Ischemic Heart Disease

Question 1

Where do atheroslcerotic plaques tend to form?

Answer 1

sites of increased turbulence

branching points

Question 2

LDL, when oxidized leads to what three processes that eventually result in non-calcified plaque formation?

Answer 2

1. endothelial dysfunction
2. fatty streak
3. inflammation

Question 3

Plaque rupture leads to what two severe conditions?

Answer 3

thrombosis and ACS

Question 4

Presence of three or more of the following results in what condition?

abdominal obesity

HDL < 40 (M) or < 50 (F)

TGs 150 or higher

FBG 110 or higher

HTN

Answer 4

metabolic syndrome

Question 5

What contributes to the increased mortality of women with IHD?

Answer 5

delayed dx and delayed tx due to atypical sxs

Question 6

Sxs of IHD in women are induced during what activities?

Answer 6

rest, sleep, mental stress

Question 7

A patient presents with the following signs/sxs and hx:

Hx of substernal chest pressure for 5-10 minutes

pain began when walking up stairs at office

radiation to jaw

Pain lessened with time

What is your presumptive Dx?

Answer 7

stable angina

Question 8

What would you expect to find on PE of a patient with stable angina?

Answer 8

tachycardia

HTN

abnormal heart sounds

Question 9

A clenched fist or hand over the chest is known as…

Answer 9

Levine’s sign

Question 10

A female patient presents with the following sxs… what should you immediately consider?

dyspnea

nausea

fatigue

faintness

Answer 10

Stable angina

Question 11

A patient presents to the clinic with the following:

• Sharp chest pain localized with one finger
• pain lasted for seconds and resolved

Do you suspect angina/ischemia?

Answer 11

no

Question 12

What sxs are not likely to be ischemia or angina related?

Answer 12

sharp, fleeting CP

prolonged ache in left precordial

localization

short lasting or constant pain

Question 13

A patient presented to the ED with crescendo/decrescendo CP lasting 7 minutes. What tests do you want to order?

Answer 13

EKG

CXR

Cardiac enzymes

Question 14

Why do we order a CXR for patients with angina?

Answer 14

to rule out other causes of CP like fx or masses

Question 15

What are you looking for during an exercise stress test on a patient with angina?

Answer 15

EKG changes

decreased perfusion on imaging

SBP drop 10mmHg

sx development

Question 16

The Bruce Protocol for an exercise stress test states that speed and incline are increased every ______ minutes until HR is at _____% of maximum

Answer 16

3 minutes

85% of max HR

Question 17

what are the indications for a stress echo?

Answer 17

prior MI

Sxs of heart failure

undiagnosed murmur

complex ventricular arrhythmia

Question 18

Which medications decrease oxygen demand?

Answer 18

Nitrates

Beta blockers

CCBs

Question 19

1st line tx for acute angina…

Answer 19

short acting nitrates

Question 20

Which medications reduce preload?

Answer 20

nitrates

Question 21

When are long acting nitrates indicated?

Answer 21

chronic angina

Question 22

1st line tx for chronic angina?

Answer 22

beta blockers

Question 23

this medication decreases HR, BP, contractility and afterload…

Answer 23

beta blockers

Question 24

The only antianginal medication proven to prevent re-infarct and improve survival post-MI…

Answer 24

beta blockers

Question 25

This medication decreases BP, contractility and afterload, but doesn't lower HR...

Answer 25

CCBs

Question 26

who is indicated for CCBs with respect to IHD?

Answer 26

non-response to nitrates and beta blockers

Question 27

Which medications increase oxygen supply via coronary vasodilation?

Answer 27

nitrates CCBs

Question 28

what antiplatelet medications can be considered for stable angina?

Answer 28

aspirin clopidogrel combo of the two

Question 29

Why are statins useful in treating stable angina?

Answer 29

reduce clinical events slow and regress coronary atherosclerosis

Question 30

What statin dosage should you consider regardless of baseline LDL-C for stable angina?

Answer 30

high intensity

Question 31

What are the two forms of revascularization?

Answer 31

percutaneous coronary intervention (PCI, angiography) Coronary artery bypass grafting

Question 32

What is the most common physiologic process by which ACS/acute MI begins?

Answer 32

plaque rupture with occlusive thrombus

Question 33

Acute Coronary Syndrome (ACS) is composed of what three conditions?

Answer 33

unstable angina non-ST Elevation MI ST Elevation MI

Question 34

Sxs of Prinzmetal's angina are secondary to what?

Answer 34

vasospasm

Question 35

When does CP occur in Prinzmetal's angina?

Answer 35

at rest

Question 36

What can be seen on EKG during Prinzmetals angina?

Answer 36

transient ST elevation

Question 37

young patients with few risk factors and CP should be considered for what condition?

Answer 37

Prinzmetal's angina

Question 38

Is stress testing helpful in dx of Prinzmetal's angina?

Answer 38

no

Question 39

What can help dx Prinzmetal's?

Answer 39

coronary angiography

Question 40

how do you treat Prinzmetal's Angina?

Answer 40

nitrates and CCBs

Question 41

A patient presents with the following sxs... what should immediately be considered? CP SOB Weakness Nausea Anxiety/Sense of impending doom

Answer 41

ACS

Question 42

What atypical sxs present in women, DM, and elderly patients?

Answer 42

sudden breathlessness, dyspnea

Question 43

Dx of unstable angina requires ischemic discomfort and one of which 3 sxs?

Answer 43

occurrence at rest severe and new onset crescendo pattern

Question 44

The diagnostic approach to UA/NSTEMI should include what 5 things?

Answer 44

1. clinical Hx 2. EKG 3. cardiac enzymes/biomarkers 4. stress testing if safe

Question 45

When should you consider stress testing for a patient with potential NSTEMI/UA?

Answer 45

no evidence of infarction/normal cardiac enzymes unclear diagnosis

Question 46

What differentiates NSTEMI from UA?

Answer 46

NSTEMI: elevated cardiac enzymes UA: normal cardiac enzymes

Question 47

What may be present on EKG of NSTEMI?

Answer 47

ST Depression, T wave inversion ST elevation typically not present

Question 48

What can be seen on EKG in UA?

Answer 48

usually normal may have ST elevation, T wave inversion

Question 49

How should UA/NSTEMI be managed?

Answer 49

Oxygen Nitro antiplatelet therapy beta blockers

Question 50

The following criteria make up what test for progression of UA/NSTEMI to STEMI? Age 65+ 3+ CHD risk factors prior coronary stenosis of 50+% ST deviation on admission 2+ anginal episodes in previous 24 hours elevated cardiac enzymes aspirin use in last 7 days

Answer 50

TIMI variables

Question 51

What factors precipitate STEMI in 50% of cases?

Answer 51

vigorous exercise extreme emotional stress medical/surgical illness

Question 52

What is the cause of STEMI?

Answer 52

rupture of vulnerable plaque leading to complete occlusion of coronary artery

Question 53

What diagnostics should you order on a pt. you suspect of STEMI?

Answer 53

EKG CXR Cardiac Enzymes CBC Coags electrolytes Lipid panel 2D echo

Question 54

ST Elevation and + cardiac enzymes should make you think of...

Answer 54

STEMI

Question 55

ST depression with (-) cardiac enzymes should make you think of...

Answer 55

UA

Question 56

no ST elevation with (+) cardiac enzymes should make you think of...

Answer 56

NSTEMI

Question 57

A patient presents with STEMI. How do you immediately manage the patient?

Answer 57

ASA 325 mg sublingual nitro beta blockers high intensity statin identify reperfusion strategy

Question 58

What is the preferred method of reperfusion in STEMI?

Answer 58

PCI

Question 59

When should you consider fibrinolytic therapy in STEMI?

Answer 59

PCI not available within 120 minutes of first medical contact sxs < 12 hrs absence of contraindications

Question 60

the following are what contraindications to fibrinolysis? hx of intracranial hemorrhage hx of stroke in past year poorly controlled HTN suspected aortic dissection internal bleeding

Answer 60

absolute contraindications

Question 61

the following are what contraindications to fibrinolysis? current anticoagulation recent invasive procedure prolonged CPR known bleeding pregnancy active peptic ulcer hemorrhagic ophthalmic condition hx of severe HTN streptokinase use allergic rxn

Answer 61

relative contraindications

Question 62

Can thrombolytics be used in NSTEMI/UA?

Answer 62

no

Question 63

CP due to pericardial inflammation following MI, CABG, or traumatic injury is known as?

Answer 63

Dressler's syndrome, pericarditis

Question 64

What medications should be used after MI tx?

Answer 64

beta blockers aspirin

Question 65

A patient is seeing you on f/u after MI. Pt. has LV dysfunction. What can be given?

Answer 65

ACE, ARB