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Ischemic Heart Disease Flashcards

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1
Q

What is the definition of ischemia?

A

Lack of adequate effective oxygenated blood flow to tissue.

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2
Q

What is considered morbid obesity?

A

BMI ≥ 40 kg/m².

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3
Q

What are the major determinants of myocardial oxygen demand?

A
  • Ventricular wall stress
  • Contractility
  • Heart rate.
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4
Q

What does Laplace’s Law describe?

A

The relationship of wall stress to systolic ventricular pressure, ventricular radius, and ventricular wall thickness.

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5
Q

What is the formula for wall stress according to Laplace’s Law?

A

Stress = (p)(r)/2h.

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6
Q

When is contractility measured?

A

During isovolumetric contraction.

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7
Q

What is the difference between hypoxia and hypoxemia?

A
  • Hypoxia: Low tissue oxygen content
  • Hypoxemia: Low arterial oxygen content.
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8
Q

Can you have hypoxia without hypoxemia?

A

Yes, due to increased demand or obstruction to flow.

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9
Q

What are the determinants of coronary blood flow?

A
  • Coronary perfusion pressure (CPP)
  • Resistance (R)
  • Existence of collateral circulation.
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10
Q

What factors determine resistance in normal coronary arteries?

A
  • External compression
  • Intrinsic control of coronary artery tone.
    * Accumulation of local metabolites.
    * Neural innervation.
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11
Q

What is considered significant obstructive CAD?

A

Lesions > 50-70%.

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12
Q

What is FFR (fractional flow reserve)?

A

The ratio of maximum blood flow distal to a stenotic lesion to normal maximum blood flow in the same vessel.

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13
Q

What FFR value is frequently associated with ischemia?

A

FFR < 0.75.

is the ratio of maximum blood flow distal
to a stenotic lesion to normal maximum blood blood flow in the same
vessel. It is calculated using the pressure ratio obtained from a pressure
wire:

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14
Q

What is the coronary sinus?

A

Drains most of the cardiac venous blood.

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15
Q

What are the tributaries of the coronary sinus?

A
  • Great Cardiac Vein
  • Oblique Vein of LA
  • Middle Cardiac Vein
  • Small Cardiac Vein.
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16
Q

What is the gold standard for defining coronary anatomy?

A

Coronary angiography.

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17
Q

What are the two types of coronary dominance?

A
  • Right dominant: PDA from RCA
  • Left dominant: PDA from LCx.
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18
Q

What is the significance of a left coronary angiogram?

A

Used to visualize lesions in the left coronary arteries.

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19
Q

What is the role of collateral circulation in coronary artery disease?

A

Buffers the problem of decreased flow due to obstructions.

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20
Q

What is the impact of endothelial cell dysfunction in coronary arteries?

A

Limits ability to effect compensatory vasodilation and maximal coronary blood flow.

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21
Q

What is the relationship between LVH and myocardial oxygen consumption?

A

A hypertrophied heart has lower wall stress per gram of tissue but higher overall oxygen consumption.

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22
Q

What is a common clinical condition that can result in ischemic repolarization abnormalities?

A

Left ventricular hypertrophy with strain pattern.

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23
Q

What does a high body mass index (BMI) indicate in relation to health?

A

It is a risk factor for various health issues, including ischemic heart disease.

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24
Q

What is the significance of coronary resistance (R) in myocardial ischemia?

A

It is a critical determinant of effective blood supply to the myocardium.

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25
What is the gold standard for defining coronary anatomy?
Coronary angiography ## Footnote Involves significant contrast administration, especially if LV angiography is performed.
26
What are the two types of angulations used in coronary angiography?
RAO and LAO ## Footnote These angulations help visualize specific coronary regions and separate vascular overlap.
27
What does LAO imaging tend to provide better viewing of?
Ostia and bifurcations
28
What is a significant consideration during LV angiography?
Significant contrast load
29
What is the main characteristic of 'stunned myocardium'?
Prolonged ventricular dysfunction after an acute ischemic event with eventual full recovery
30
What is the condition characterized by ventricular dysfunction related to chronic ischemia?
Hibernating myocardium
31
What imaging studies can differentiate hibernating myocardium from infarcted tissue?
Viability imaging studies such as PET or dobutamine TTE -typically due to chronic/reversible ischemia
32
What is stable angina?
Chest discomfort of similar quality and duration, predictable supply-demand issue
33
What triggers unstable angina?
Plaque disruption triggering platelet aggregation, thrombus formation, and vasoconstriction
34
What is silent angina associated with?
Autonomic and/or peripheral neuropathy in diabetics
35
What causes variant angina?
Coronary artery vasospasm
36
What is the primary characteristic of microvascular angina?
Due to microvascular disease not visualized by coronary angiography
37
What are some ischemic causes of myocardial infarction related to ischemia with no or minimal obstructive coronary artery disease?
* Vasospasm * Microvascular disease * Coronary artery dissection * Coronary artery embolism * Non-obstructive plaque rupture * Type 2 MI (demand > supply)
38
What are common risk factors for obstructive ischemic heart disease?
* Male * Age * Family history * Diabetes mellitus * Hypertension * Hyperlipidemia * Cigarette smoking * Obesity
39
What is the most sensitive diagnostic technique for angina?
Taking a thorough history
40
What are the characteristics of classic angina?
* Quality: tightness * Location: retrosternal radiating to neck, jaw, L shoulder * Duration: usually < 10 min * Precipitant: exertion, anxiety * Relief: rest or TNG
41
What should be done if a patient has new onset epigastric discomfort before elective surgery?
Postpone operation pending cardiac clearance
42
What is the differential diagnosis of atraumatic chest pain?
* Ischemic heart disease * Inflammatory diseases of the heart * Aortic dissection * Pulmonary embolus * Gastrointestinal issues * Costochondritis * Cervical radiculitis
43
What is the most common ECG finding in patients with ischemic heart disease?
Normal ECG
44
What ECG findings suggestive of ischemic heart disease?
* Significant Q waves * ST segment depression * ST segment elevation * Hyperacute T waves
45
What are the types of stress tests used to provoke findings of ischemic heart disease?
* Exercise Electrocardiography * Stress Echocardiography * Stress Cardiac MRI * Nuclear Stress Studies (MPI)
46
What is the sensitivity and specificity of exercise stress testing in diagnosing ischemic heart disease?
Approximately 70% and 75%
47
What is a key advantage of stress echocardiography over exercise electrocardiography?
Increased sensitivity and specificity (approximately 85%)
48
What is visualized on MPI studies?
Coronary perfusion indicated by radioactive tracers
49
What is the primary marker for diagnosing myocardial infarction?
Troponin
50
What is troponin?
A complex of regulatory proteins integral to skeletal and cardiac muscle contraction Not present in smooth muscle!!!
51
What are regional wall motion changes indicative of?
Ischemia and/or MPI evidence of loss of viable myocardium
52
What is Myocardial Infarction?
A condition resulting from the loss of blood supply to the heart muscle
53
What is troponin?
A complex of regulatory proteins integral to skeletal and cardiac muscle contraction ## Footnote Smooth muscle does not have troponin
54
Which troponin subunits are released into the blood with cardiac injury?
* cTnI * cTnT
55
What conditions can cause elevated levels of cTnI and cTnT?
* Cardiac injury * Inflammatory conditions of the heart * Cardiomyopathies * Trauma * Defibrillation * Renal failure
56
How long after an MI should elective noncardiac surgery be delayed?
> 60 days for mortality risk and > 6 months for perioperative stroke
57
Is the risk of surgery related to mortality modified by coronary intervention?
Yes
58
What is the minimum duration for DAPT after DES placement?
3 months
59
What are the current guidelines for DAPT after ACS?
1 year
60
What is a MET?
Metabolic equivalent representing resting oxygen consumption Resting oxygen consumption of a 40-year-old, 70 kg man
61
What activities correspond to < 4 METs?
* Slow ballroom dancing * Golfing with a cart * Playing a musical instrument * Walking on level ground at 2-3 mph
62
What activities constitute > 4 METs?
* Pushing a power mower (4 METs) * Raking leaves (4 METs) * Social dancing (5 METs) * Walking 4 miles on level ground (5 METs) * 9 holes of golf carrying clubs (6 METs) * Using a push mower (6 METs)
63
Which patients with IHD or risk factors need a stress study preoperatively?
Patients with elevated risk (MACE > 1%) and poor functional capacity
64
What pharmacological treatments are used for IHD?
* Nitrates * Beta blockers * Calcium channel blockers * Ranolazine
65
What is the purpose of nitrates in treating IHD?
Decrease preload (venodilation) and increase coronary supply
66
What is the risk associated with Bare Metal Stents?
Neointimal proliferation leading to in-stent restenosis
67
What do Drug-Eluting Stents (DES) contain?
Antiproliferative medication released over 2-4 weeks
68
What is the recommended duration of antiplatelet therapy after DES?
3 months minimum; longer is better
69
What is the patency rate of vein grafts at 10 years after CABG?
50%
70
What is the patency rate of arterial grafts at 10 years after CABG?
90%
71
What is the sensitivity and specificity of Treadmill Test (TMT)?
Sensitivity: 70%, Specificity: 75%
72
What is the sensitivity and specificity of Stress MRI?
Sensitivity: 89%, Specificity: 85%
73
What is the significance of a rise in troponin levels?
Indicates myocardial injury in the context of symptoms and other diagnostic criteria
74
What should be done for patients with IHD undergoing elective surgery?
Obtain a recent preoperative ECG and TTE if there is a history of heart failure or abnormal ventricular function
75
True or False: Stress studies are usually performed in patients with symptomatic IHD.
False
76
What is ventricular wall stress?
The tangible force acting on myocardial fibers, tending to pull them apart: Energy is expended opposing this force
77
Describe oxygen consumption in a hypertrophied ventricle from the perspective of wall stress
A hypertrophied heart has lower wall stress per gram of tissue: hence lower oxygen consumption per gram of tissue BUT there is more tissue so overall oxygen consumption is increased
78
CPP equation
DBP-LVEDP
79
What factors determine resistance in diseased coronary arteries?
Degree of obstruction Ability of the vessel to dilate distal to obstruction
80
Chordae from left and right papillary muscle go to which leaflets?
They go to both!!!
81
S3 vs S4
● S3; mid-diastolic sound related to filling of dilated V: always pathologic S4 (loud atrial kick with stiff [noncompliant] ventricle secondary to ischemia)
82
When do you have a false negative in MPI studies?
When there is global ischemia
83
What is DAPT?
ASA+P2Y12 receptor inhibitor The P2Y12 receptor is a platelet surface receptor (G protein coupled) that binds ADP and thereby plays a crucial role in platelet activation, aggregation, and thrombus formation.

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