Ischemic Heart Disease

Question 1

What are 5 types of cardiovascular diseases?

Answer 1

Coronary artery disease
Ischemic heart disease
Hypertension
Peripheral vascular disease
Stroke (generally ischemic)

Question 2

T/F: CVD remains leading cause of death in U.S.

Answer 2

True

Question 3

What are clinical signs and symptoms of CAD?

Answer 3

Can have obstruction but doesn’t affect heart function.

Depends on severity of obstruction per vessel and the number of vessels involved

Question 4

What are main coronary arteries to the heart?

Answer 4

Right coronary
LAD
Circumflex

Question 5

What are determinants of myocardial blood flow?

Answer 5

Diastolic BP
Resistance
Vasomotor tone
LV end diastolic volume

Question 6

What is atherosclerosis?

Answer 6

Atherosis= fatty streak
Sclerosis= fibrotic

Active process involving molecular signals that produce altered cellular behavior as well as endothelial dysfunction and subsequent inflammatory response.

Lipid deposition is a fundamental part of this process

Question 7

What is progression of atherosclerosis?

Answer 7

Fatty streaks: lipid deposits in aorta and coronary arteries
Fibrous plaque: increased levels of collagen, destruction of medial elastin, changes in composition of fibrous proteins (stable or unstable, progression based on risk factors)

Question 8

What is the atherogenesis chain of effect (6 steps)?

Answer 8

1) endothelial injury with increased infiltration of atherogenic lipoprotein
2) Sub endothelial retention and modification of LDL, VLDL leads to intimal entry of monocytes and T lymphocytes
3) Subintimal diffusion of monocytes to macrophage which internalize LDL, transform into foam cells (First stage of fatty streak development)
4) Hemodynamic stress or inflammatory process activate Platelet-derived growth factor or PDGF which will stimulate Smooth Muscle Cells ending by having atherosclerotic plaque separated from blood by fibrous cap
5) Death of foam cells by necrosis or apoptosis lead to necrotic core formation
6) Rupture of fibrous cap, exposure of thrombogenic substrate, subsequent arterial thrombosis

Question 9

What is etiology of HTN?

Answer 9

Essential/Primary: occurs in absence of disease, areteriole resistance
Non-essential/Secondary: occurs in presence of disease
Labile: comes and goes

Question 10

What is PT implications for high BP?

Answer 10

Get medical clearance if resting SBP>200 mmHg or DBP >105 mmHg

Terminate exercise if SBP >250 or DBP >115

Question 11

What are side effects for BP medication?

Answer 11

Orthostatic hypotension

With activity: drop in BP 20 mmHg SBP or 10 mmHg systolic AND diastolic

Question 12

What are considerations for HTN and exercise?

Answer 12

avoid Valsalva

Aerobic exercise: 4-7x/week, 30-45 minutes, 60-85% HR max, RPE 12-16

Question 13

What is presentation of Ischemic heart disease?

Answer 13

Depends on rate of progress of atherosclerosis and has different presentations

Question 14

What are possible presentations of IHD?

Answer 14

Chronic stable angina
Unstable angina
Myocardial infarction
Silent ischemia
Arrythmia
Sudden death

Question 15

What are signs and symptoms of MI for men?

Answer 15

Pain radiating down left arm
Crushing pain: hard to breathe, elephant on chest
Sweating
Skin color

Question 16

What are signs and symptoms of MI for women?

Answer 16

Unusual fatigue, sleep disturbances, SOA, indigestion, anxiety, chest discomfort

LV dysfunction found on functional study, arrhythmia (more VT or VF, but can be seen with atrial flutter or fib)
Syncope
Silent

Question 17

What are precipitating factors and relieving factors for MI in women?

Answer 17

Precipitating: cold, exertion, anxiety, heavy meals, tachycardia, hypoglycemia
Relief: rest, NTG

Question 18

What is stable angina?

Answer 18

Characterized by chest pain: transient hypoxia, relieved with change in activity or SLNG

Has well established onset: myocardial oxygen demand, rate pressure product

Question 19

When is angina considered stable?

Answer 19

When characteristics remain unchanged for 60 days

Question 20

What is unstable angina?

Answer 20

Presence of signs and symptoms of inadequate blood supply to myocardium: absent of demand

Question 21

What are factors contributing to unstable angina?

Answer 21

Circadian variation (4 hours) in catecholamine levels- increases HR and BP
Increased platelet activation
Pathologic changes in atherosclerotic plaques

Question 22

What are clinical clues of unstable angina (when should you notify physician or nursing staff)?

Answer 22

Angina at rest
Typical angina occurs at lower exertion
Deterioration of previously stable pattern
Physiological changes: drop in HR or BP with usual exercise

Question 23

What is prinzmetal angina?

Answer 23

Unusual syndrome of cardiac pain secondary to myocardial ischemia.
Exclusively at rest
ST segment elevation on EKG
Secondary to incrased coronary vasomotor tone or vasospasm

Question 24

What is treatment for prinzmetal angina?

Answer 24

Combination of nitrates and calcium channel blockers

Beta blockers are usually avoided: alpha adrenergic activity, worsening vasoconstriction

Question 25

What are two types of acute MI?

Answer 25

Transmural | Non-transmural (subendocardial): endocardium or endocardium to myocardium

Question 26

What does STEMI stand for?

Answer 26

ST elevation MI

Question 27

What is definition of STEMI?

Answer 27

In at least two contiguous leads. > 2mm in leads V1, V2, V3 >1 mm in all other leads

Question 28

What does STEMI indicate?

Answer 28

Occlusion in a large vessel, and large area at risk. | Cardiac emergency requiring either thrombolytic therapy, or immediate cardiac catheterization

Question 29

What is NSTEMI?

Answer 29

Findings of MI without ST elevation on EKG | Not always, but may represent smaller area, or high grade lesion, without total occlusion

Question 30

Where would you see localization of infarction of right coronary artery?

Answer 30

Location: inferior EKG: 2, 3, aVF

Question 31

Where would you see localization of infarction of LAD (2 possible answers)?

Answer 31

Location: anteroseptal EKG: V1-V3 Location: Anterior EKG: V2-V4

Question 32

Where would you see localization of infarction of LAD or circumflex?

Answer 32

Location: lateral EKG: 1, aVL, V5, V6

Question 33

Where would you see localization of infarction for posterior descending?

Answer 33

Location: posterior EKG: V1-V2, tall broad initial R wave, ST depression, tall upright T wave

Question 34

What are corresponding EKG lines for inferior, anteroseptal, anterior, lateral, and posterior part of heart?

Answer 34

``` Inferior: 2, 3, aVF Anteroseptal: V1-V3 Anterior: V2-V4 Lateral: 1, aVL, V5, V6 Posterior: V1-V2, tall broad initial R wave, ST depression, tall upright T wave ```

Question 35

What artery corresponds with V1-V3 leads?

Answer 35

LAD

Question 36

What artery corresponds with V2-V4 leads?

Answer 36

LAD

Question 37

What artery goes with 2, 3, and aVF leads?

Answer 37

Right coronary

Question 38

What artery goes with 1, aVL, V5, and V6 leads?

Answer 38

LAD or circumflex

Question 39

What artery goes with V1-V2?

Answer 39

posterior descending also will have tall broad initial R wave, ST depression, tall upright T wave

Question 40

What is treatment of MI (acute coronary syndrome)?

Answer 40

In ER- up to/through admission: Morphine sulfate, beta blockers (also nitrates or calcium channel blockers), aspirin, EKG, blood draw for cardiac markers

Question 41

What does MONA stand for?

Answer 41

Morphine Oxygen Nitrates Aspirin

Question 42

What are the cardiac markers they test for when looking at MI?

Answer 42

CK- total and MB Troponins Myoglobin LDH

Question 43

What is onset, peak, return to normal for CK?

Answer 43

Onset: 3-4 hours Peak: 33 hours Return to normal: 3 day

Question 44

What is onset, peak, return to normal for troponins?

Answer 44

Onset: 3-12 hours Peak: 18-24 hours Return: up to 10 days

Question 45

What is onset, peak, return to normal for myoglobin?

Answer 45

Onset: 1-4 hours Peak: 3-15 hours

Question 46

What is onset, peak, return to normal for LDH?

Answer 46

Onset: 12-24 hours Peak: 72 hours Return: 5-14 days

Question 47

What are cardiovascular risk factors and prevention techniques?

Answer 47

``` Family history Age Diabetes: nutrition and exercise Hypercholesterolemia: nutrition and exercise Hypertension: nutrition and exercise Smoking: stop Obesity: nutrition and exercise Inactivity/sedentary lifestyle: exercise ```

Question 48

What type of effect does physical activity have on prevention and treatment?

Answer 48

Clear cardio protective effect of physical activity and proatherogenic effect of inactivity. No other therapeutic intervention has mulit-faceted potency and preventative efficacy of aerobic exercise

Question 49

What are exercise induced changes in myocardial function?

Answer 49

Effects on: HR, systolic BP, rate-pressure product, oxygen demand via decreased energy demand, changes in myocardial oxygen consumption (demand versus delivery)

Question 50

What does training help if there is damage in the central mechanism (heart)?

Answer 50

Heart is rate limiting factor. Training will help with the periphery. We want to improve a-v O2 difference with training to have better oxygen exchange

Question 51

What may cause a reduction in cardiac output?

Answer 51

Chronotropic incompetence LV dysfunction due to an MI Transient ischemia Cardiomyopathy that results in reduced EF, SV, and diastolic filling

Question 52

What is the cause of reduction in VO2?

Answer 52

Is seldom the result of decreased oxygen extraction but rather the result of decreased oxygen delivery

Question 53

What is peak VO2 in healthy versus patients with CAD?

Answer 53

healthy, active: between 35-70 | In CAD patients: below 20

Question 54

What are disease specific effects on physiologic responses and fitness?

Answer 54

affects VO2, HR, and BP

Question 55

What is chronotropic incompetence?

Answer 55

Failure to reach 85% of APMHR in the absence of beta blockers or other medications with similar effects

Question 56

What is abnormal HR recovery?

Answer 56

Decrease in HR of

Question 57

What happens to BP because of heart disease?

Answer 57

In absence of beta blockers or ACE inhibitors, a failure of systolic BP to rise in proportion to exercise intensity

Question 58

What are surgical and pharmacological treatments?

Answer 58

Oxygen- increase oxygen saturation and delivery Nitroglycerin- decrease myocardial oxygen demand, vasodilator Aspirin/clopidrigrel- anti platelet Heparin/enoxaparin- anti coagulation Pain relief Revascularization Beta-blockers Calcium channel blockers- if beta not working ACE inhibitors- improve LV function Statins- decrease production of cholesterol in liver, and anti-inflammatory

Question 59

What are phases of cardiac rehab?

Answer 59

Phase I or inpatient phase was introduced in the 1960s and consists of the early graded mobilization of the stable cardiac patient to the level of activity required to perform simple household tasks. Phase II consists of outpatient monitored exercise and risk factor reduction. This multidimensional approach gained popularity in the 1970s and became well structured in the 1980s. Phase III or maintenance phase consists of home- or gymnasium-based exercise with the goal of continuing the risk factor modification and exercise program learned during phase II.

Question 60

What is incidence of cardiac arrest?

Answer 60

295 000 cases of cardiac arrest in the US per year | 7.9% survival to discharge

Question 61

What is cause of cardiac arrest?

Answer 61

60-70% of cardiac arrest occurs in individuals with CAD

Question 62

What is the only method for sustainable cardio protection?

Answer 62

Aerobic exercise

Question 63

What does regular exercise protect the heart against?

Answer 63

Arrhythmias Stunning Infarction Remodeling