Ischemic Heart Disease

Question 1

2 groups of IHD

Answer 1

STABLE CAD (SCAD)

-present w/ CHRONIC STABLE ANGINA PECTORIS (SCAP)

ACS

• NSTE-ACS
• unstable angina (UA)
• NSTEMI

-STEMI

Question 2

Chronic Stable Angina Pectoris (CSAP)

Answer 2

heaviness, pressure, squeezing, smothering, choking (Levine’s sign)

crescendo-decrescendo

lasts for 2-5 mins

physical exertion or stress

radiation - both shoulders or arms but does NOT radiate to trapezius muscles

relieved w/n 5-10 mins and/or sublingual nitroglycerin

Question 3

Levine’s sign

Answer 3

hand place over sternum w/ a clenched fist to indicate a squeezing, central, substernal discomfort

Question 4

Typical angina - 3 CRITERIA

Answer 4

substernal chest discomfort of characteristic quality and duration

provoked by exertion or stress

relieved by rest and/or nitrates w/n minutes

Question 5

Atypical angina

Answer 5

meets 2 of the manifestations of typical angina

Question 6

12-Lead ECG

Answer 6

may be normal at rest

ST segment and T wave changes, LV hypertrophy, intraventricular conduction disturbances, arrhythmias

Question 7

Used to assess LV function, wall motion abnormalities, EF, presence of thrombus

Answer 7

2D Echo

Question 8

Most widely used for both diagnosis of IHD and estimating prognosis

involves recording the 12-lead ECG before, during and after exercise

Answer 8

ECG exercise stress

Question 9

Preferred when the resting ECG is already abnormal

Answer 9

stress imaging (stress echocardiography, radionuclide perfusion or MPI, stress cardiac MRI)

Question 10

Imaging technique for anatomical diagnosis of obstructive coronary lesions

Used as an alternative to stress imaging to R/O SCAd

Answer 10

CT angiography

Question 11

MC indication for percutaneous coronary intervention (PCI)

Answer 11

persistent or symptom-limiting angina pectoris despite medical therapy accompanied by evidence of ischemia during a stress test

Question 12

Patients who have received a drug eluting stent will need

Answer 12

dual antiplatelets for 1 year (aspirin + ADP-P2Y12 inhibitor)

THEN

single platelet indefinitely (usually aspirin)

Question 13

Done to achieve complete revascularization by grafting all coronary arteries of sufficient caliber that have significant proximal stenoses

Answer 13

Coronary Artery Bypass Grafting (CABG)

PREFERRED APPROACH FOR:
left main CAD
3 vessel CAD esp w/ LV dysfunction
2 vessel CAD w/ significant proximal LAD artery disease w/ LV dysfunction or high risk findings on non-invasive tests
patients w/ multi-vessel CAD and diabetes

Question 14

Clinical features that INCREASE the likelihood of ACUTE MI

Answer 14

radiation to the R arm or shoulder (HIGHEST LIKELIHOOD)

radiation to both arms or shoulders

association with exertion

radiation to the L arm

associated with diaphoresis

associated w/ N/V

worse than previous angina or similar to previous MI

described as PRESSURE

Question 15

Clinical features that DECREASE the likelihood of ACUTE MI

Answer 15

inframammary location

reproducible palpation

described as SHARP

described as POSITIONAL

described as PLEURITIC – LOWEST LIKELIHOOD

Question 16

Canadian Cardiovascular Society (CCS)
Functional Classification of Angina

Class I

Answer 16

Ordinary physical activity (walking and climbing stairs) does NOT cause angina

Question 17

Canadian Cardiovascular Society (CCS)
Functional Classification of Angina

Class II

Answer 17

Slight limitation of ordinary activity

Emotional stress in cold or a few hours from after awakening

Question 18

Canadian Cardiovascular Society (CCS)
Functional Classification of Angina

Class III

Answer 18

Marked limitation of ordinary physical activity

Question 19

Canadian Cardiovascular Society (CCS)
Functional Classification of Angina

Class IV

Answer 19

Inability to carry on any physical activity without discomfort

Question 20

Done if the patient has INTERMEDIATE PRETEST PROBABILITY OF CAD - (+) risk factors but atypical chest pain

Answer 20

Stress Test

Question 21

Stress test used for patients who cannot exercise such as those with severe COPD, amputated leg, deconditioned state, severely obese, residual weakness from stroke or dementia

Answer 21

Pharmacologic Stress Test

Adenosine, Dipyridamole, Dobutamine

Question 22

Drugs for EVENT PREVENTION

Answer 22

Aspirin
Clopidogrel (if aspirin intolerant)
Statins
ACEi or ARBS

Question 23

Drugs for RELIEF OF ANGINA

Answer 23

Beta blockers/ CCB - Verapamil and Diltiazem
Amlodipine, Felodipine, Nifedipine

Nitrates
Ivabradine
Nicorandil
Trimetazidine