Ischemic Heart Disease (Exam IV)

Question 1

What chemical mediators are released from ischemia that activate cardiac nociceptors?

Answer 1

Adenosine and Bradykinin

Question 2

What are the two main risk factors in the development of atherosclerosis?

Answer 2

• Male
• Older age

Question 3

What are the first 3 manifestations of IHD?

Answer 3

• Angina
• Acute MI
• Sudden death

Question 4

What is the path for cardiac pain signals to reach the spinal cord?

Answer 4

Cardiac nociceptors → Afferent Neurons → T1 - T5 SNS ganglia.

Question 5

What is the CNS response to cardiac ischemia?

Answer 5

• ↓ AV conduction and thus ↓HR
• ↓ Contractility

Question 6

Angina is an imbalance between what two things?

Answer 6

• Increased myocardial oxygen consumption
• Decreased coronary blood flow

Question 7

Differentiate stable vs unstable angina.

Answer 7

• Stable - No change in chest pain severity or frequency in 2-mo period.
• Unstable - Increasing frequency and severity of chest pain without an increase in cardiac biomarkers.

Question 8

Are cardiac biomarkers (troponin) present with unstable angina?

Answer 8

NO. If they were, that would be an MI.

Question 9

What EKG abnormality is associated with old MI’s and/or current ischemia?

Answer 9

T-wave inversion

Question 10

What is nuclear stress testing utilized for?

Answer 10

Coronary Perfusion assessment

Question 11

What determines the significance of CAD during a nuclear stress test?

Answer 11

Size of the perfusion abnormality

Arrows point to arrows of lesser perfusion.

Question 12

What test can differentiate a new vs and old perfusion abnormality?

Answer 12

Nuclear Stress Testing

Question 13

What nuclear stress test tracers are used with exercise?

Answer 13

Thallium

Question 14

What nuclear stress test drugs are used without exercise?

Answer 14

Atropine
Dobutamine
Pacing

Question 15

When are adenosine and dipyridamole used with nuclear stress testing? Why?

Answer 15

Used after test to dilate normal, non-ischemic areas of the heart.

Question 16

What test would be useful for imaging wall motion abnormalities or valvular function?

Answer 16

Echocardiography

Question 17

What is Prinzmetal Angina?

Answer 17

Coronary Spasm

Question 18

What is the mechanism of action for aspirin?

Answer 18

COX-1 Inhibition → TXA2 inhibition → Plt aggregation inhibition.

Question 19

How can aspirin be reversed?

Answer 19

Trick question. It can’t be, platelets are damaged until they die and are replaced.

Question 20

What is the mechanism of action of abciximab, eptifibatide, and tirofiban?

Answer 20

Platelet glycoprotein IIb/IIIa receptor antagonists

Inhibit platelet activation, adhesion, and aggregation.

Question 21

What drugs (discussed in lecture) are P2Y₁₂ inhibitors?

Answer 21

Clopidogrel and Prasugrel

Question 22

What common drug class will antagonize P2Y₁₂ inhibitors?

Answer 22

PPIs

Question 23

How does Prasugrel compare to Clopidogrel?

Answer 23

More predictable pharmacokinetics but greater bleeding risk.

Question 24

How do P2Y₁₂ inhibitors work?

Answer 24

Inhibit ADP receptor P2Y₁₂ and thus inhibit platelet aggregation.

Question 25

What drug classes are synergistic with nitrates?

Answer 25

- β-blockers - CCBs

Question 26

When are nitrates contraindicated?

Answer 26

- Aortic Stenosis - Hypertrophic Cardiomyopathy

Question 27

What drug class is the only one proven to prolong life in CAD patients?

Answer 27

β-blockers

Question 28

What properties do β-blockers have?

Answer 28

- Anti-ischemia - Anti-HTN - Anti-dysrhythmic

Question 29

Which β blockers are cardioselective?

Answer 29

- Atenolol - Metoprolol - Acebutolol - Bisoprolol

Question 30

Which β blockers are non-selective?

Answer 30

- Propanolol - Nadolol

Question 31

What risk is associated with non-selective β blockers in asthma patients?

Answer 31

↑ risk of bronchospasm in reactive airway disease patients.

Question 32

What drug class is uniquely effective is decreasing the severity/frequency of coronary vasospasm?

Answer 32

CCBs

Question 33

Angiotensin II will increase what four things?

Answer 33

- Myocardial hypertrophy - Interstitial myocardial fibrosis - Coronary vasoconstriction - Inflammatory responses

Question 34

Is troponin or CK-MB more specific for myocardial injury?

Answer 34

Troponin

Question 35

How soon with troponin start to increase after myocardial injury?

Answer 35

3 hours

Question 36

How long will troponin stay elevated after a MI?

Answer 36

Up to 2 weeks

Question 37

What is ST segment depression characteristic of?

Answer 37

Subendocardial ischemia

Question 38

What diagnostic studies might indicate a myocardial infarction?

Answer 38

- EKG: abnormality (ex. LBBB) - US: Regional wall motion abnormalities

Question 39

What are indications for PCI treatment of an MI?

Answer 39

- Contraindicated tPa therapy - Severe HF and/or pulm edema - S/S for 2-3 hours - Mature clot

Question 40

When is CABG preferred over PCI?

Answer 40

- Significant left main coronary artery disease - Three-vessel coronary artery disease - DM and two/three-vessel coronary artery disease

Question 41

What are 3 cases when revascularization is indicated?

Answer 41

- >50% left main coronary artery occlusion - >70% epicardial coronary artery occlusion - EF <40% (impaired LV contractility)

Question 42

What risks are associated with PCI (percutaneous coronary intervention) ?

Answer 42

- Endothelial destruction - Bleeding - Thrombosis

Question 43

What is Dual Antiplatelet Therapy (DAPT) ?

Answer 43

- ASA w/ P2Y₁₂

Question 44

Why is dual anti-platelet therapy used?

Answer 44

To prevent thrombus after stent placement

Question 45

What are the 4 steps of acute coronary syndrome?

Answer 45

- Disruption of atheromatous clot - Coagulation cascade activation - Thrombin generation - Arterial occlusion by thrombus

Question 46

What 4 chemical mediators stimulate PLT aggregation?

Answer 46

- Collagen - ADP - Epinephrine - Serotonin

Question 47

What are the effects of TXA2?

Answer 47

Vasoconstriction

Question 48

What diagnostic data indicates MI?

Answer 48

- Elevated troponin (cardiac biomarkers) - Ischemia - ST changes, new LBBB, Q waves present - Regional wall motion abnormality

Question 49

What drug should be given with an aspirin allergy?

Answer 49

P2Y12 inhibitor

Question 50

Who are beta blockers not given to?

Answer 50

Those with a heart block

Question 51

What two drugs should be avoided with a STEMI?

Answer 51

- Glucocorticoids - NSAIDs

Question 52

When should tPA be initiated?

Answer 52

Within 30-60 mins of arrival to the hospital and within 12 hours of onset of symptoms

Question 53

When should angioplasty be performed? (Timeframe)

Answer 53

Within 90 mins upon arrival to the hospital and within 12 hours of symptom onset

Question 54

What are the causes of unstable angina/NSTEMI?

Answer 54

- Ruptured coronary plaque - Obstruction due to vasoconstriction - Worsening coronary luminal narrowing - Inflammation - Myocardial ischemia

Question 55

How long until a vessel reendothelializes after a balloon angioplasty?

Answer 55

2-3 weeks

Question 56

How long will reendothelialization occur after a bare-metal stent placement?

Answer 56

Up to 12 weeks

Question 57

When will a drug-eluting stent reendothelialize?

Answer 57

After a year

Question 58

How long is DAPT required after balloon angioplasty without stent?

Answer 58

At least 2 weeks

Question 59

How long is DAPT required after a bare-metal stent placement?

Answer 59

At least 6 weeks

Question 60

How long is DAPT needed after a drug-eluting stent placement?

Answer 60

At least a year

Question 61

How long would one want to wait for elective surgery post angioplasty **with no stenting**?

Answer 61

2 - 4 weeks

Question 62

How long would one want to wait for elective surgery post angioplasty **with bare-metal stent placement**?

Answer 62

At least 30 days (12 weeks preferable)

Question 63

How long would one want to wait for elective surgery post angioplasty **with drug-eluting stent placement**?

Answer 63

At least 6 months (12 months if post ACS)

Question 64

How long would one want to wait for elective surgery post-CABG?

Answer 64

At least 6 weeks (12 weeks preferable)

Question 65

Is glycopyrrolate or atropine preferred for treatment of bradycardia?

Answer 65

Glycopyrrolate

Question 66

Are β blockers or ACE-inhibitors continued peri-operatively?

Answer 66

β-blockers

Question 67

Are β blockers or ACE-inhibitors discontinued 24 hours prior to surgery?

Answer 67

ACE inhibitors

Question 68

What components are worth 1 point on the Revised Cardiac Risk Index (RCRI) ?

Answer 68

Question 69

What % risk of major cardiac events would be conferred by a RCRI score of 0 ?

Answer 69

0.4%

Question 70

What % risk of major cardiac events would be conferred by a RCRI score of 1 ?

Answer 70

1.0%

Question 71

What % risk of major cardiac events would be conferred by a RCRI score of 2 ?

Answer 71

2.4%

Question 72

What % risk of major cardiac events would be conferred by a RCRI score of ≥3 ?

Answer 72

5.4%

Question 73

What does 1 MET equal?

Answer 73

3.5mLO₂/kg/min

Question 74

What drug is the preferred treatment for tachycardia?

Answer 74

Esmolol

Question 75

What anticholinergic is the better option for treatment of bradycardia in CAD patients?

Answer 75

**Glycopyrrolate** > Atropine

Question 76

What coronary artery would you expect to be effected from abnormalities noted on II, III, and aVF?

Answer 76

RCA

Question 77

What coronary artery would you expect to be effected from abnormalities noted on I and aVL?

Answer 77

Circumflex artery

Question 78

What coronary artery would you expect to be effected from abnormalities noted on V3 - V5?

Answer 78

LAD