
- No- initiate guideline-directed medical therapy
- techincally adequate?
- No
- Determine if they have any contraindications to stress testing
When working up a patient with stable angina & an unkown risk, what do you do after you determine if they have any contraindications to stress testing?
- Contraindications
- Yes- Guideline-directed medical therapy OR CCTA
- No- Determine if the patient is able to exercise
- Yes - Determine if the patient has had previous coronary revascularization
- No- Pharm stress MPI or Echo; Pharm CMR or CTA or Pharm Stress echo
When working up a patient with stable angina & an unkown risk, what do you do after you determine if they have had previous coronary revascularization?
- Previous Coronary Revascularization
- Yes- MPI or echo with exercise
- No- Resting ECG interpretable?
- Yes-
- intermediate likelihood IHD: Standard ECG
- low likelihood IHD: Standard exercise ECG
- intermediate to high liklihood IHD: MPI or Echo w/ exercise or pharm CMR
- No- MPI or Echo w/o exercise
- Yes-
- If test results indicate high-risk coronary lesions?
- Yes- guideline-directed medical therapy; consider coronary revascularization to improve survival
- No- guideline-directed medical therapy
Draw this if you don’t yet feel comfortable
What are the goals of treatment for angina?
- Aims:
- relief of symptoms
- slowing progressin of the disease
- reduction of future events like myocardial infarction
What are the “arms” associated with guideline-directed medical therapy witj ongoing patient education for a patient with stable ischemic heart disease?
Which is the foundational arm?
- Foundational arm
- aspirin- 75 - 162 mg daily
-
Lifestyle modification
- diet, weight loss, physical activity
- smoking cessation
- moderate to high dose statin
- if hypertension, treat hypertension
- appropriate glycemic control if diabetic
- if any anginal symptoms present
How do you treat continued anginal symptoms for a patient with stable ischemic heart disease?
- Sublingual NTG
- beta-blocker (decrease O2 demand) if no contraindication
- add/substitute CCB and/or long-acting nitrate if no contraindications
- add/substitute ranolazine (last resort)
- consider revascularization to improve symptoms
- add/substitute ranolazine (last resort)
- add/substitute CCB and/or long-acting nitrate if no contraindications
- beta-blocker (decrease O2 demand) if no contraindication
Draw this diagram if you do not yet feel comfortable with it
What class of drugs do you use to treat the following situations in ischemic heart disease? Why do you choose them?
acute attacks?
prophylaxis?
- Acute attacks
- organic nitrates
-
vasodilation - improve flow - improve oxygen supply
- decreases preoad b/c venous return is decreased from the dilation - decreases oxygen demand
-
vasodilation - improve flow - improve oxygen supply
- organic nitrates
- Prophylaxis
- organic nitrates
- beta blockers
- decrease heart rate & contractility - decrease oxygen demand
- calcium channel blockers
- vasodilation - improve flow - improve oxygen supply
- decrease heart rate & contractility - decrease oxygen demand
- ranolazine
- decreases cardiac contractility- decrease oxygen demand
- K+ channel opener- Nicorandil
- (?)
How can antithrombic & statins improve ischemic heart disease?
Improve flow so they improve the oxygen supply to the heart, lessening the mismatch between supply & demand of oxygen that leads to ischemis
Nitrates are contraindicated in what type of MI?
Why?
What if you accidentally do this? What do you do?
Nitrates are contraindicated in an inferior MI (affecting the right ventricle) because if you drop their preload then the amount of blood in the RV will drop, which can kill the patient
- Response
- have to bolus them with fluids if you didn’t lose their heart rate (code)
Describe the mechanism of action of organic nitrates
Uses?
- Pro drug that release NO
- NO increases intracellular levels of cGMP
- this leads ot dephosphorylation of myosin light chain & a decrease in cytosolic calcium
- causes relaxation of smooth muscle & hence vasodilation but also relaxation of bronchi & GI tract
- NO-mediated guanyl cyclase activation inhibits platelet aggregation (obviously beneficial in setting of MI)
- Uses
- angina pectoris, CHF, MI
