Stable Angina

Question 1

What is the most common cause of myocardial ischemia?

Answer 1

Atherosclerotic disease of an epicardial coronary artery (or arteries)

Question 2

Powerful risk factors for IHD

Answer 2

Obesity
insulin resistance
type 2 diabetes mellitus

Question 3

Major determinants of myocardial oxygen demand (MVO2)

Answer 3

Heart rate
Myocardial contractility
Myocardial wall tension (stress)

Question 4

Blood flows through the coronary arteries in a phasic fashion, with the majority occurring during ____.

Answer 4

diastole

Question 5

Coronary resistance occurs in three sets of arteries:
_____(R1)
Prearteriolar vessels (R2)
Arteriolar and intramyocardial capillary vessels (R3)

Answer 5

Large epicardial arteries

Question 6

In the absence of significant flow-limiting atherosclerotic obstructions, R 1 is trivial; the major determinant of coronary resistance is found in __

Answer 6

R2 and R3

Question 7

The normal coronary circulation is dominated and controlled by the heart’s requirements for _____

Answer 7

oxygen

Question 8

The major site of atherosclerotic d ease.

Answer 8

Epicardial coronary arteries.

Question 9

What are the major risk factors for atherosclerosis?

Answer 9

High levels of plasma low-density lipoprotein (LDL)
Cigarette smoking
Hypertension
Diabetes mellitus

Question 10

nomal functions of the vascular endothelium

Answer 10

local control of vascular tone
maintenance of an antithrombotic surface
and control of inflammatory cell adhesion and diapedesis.

Question 11

There is also a predilection for atherosclerotic plaques to develop at sites of increased turbulence in coronary flow, such as at branch points in the ___

Answer 11

epicardial arteries.

Question 12

Critical obstructions in vessels, such as the ____ and the ____ coronary artery, are particularly hazardous.

Answer 12

left main coronary artery
proximal left anterior descending

Question 13

Transient T-wave inversion probably reflects ____

Answer 13

nontransmural, intramyocardial ischemia

Question 14

Transient ST-segment depression often reflects ___

Answer 14

patchy subendocardial ischemia;

Question 15

ST-segment elevation is thought to be caused by more severe ____

Answer 15

transmural ischemia

Question 16

The typical patient with angina

Answer 16

man >50 years or a woman >60 years of age who complains of episodes of chest discomfort, usually described as heaviness, pressure, squeezing, smothering, or choking and only rarely as frank pain

Question 17

Hand over the sternum, s times with a clenched fist, to indicate a squeezing, central, substernal discomfort

Answer 17

(Levine’s sign)

Question 18

Angina is usually ____ in nature (typically with the severity of the discomfort not at its most intense level at the outset of symptoms), typically lasts ____, and can radiate to either ___ (especially the ulnar aspects of the forearm and hand). It also can arise in or radiate to the back, interscapular region, root of the neck, jaw, teeth, and epigastrium.

Answer 18

crescendo-decrescendo

2–5 min

shoulder and to both arms

Question 19

may be due to episodic tachycardia, diminished oxygenation as the respiratory pattern changes during sleep, or expansion of the intrathoracic blood volume that occurs with recumbency; the latter causes an increase in cardiac size (end-diastolic volume), wall tension, and myocardial oxygen demand that can lead to ischemia and transient LV failure.

Answer 19

Nocturnal angina

Question 20

Exertional angina typically is relieved in ___ by slowing or ceasing activities and even more rapidly by rest and sublingual nitroglycerin

Answer 20

1–5 min

sublingual nitroglycerin

Question 21

Anginal “equivalents” are symptoms of myocardial ischemia other than angina. They include _______ and are more common in the elderly and in diabetic patients.

Answer 21

dyspnea, nausea, fatigue, and faintness

Question 22

A particularly challenging problem is the evaluation and management of patients with persistent ischemic-type chest discomfort but no flow-limiting obstructions in their epicardial coronary arteries. This situation arises more often in women than in men. Potential etiologies include ____(detectable on coronary reactivity testing in response to vasoactive agents such as intracoronary adenosine, acetylcholine, and nitroglycerin) and ____.

Answer 22

microvascular coronary disease
abnormal cardiac nociception.

Question 23

Auscultation can uncover arterial bruits, a third and/or fourth heart sound, and, if acute ischemia or previous infarction has impaired papillary muscle function, an apical systolic murmur due to mitral regurgitation. These auscultatory signs are best appreciated with the patient in the ____position.

Answer 23

left lateral decubitus

Question 23

Tenderness of the chest wall, localization of the discomfort with a single fingertip on the chest, or reproduction of the pain with palpation of the chest makes it unlikely that the pain is caused by myocardial ischemia.

Answer 23

True

Question 24

Evidence exists that an elevated level of high-sensitivity ____ (specifically, between 1 and 3 mg/L) is an independent risk factor for IHD and may be useful in therapeutic decision-making about the initiation of hypolipidemic treatment.

Answer 24

C-reactive protein (CRP)

Question 25

A positive result on exercise indicates that the likelihood of CAD is 98% in males who are >50 years with a history of typical angina pectoris and who develop chest discomfort during the test.

Answer 25

True

Question 26

Obstructive disease limited to the circumflex coronary artery may result in a ___stress test since the posterolateral portion of the heart that this vessel supplies is not well represented on the surface 12-lead ECG.

Answer 26

false-negative

Question 27

Modified (heart rate–limited rather than symptom-limited) exercise tests can be performed safely in patients as early as __ days after uncomplicated myocardial infarction

Answer 27

6

Question 28

Contraindications to exercise stress testing include r___

Answer 28

rest angina within 48 h, unstable rhythm, severe aortic stenosis, acute myocarditis, uncontrolled heart failure, severe pulmonary hypertension, and active infective endocarditis.

Question 29

Failure of the blood pressure to increase or an actual decrease with signs of ischemia during the exercise stress test is an important adverse prognostic sign, since it may reflect ___

Answer 29

ischemia-induced global LV dysfunction.

Question 30

Exercise Stress Test Discontinued on symptoms or specific signs: __

Answer 30

chest discomfort, shortness of breath, dizziness, severe fatigue, ST-segment depression >0.2 mV, drop in systolic BP >10 mmHg, or ventricular tachyarrhythmia.

Question 31

The principal prognostic indicators in patients known to have IHD are ____

Answer 31

age, the functional state of the left ventricle, the location(s) and severity of coronary artery narrowing, and the severity or activity of myocardial ischemia.

Question 32

Angina Characteristics Indicating Higher Risk or coronary events

Answer 32

Recent-onset or unstable angina Post-myocardial infarction angina Angina unresponsive to medical therapy Angina with congestive heart failure symptoms

Question 33

Most important, any of the following signs during noninvasive testing indicates a high risk for coronary events:

Answer 33

Inability to complete 6 minutes (Stage II) on Bruce protocol exercise test Strongly positive exercise test: Onset of ischemia at low workloads ≥0.1 mV ST-segment depression before Stage II or ≥0.2 mV at any stage Persistent ST-segment depression >5 minutes post-exercise Systolic pressure drop >10 mmHg or ventricular tachyarrhythmias during exercise

Question 34

On cardiac catheterization, elevations of ___ and ___ and reduced ____are the most important signs of LV dysfunction and are associated with a poor prognosis.

Answer 34

LV end-diastolic pressure ventricular volume ejection fraction

Question 35

Obstructive lesions of the ___ (>50% luminal diameter) or ____coronary artery proximal to the origin of the first septal artery are associated with a greater risk than are lesions of the right or left circumflex coronary artery because of the greater quantity of myocardium at risk.

Answer 35

left main left anterior descending

Question 36

With any degree of obstructive CAD, mortality is greatly increased when ____is impaired; conversely, at any level of LV function, the prognosis is influenced importantly by the quantity of myocardium perfused by critically obstructed vessels

Answer 36

LV function

Question 37

The greater the number and severity of risk factors for coronary atherosclerosis , the worse the prognosis of an angina patient. What are the risk factors?

Answer 37

advanced age [>75 years] hypertension dyslipidemia diabetes morbid obesity accompanying peripheral and/or cerebrovascular disease previous myocardial infarction

Question 38

In addition, obesity often is a accompanied by three other risk factors: ____

Answer 38

diabetes mellitus hypertension and hyperlipidemia.

Question 39

A diet low in ____and a reduced caloric intake to achieve optimal body weight are a cornerstone in the management of chronic IHD.

Answer 39

saturated and trans-unsaturated fatty acids

Question 40

_____ accelerates coronary atherosclerosis in both sexes and at all ages and increases the risk of thrombosis, plaque instability, myocardial infarction, and death.

Answer 40

Cigarette smoking

Question 41

There is evidence that long-term effective treatment of ____ can decrease the occurrence of adverse coronary events

Answer 41

hypertension

Question 42

____accelerates coronary and peripheral atherosclerosis and is frequently associated with dyslipidemia and increases in the risk of angina, myocardial infarction, and sudden coronary death.

Answer 42

Diabetes mellitus

Question 43

Aggressive control of the dyslipidemia (target LDL cholesterol __ mg/dL) and hypertension (blood pressure ___ mmHg) that are frequently found in diabetic patients is highly effective and therefore essential

Answer 43

<70 <130/80

Question 44

Nearly always, ____are required and can lower LDL cholesterol (25–50%), raise HDL cholesterol (5–9%), and lower triglycerides (5–30%).

Answer 44

HMG-CoA reductase inhibitors (statins)

Question 45

Used to lower triglycerides, especially when elevated.

Answer 45

Fibrates, Niacin, and Icosapent Ethyl

Question 46

To minimize the effects of nitrate tolerance, the minimum effective dose should be used and a minimum of___each day kept free of the drug to restore any useful response(s).

Answer 46

8 h

Question 47

__ improve exercise tolerance in patients with chronic angina and relieve ischemia in patients with unstable angina as well as patients with Prinzmetal’s variant angina

Answer 47

Nitrates

Question 48

They reduce myocardial oxygen demand by inhibiting the increases in heart rate, arterial pressure, and myocardial contractility caused by adrenergic activation.

Answer 48

B blockers

Question 49

The therapeutic aims include relief of angina and ischemia.

Answer 49

B blockers

Question 50

These drugs also can reduce mortality and reinfarction rates in patients after myocardial infarction and are moderately effective antihypertensive agents.

Answer 50

B blockers

Question 51

Relative contraindications to beta blockers include ____

Answer 51

asthma and reversible airway obstruction in patients with chronic lung disease, atrioventricular conduction disturbances, severe bradycardia, Raynaud’s phenomenon, and a history of mental depression.

Question 52

Beta blockers with relative β1 -receptor specificity such as ___ and ___ may be preferable in patients with mild bronchial obstruction and insulin-requiring diabetes mellitus.

Answer 52

metoprolol atenolol

Question 53

____(Table 273-6) are coronary vasodilators that produce variable and dose-dependent reductions in myocardial oxygen demand, contractility, and arterial pressure.

Answer 53

Calcium channel blockers

Question 54

They are indicated when beta blockers are contraindicated, poorly tolerated, or ineffective.

Answer 54

Calcium channel blockers

Question 55

Variant (Prinzmetal’s) angina responds particularly well to calcium channel blockers (especially members of the __ class),

Answer 55

dihydropyridine

Question 56

Dihydropyridine vs. Nondihydropyridine May cause bradyarrhythmias and negative inotropic effects, increasing risk of LV failure, especially in patients with LV dysfunction or on beta blockers.

Answer 56

Nondihydropyridine

Question 57

Dihydropyridine vs. Nondihydropyridine Strong vasodilators with lower risk of bradyarrhythmias; preferred in angina and hypertension management.

Answer 57

Dihydropyridine

Question 58

Combination of this CCB with beta blocker Generally should not be combined due to risk of adverse effects on heart rate and contractility.

Answer 58

Verapamil

Question 59

Combination of this CCB with beta blocker Complementary effects; amlodipine decreases blood pressure and dilates coronary arteries, while beta blockers slow heart rate and reduce contractility.

Answer 59

Amlodipine

Question 60

Calcium channel blockers are indicated in patients with the following:

Answer 60

(1) inadequate responsiveness to the combination of beta blockers and nitrates; many of these patients do well with a combination of a beta blocker and a dihydropyridine calcium channel blocker; (2) adverse reactions to beta blockers such as depression, sexual disturbances, and fatigue; (3) angina and a history of asthma or chronic obstructive pulmonary disease; (4) sick-sinus syndrome or significant atrioventricular conduction disturbances; (5) Prinzmetal’s angina; or (6) symptomatic peripheral arterial disease.

Question 61

Irreversibly inhibits platelet cyclooxygenase, reducing platelet activation.

Answer 61

Aspirin

Question 62

Blocks P2Y₁₂ ADP receptor–mediated platelet aggregation.

Answer 62

Clopidogrel

Question 63

Chronic administration of 75–325 mg orally per day has been shown to reduce coronary events in asymptomatic adult men over age 50, patients with chronic stable angina, and patients who have or have survived unstable angina and myocardial infarction.

Answer 63

Aspirin

Question 64

Alternative for patients who cannot tolerate aspirin due to side effects. Combined with aspirin, it reduces death and ischemic events in acute coronary syndrome (ACS) and lowers thrombus risk in stent implantation.

Answer 64

Clopidogrel

Question 65

A specific sinus node inhibiting agent that may be helpful for preventing cardiovascular events in patients with IHD who have a resting heart rate ≥70 beats/ min (alone or in combination with a beta blocker) and LV systolic dysfunction.

Answer 65

Ivabradine

Question 66

Not cost-effective for IHD patients with normal LV function who have achieved BP and LDL goals, as routine use does not lower event incidence.

Answer 66

ACE Inhibitors

Question 67

Beneficial for chronic angina patients who continue to experience symptoms despite standard medical therapy.

Answer 67

Ranolazine

Question 68

Inhibits the late inward sodium current (INa), reducing Na and Ca overload in ischemic myocytes.

Answer 68

Ranolazine

Question 69

Initially for diabetes management, now with cardiovascular and renal protective effects.

Answer 69

SGLT2 Inhibitors

Question 70

Promotes weight loss, lowers blood pressure, and reduces plasma volume. Reduces intraglomerular hypertension and hyperfiltration, beneficial for patients with reduced LV ejection fraction, with or without diabetes.

Answer 70

SGLT2 Inhibitors

Question 71

Reduces intracellular calcium by opening ATP-sensitive potassium channels.

Answer 71

Nicorandil

Question 72

The most common clinical indication for PCI is ____

Answer 72

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

Question 73

T/F in patients with stable exertional angina, clinical trials have confirmed that PCI does not reduce the occurrence of death or myocardial infarction compared to optimum medical therapy.

Answer 73

T

Question 74

T/F PCI can be used to treat stenoses in native coronary arteries as well as in bypass grafts in patients who have recurrent angina after CABG.

Answer 74

T

Question 75

PCI or CABG Preferred for one- or two-vessel stenoses, selected three-vessel cases, and sometimes in left main disease depending on patient suitability and operator skill.

Answer 75

PCI

Question 76

PCI or CABG Patients with left main coronary artery stenosis, three-vessel disease (especially with diabetes or LV dysfunction), are better candidates for ___.

Answer 76

CABG

Question 77

It is usual clinical practice to administer oral ___ indefinitely and a P2Y 12 antagonist for 1–3 months after the implantation of a bare metal stent.

Answer 77

aspirin

Question 78

___ should be administered indefinitely and a P2Y 12 antagonist daily (dual antiplatelet therapy [DAPT]) for at least __ year after implantation of a drug-eluting stent. Evidence exists of a benefit of continuing DAPT for up to 30 months, albeit at the cost of a higher risk of bleeding.

Answer 78

Aspirin 1 year

Question 79

When directly compared in patients with diabetes or three-vessel or left main CAD, ___ was superior to ___ in preventing major adverse cardiac or cerebrovascular events over a 12-month follow-up.

Answer 79

CABG was superior to PCI

Question 80

Indications for CABG usually are based on

Answer 80

severity of s toms coronary anatomy and ventricular function

Question 82

Associated with a higher perioperative mortality rate in CABG

Answer 82

Congestive heart failure and/or LV dysfunction advanced age (>80 years) reoperation urgent need for surgery and the presence of diabetes mellitus

Question 83

PCI or CABG Two-vessel disease with proximal left anterior descending artery involvement

Answer 83

CABG