Ischemic Heart Disease

Question 1

What is ischemic heart disease?

Answer 1

Imbalance in demand of 02 and supply

Question 2

How does tachycardia lead to ischemia?

Answer 2

Tachycardia (>180bpm)>decreased filling time of coronary arteries>ischemia

Question 3

What does the LAD supply?

Answer 3

Anterior portion of LVAnterrior 2/3 IVSApex

Question 4

What is the most common site for coronary artery thrombosis?

Answer 4

LAD

Question 5

What does the RCA supply?

Answer 5

Posterior LVposterior 1/3 IVSRVposteromedial papillary muscleSA/AV nodes

Question 6

What percent of coronary artery thromboses occur in the RCA?

Answer 6

30-40%

Question 7

What does the LCA supply?

Answer 7

Lateral wall of the left ventricle15-20% coroanry thrmboses

Question 8

What is the most common cause of death in the US?

Answer 8

IHDIncidence peaks in mean after 60 and women after 70

Question 9

What are the risk factors for IHD?

Answer 9

Age (M>45, W >55)Family hx of premature CAD or strokeLipid abnormatlitiesSmokingHTNDiabetes

Question 10

Angina pectoris is most commonly observed in what population?

Answer 10

Middle aged/elderly malesWomen after menopause

Question 11

What is stable angina? Common Sxs? EKG? Tx?

Answer 11

1. Exercise induces substernal chest pain lasting >30 mins2. SOB, diaphoresis, numbness, pain in arm/shoulder/jaw3. Subendocardial ischemia> ST segment DEPRESSION> 1 mm4. Nitroglycerin

Question 12

What causes stable angina?

Answer 12

Atherosclerosis of coronary artery >70%>subendocardial ischmeia d/t decreased coronary blood flow (concentric hypertrophy)

Question 13

What is prinzmetal varian angina?

Answer 13

Vasospasm with TRANSMURAL ischemia > ST ELEVATION

Question 14

What is unstable angina?

Answer 14

Angina at RESTMultivessel atherosclerosis>Disrupted plaques>Frequent bouts of chest pain w/ minimal exertion

Question 15

What is worrisome about unstable angina?

Answer 15

It can progress to MI

Question 16

What diagnostic tests can be done to work up chest pain?

Answer 16

1. Resting EKG2. Exercise test with ECG monitoring3. Stress echocardiography4. Coronary angiography

Question 17

How do you commonly treat Prinzmetal angina?

Answer 17

Ca channel blockers> vasodilate arteries

Question 18

What is the common pharmacological therapy for angina?

Answer 18

1. Nitrates (decrease preload and afterload through vaso/venodilation)2. B blockers (decrease O2 consumption, decrease HR)3. Aspirin- decreases platelet aggregation/thrombus4. Clopidogrel- used if pt allergic to aspirin

Question 19

What treatment is often used for pts with unstable angina?

Answer 19

Heparin plus aspirin–> decreases risk of developing MI

Question 20

What is chronic IHD?

Answer 20

long term ischemid damge to myocardium>Muscle replaced by noncontractile fibrous tissue>progressive CHF

Question 21

What is Sudden Cardiac death?

Answer 21

Unexpected death from cardiac cause in persons w/out symptomatic heart disease or w/in 1 hour of onset of sxs

Question 22

What are the risk factors for SCD?

Answer 22

1. IHD**2. Obesity diabeties, hyperlipidemia, LVH, HTN, smoking, recent NSTEMI

Question 23

What does SCD most commonly occure?

Answer 23

morning hrs 8-11 am and late afternoon 4-7 pm

Question 24

What are non coronary artery causes of SCD syndrome?

Answer 24

1. Cardiomyopathy2. AV stenosis3. Mitral valve prolapse, cocaine, myocarditis, WPW

Question 25

What are causes of SCD in children?

Answer 25

AV stenosisCardiomyopathiesWPW

Question 26

What is the most common cause of death in adults in the US?

Answer 26

Acute MI

Question 27

What is the pathogenesis of MI?

Answer 27

Rupture of disrupted plaque>exposure subendothelial collagen>platelet thrombosis>MI

Question 28

What are less common causes of MI?

Answer 28

1. Vasculatis (polyarteris nodosa, kawasaki disease)2. Cocain use3. Embolization of plaque from aorta or CA4. Thrombosis syndromes5. Dissection of blood into into wall of CA

Question 29

What are the two types of MI?

Answer 29

STEMINSTEMI

Question 30

What is a STEMI? Depth of heart involved? What is seen on EKG?

Answer 30

ST segment elevation MIFULL thickness myocardium involvedNew Q waves on ECG

Question 31

What is a NSTEMI? Depth of heart involved? ECG?

Answer 31

Inner third of myocardium (subendocardium) involvedQ waves are absent

Question 32

What are the benefits of reperfusion following MI?

Answer 32

Previously ischemic cells are salvagedCells irreversibly damaged are destroyedLIMITS the size of infarction

Question 33

What is reperfusion injury following MI?

Answer 33

Ischemic myocardial cells not already irreversibly damaged become so after reperfusion

Question 34

How does the timing of reperfusion affect the extent of myocardial damage?

Answer 34

cell death> contraction bands>3 hrsGreater chance of reperfusion injury (previously ischemic cells are irreversibly damaged)

Question 35

What is the mechanism of irreversible myocardial injury?

Answer 35

1. Superoxide free radicals FRs2. Neutrophils (occlude BVs and decrease blood flow, and increase production of ROS)

Question 36

What type of necrosis is seen in the heart within 24 horus?

Answer 36

Coagulation necrosis

Question 37

Following MI, when is the heart the softest and most in danger of rupturing?

Answer 37

3-7 days after MI

Question 38

A pt presents with retrosternal pain >30 mins, radiating to the left arm/shoulder and is diaphoretic. What do you expect?

Answer 38

Acute MI

Question 39

What nerves supply the heart?

Answer 39

T1-T5

Question 40

Inner arm pain is associated with what nerve?

Answer 40

T1

Question 41

Epigastrum (upper/central region of abdomen) radiation is associated with what nerves?

Answer 41

T4-T5

Question 42

When do silent MIs occur?

Answer 42

20% of casesUsually in elderly and individulas with diabetes who frequently have neuropathies and can't feel pain.

Question 43

Do STEMI or NSTEMI have increased early mortality rate?

Answer 43

STEMI

Question 44

What complications commonly follow STEMIS?

Answer 44

1. Cardiogenic shock2. Arrythmias (PVS or v. fib> death)3. CHF (w/in 24 hrs)4. Rupture (3-7 days)5. Mural thrombosis6. Fibrous pericarditis7. Ventricular aneurysm8. Right ventricular AMI

Question 45

What is associated with mural thrombosis?

Answer 45

Danger of embolization

Question 46

What is fibrinous pericarditis?

Answer 46

Occurs w/in 1-7 days of a STEMI-Substernal chest pain that is relieved when pt leans forward-Precordial friction rub present on asucultation

Question 47

What is autoimmune pericarditis (Dressler syndrome)?

Answer 47

Occurs 1-8 wks after a STEMIAutoantibodies are directed against the damaged pericardial antigens (type II hypersensitivityFever and precordial friction rub present

Question 48

When is a ventricular aneurysm recognized after a STEMI?

Answer 48

4-8 weeks after, but begins to develop during the first 48 hrs

Question 49

What is a ventricular aneurysm?

Answer 49

Precordial bulge during systole

Question 50

What is the gold standard for diagnosing Acute MI?

Answer 50

Troponinappear within 3-12 hrs and peak at 24 dissappear within

Question 51

What is CK-MB used for?

Answer 51

Detect reinfarction

Question 52

What ECG findings do you expect to see on a STEMI?

Answer 52

Inverted T waves (areas of ischemia at periphery of infarct)Elevated ST waves (injured myocardial cells around areas of necrosis)New Q waves (coagulation necrosis)

Question 53

Q waves in V1-V2

Answer 53

LAD anterior wall infarctionAnterioseptal infarction

Question 54

Q waves in leads V4-V6, I, aVL

Answer 54

Anterolateral infarction d/t mid LAD or circumflex artery occlusion

Question 55

Q waves in I, aVL

Answer 55

Lateral wall infarction d/t left circumflex

Question 56

Q waves in II, III, aVR

Answer 56

Inferior wall infarction d/t RCA occlusion