Ischemic Heart Disease

Question 1

What is the leading cause of death in adults in the United States, accounting for about one-third of all deaths in subjects over age 35?

Answer 1

Coronary Artery Disease

Question 2

What are the risk factors for CAD? (7)

Answer 2

Age
HTN
Smoking
Elevated Cholesterol
Diabetes
Family history
Obesity

Question 3

What term is applied to patients in whom there is a suspicion of myocardial ischemia?

Answer 3

Acute Coronary Syndrome

Question 4

What are the types of acute coronary syndrome? (3)

Answer 4

ST elevation (formerly Q-wave) MI (STEMI)
 Unstable angina (UA)
 Non-ST elevation (formerly non-Q wave) MI (NSTEMI)

Question 5

What is a clinical event consequent to the death of cardiac myocytes (myocardial necrosis) that is caused by ischemia?

Answer 5

Myocardial Infarction

Question 6

What is the criteria for a myocardial infarction? (4)

Answer 6

Rise and fall of cardiac biomarkers
EKG changes
New wall motion abnormalities
Symptoms of ischemia

Question 7

What patients may not realize that they have had an MI?

Answer 7

Diabetes due to neuropathy, perhaps.

Question 8

What types of therapy can be used for CAD? (2)

Answer 8

Anti-anginal therapy

Preventative therapy

Question 9

What are anti-anginal therapies? (3)

Answer 9

Beta-Blockers

Calcium Channel Blockers

Nitrates

Question 10

Should nitrates be skipped in the evening or in the morning?

Answer 10

They should NOT be skipped in the evening!

Question 11

What are preventative therapies for CAD? (3)

Answer 11

Antiplatelet therapy

Risk reduction

Statins

Question 12

Should you ever give ASP with ibuprofen?

Answer 12

If ASP taken first thing in the morning, then ibuprofen much later, then OK.

Question 13

What are the methods to treat CAD?

Answer 13

PCI

Surgical

Question 14

What is the difference between bare metal and drug eluting stent?

Answer 14

Bare metal stents are susceptible to inflammation.

Drug eluting never get inflammation, but need to stay on antiplatelet therapy for life.

Question 15

What is the failure of the heart to maintain a cardiac output sufficient to meet the metabolic demands of the body?

Answer 15

cardiac failure

Question 16

What is the equation for cardiac output?

Answer 16

stroke volume * heart rate

Question 17

Define the following NYHA Class Symptoms:

I
II
III
IV

Answer 17

I No symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.

II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.

III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20-100 m). Comfortable only at rest.

IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

Question 18

Define the following Canadian Cardiovascular Society Angina Grading Scales:

I
II
III
IV

Answer 18

Class I – Angina only during strenuous or prolonged physical activity

Class II – Slight limitation, with angina only during vigorous physical activity

Class III – Symptoms with everyday living activities, i.e., moderate limitation

Class IV – Inability to perform any activity without angina or angina at rest, i.e., severe limitation

Question 19

What are modified major Framinham clinical criteria for the diagnosis of heart failure? (8)

Answer 19

Paroxysmal nocturnal dyspnea
Orthopnea
Elevated jugular venous pressure
Pulmonary rales
Third heart sound
Cardiomegaly on chest x-ray
Pulmonary edema on chest x-ray
Weight loss 4.5 kg in five days in response to treatment

Question 20

What are modified minor Framinham clinical criteria for the diagnosis of heart failure? (7)

Answer 20

Bilateral leg edema
Nocturnal cough
Dyspnea on ordinary exertion
Hepatomegaly
Pleural effusion
Tachycardia (heart rate 120 beats/min)
Weight loss 4.5 kg in five days

Question 21

How can heart failure be diagnosed according to the Framinham criteria?

Answer 21

The diagnosis of heart failure requires that:

2 major or

1 major and 2 minor criteria cannot be attributed to another medical condition.

Question 22

What are the causes of cardiac failure? (6)

Answer 22

Ischemic
Alcoholic
Infectious
Inflammatory
Congenital
Valvular

Question 23

KNOW

What are the causes of cardiac failure relating to circulation? (5)

Answer 23

Heart Rate–too fast, too slow
Rhythm–ventricular (ICD), supraventricular (ablation)
Pre-load
After-load
Contractility

Question 24

What can treat intraventricular conduction delay?

Answer 24

Cardiac resynchronization therapy - CRT

CRT uses a special pacemaker to contract both Right and Left ventricle.

Question 25

What will 30% of pts with CHF have? What changes will occur with the EKG?

Answer 25

asynchronous contractions of the right and left ventricle wide QRS

Question 26

What is myocardial or myocyte fiber length just prior to contraction equivalent to compliant stretch?

Answer 26

Pre-load

Question 27

Basically, preload = \_\_\_\_\_\_\_.

Answer 27

volume

Question 28

What can impair venous return? (4)

Answer 28

Hemorrhage Dehydration Vascular occlusion Increased intra-thoracic pressure

Question 29

What is after-load? (5)

Answer 29

the tension produced by the heart in order to contract pressure created in order to eject blood out of chamber related to "wall stress" RESISTANCE TO FORWARD FLOW excessive arterial blood pressure

Question 30

What is contractility? (4)

Answer 30

intrinsic ability of a cardiac muscle fiber to contract at a given fiber length Augmented and impaired by many components Inotropic refers to contractility Lusitropic refers to relaxation

Question 31

What is an acquired form of cardiomyopathy? (3)

Answer 31

ETOH Sepsis/Viral Catecholamines

Question 32

Contractility can be adversely affected by what? (2)

Answer 32

ischemia cardiomyopathy

Question 33

What will you notice on the physical exam for someone suffering from cardiac failure? (7)

Answer 33

Coughing Pleural effusion Swelling in abdomen Tiredness SOB Pulmonary edema Swelling in ankles and legs

Question 35

What will you notice in the extremeties on the cardiac exam? (2)

Answer 35

cool extremeties mottling

Question 36

What do we need to know about S3 sounds?

Answer 36

may be normal abnormal Note: The pathologic S3 indicates decreased compliance of the ventricles, as in CHF and may be the earliest sign of heart failure

Question 37

What are blood tests we can use to monitor cardiac failure?

Answer 37

Cardiac enzymes ## Footnote Acid production Venous blood

Question 38

Normal aerobic metabolism produces a small amount of extra acid that can be measured in the blood as lactic acid or lactate. What is a normal lactate level?

Answer 38

\< 2 Note: Lactate \> 10 usually means death is imminent.

Question 39

Lactate is a global, not local, indicator. True or false? Lactate drawn serial can guide therapy. True or false?

Answer 39

Both are true

Question 40

What may cause a decrease in venous saturation? (4)

Answer 40

Decreased arterial saturation Decreased hemoglobin Decreased cardiac output (oxygen delivery) Increased consumption

Question 41

What may cause an increase in venous saturation? (2)

Answer 41

Increased arterial saturation (100% O2) Decreased extraction * Sepsis * Liver failure

Question 42

Where is venous blood (mixed venous) is best obtained? Where is second best?

Answer 42

from the distal port of a pulmonary artery catheter central line

Question 43

What information can the arterial line provide? (2)

Answer 43

Preload (Pulse pressure variation) Cardiac output * Pulse power * Pulse contour

Question 44

What information can the CVP provide? (2)

Answer 44

venous blood gas pressure (preload)

Question 45

What information can the PA catheter provide?

Answer 45

Venous blood Cardiac output by thermodilution

Question 46

What are the catecholamines? (4)

Answer 46

Epinephrine Norepinephrine Dopamine Dobutamine

Question 47

What is milrinone?

Answer 47

Phosphodiesterase inhibitors

Question 48

What are the vasodilators? (4)

Answer 48

Nitropruside Nitroglycerine Nicardipine Sildenafil

Question 49

What is inhalational therapy for cardiac failure? (3)

Answer 49

NO (nitric oxide) Milrinone Epoprostenol (Flolan)

Question 50

What is epinephrine? (3)

Answer 50

Dose dependant alpha/beta agonist Increasing alpha with increasing dose Indications: * Low cardiac index * low blood pressure * anaphylaxis

Question 51

What is norepinephrine? (3)

Answer 51

Dose dependant alpha/beta agonist Increasing beta with increasing dose Indications: * Vasodilation with decreased contractility

Question 52

What is dopamine? (4)

Answer 52

Alpha/beta/dopaminergic Dose dependant and variable Cardiologists favorite drug (lousy epinephrine) “renal dose dopamine

Question 53

What is dobutamine? (3)

Answer 53

Synthetic catecholamine Pure Beta Indicated in heart failure not as bad as may require epinephrine

Question 54

What is milrinone? (3)

Answer 54

“inodilator" Increases contractility synergistically with the catecholamines Indicated in heart failure with increased systemic vascular resistance

Question 55

What is HOCM? (4)

Answer 55

Hypertrophic cardiomyopathy ## Footnote Asymmetric septal hypertrophy Dynamic outflow tract obstruction Systolic anterior motion (SAM) Treatment is B-blocker, fluids, increase in SVR

Question 56

How do you treat SAM?

Answer 56

Tight, slow, full

Question 57

What are the 2 types of VADS?

Answer 57

Heartmate I and II ## Footnote Heartware

Question 58

What are mechanical pumps? (2)

Answer 58

IABP Impella Mechanical is better.

Question 59

CAD is a common and serious condition that has extensive morbidity and mortality. True or false?

Answer 59

true

Question 60

Treatment is aimed at symptom control and prevention of subsequent myocardial infarction. Treatment is: (3)

Answer 60

medical/stenting/surgical

Question 61

CHF is always ischemic. True or false?

Answer 61

False. CHF is a common condition with ischemic and non ischemic causes.

Question 62

Mechanical therapy is superior to medical therapy in certain situations. True or false?

Answer 62

true