CAD

Question 1

Coronary heart disease or atherosclerotic coronary artery disease (CAD) is ____________ of the small blood vessels that supply blood and oxygen to the heart

Answer 1

narrowing

Question 2

Patho phys of atherosclerosis: ….

Answer 2

endothelial dysfunction allows LDL to be pulled into the artery wall > LDL is oxidized and taken up by macrophages into the subendothelial space = foam cells > cytokines are release and smooth muscle cells migrate to the lesion > smooth muscle cells release collagen > fibrous cap forms over the lesion

Question 3

CAD pathophys:
Atherosclerotic plaques may:

1. Remain stable
2. Progress rapidly
   2a) …
   2b) …
3. Rupture
   3a)…

Answer 3

1. Remain stable
2. Progress rapdily
   - stable angina when increased oxygen demand
   -stenosis to cause rest anginal symptoms
3. Rupture
   causing thrombosis

Question 4

CAD Risk factors: (10)

Answer 4

fam hx
male
hyperlipidemia
DM
HTN
Inactivity
Abdominal obesity
cig smoking
diet low in fruits/veggies
heavy alcohol use

Question 5

What are primary and secondary preventions for CAD?

Answer 5

smoking cessation
weight loss
exercise
prevention and control of HTN
statin therapy
ACEI in DM
antiplatelet therapy (in secondary)

Question 6

Angina is chest pain of cardiac origin caused by oxygen ___________ and _________ mismatch. There is _____________ pain and the most common cause is ____________________ heart disease.

Answer 6

supply, demand
ischemic
atherosclerotic

Question 7

What are the symptoms of angina?

Answer 7

1. occurs during activity, relieved with rest
2. pain = tightness, burning, squeezing, choking. Not spasmodic
3. Location = mid sternal/left of sternum
4. radiate to L shoulder/arm, jaw, neck, back
5. Duration = <3 min no longer than 20-30
6. Relieved with rest/nitroglycerin

Question 8

What are the signs of angina?

Answer 8

1. pts often have their clenched fist over sternum
2. elevated BP
3. Tachy secondary to pain
4. CV exam listen for AS/AR
5. assess for signs of diseases that may be related to CAD (neuropathy in DM, HTN, PAD)

Question 9

What are the atypical angina symptoms of women/pts

Answer 9

“anything with extertion”
nausea, back pain, epigastric pain, palpitations

Question 10

Angina work up
What blood work?
What imaging?

Answer 10

BW: cardiac enzymes, CBC to r/o anemia, lipids, glucose/HbA1C

Imaging: ECG (resting ECG without pain is normal)
anginal episode: horizontal/downslopping ST segment depression that resolves when ischemia resoles
Severe cases: ST elevation/T wave inversion

Question 11

Stable Angina

Answer 11

predictable
“ i can always walk 3 blocks, then i get pain”
can get progressively worse over time - SLOWLY

Question 12

Unstable Angina

Answer 12

unpredictable
“i used to be able to walk 3 blocks, now i can only walk 10 ft before i get pain”
angina at rest
rapid worsening of once stable symptoms

Question 13

Stress Test Indications:
1
2
3
4
5
6

Answer 13

To confirm the diagnosis of angina
To determine the severity of limitation of activity due to angina
To evaluate responses to therapy/revascularization
To evaluate functional ability after MI
Pre-op clearance
Occupational evaluation

Question 14

A positive stress test is _________________

Answer 14

1mm ST depression

Question 15

How does a nuclear stress test give more information than the exercise ECG alone? In what case should this be done?

Answer 15

It shows the localized region of the ischemia better. This should be done if the patient has baseline ECG abnormalities

Question 16

What does a stress echocardiography look for?

Answer 16

looks for exercise induced segmental wall motion abnormalities that may represent ischemia

Question 17

A holter monitor is not typically used for the detection of ______________ rather it is more for _______________. The patient wears this for 24-48 hours during normal activity and is monitored continuously for ECG changes.

Answer 17

ischemia, dysrythmias

Question 18

A ________________ is the definitive diagnostic procedure for CAD. It offers the best evaluation of ___________________ function. It is both, diagnostic and therapeutic. Narrowing of _______________ is considered significant

Answer 18

cardiac cath
left ventricular
> 50%

Question 19

What is the treatment for an acute angina attack?

Answer 19

1. Rest
2. Nitroglycerin
   -acts in 1-2 minutes
   -reduces preload/afterload, decreases tone, lower oxygen demand
   -sublingual- 1 tab every 3-5 minutes. Can repeat 3 times.

Question 20

How do you prevent angina?

Answer 20

1. Nitro prior to strenuous activity
2. BB FIRST LINE FOR ANGINA
3. Long acting nitrates
4. Ranexa
5. CCB- NOT FIRST LINE
6. ALL PTS SHOULD BE ON ANTIPLATELETS (aspirin, clopidogrel, brilinta)

Question 21

What are the indications for revascularization for angina? Which types of pts may not receive a significant benefit to revascularization?

Answer 21

1. unacceptable symptoms despite medical therapy
2. left main stenosis >50%
3. 3 vessel disease with LV dysfunction
4. unstable angina
5. Post MI with continuing angina

Pts who have mild to moderate CAD and limited symptoms

Question 22

Percutaneous coronary intervention (PCI) (balloon angioplasty and coronary stenting) opens up ______________ It is either bare metal stents or drug-eluting stents.
_________________ reduce the risk of re-stenosis
Antiplatelet therapy after stenting decreases the risk of _______________ (aspirin + clopidogrel)

Continue ____________ for at least 1 yr post stenting

Answer 22

stenotic coronary arteries
drug-eluting stents
acute thrombosis
P2Y12

Question 23

What is coronary artery bypass grafting CABG? Grafts are typically harvested from the _____________ OR the _____________ OR _____________

Answer 23

uses healthy blood vessels from another part of the body to bypass stenosed areas of the coronary arteries to improve blood flow and oxygenation

internal mammary arteries, saphenous vein, radial artery

Question 24

Patients with left main disease or 3 vessel disease, with reduced EF and DM pts have better outcomes with _______________

Answer 24

CABG

Question 25

Coronary vasospasm aka Prinzmetal (variant) angina is chest pain caused by ___________________. Often it affects ____________ and occurs in the _______________. The EKG changes are consistent with ___________________. Treat with ___________ or ___________. Cocaine can also cause coronary artery vasoconstriction

Answer 25

coronary vasocontriction. young adults early morning ischemia nitrates, CCB

Question 26

Acute coronary syndrome is the spectrum of ___________ cardaic ischemia. Unstable angina (may be reversible) to MI (irreversible). Classified based on ECG findings: 1. 2.

Answer 26

unstable. 1. STEMI 2. NSTEMI

Question 27

What are the signs and symptoms of acute coronary syndrome? The pain often occurs___________. Patients may present saying that "it just feels different". How do patients often appear?

Answer 27

substernal CP that may radiate to the jaw, left shoulder, arm, back, dyspnea, nausea, vomiting, diaphoresis, CHF, sudden cardiac death. at rest Pts often appear anxious, brady/tachy, elevated BP/low BP, JVD, new murmur, papillary muscle dysfunction, cyanosis

Question 28

MI is the rise of cardiac biomarkers with at least one value above the __________percentile of the upper reference limit together with evidence of ______________ with at least one of the following:

Answer 28

99th myocardial ischemia symptoms of ischemia, ECG changes of new ischemia, new Q waves, or imaging evidence of new loss of viable myocardium or new wall motion abnormality.

Question 29

MI lab findings: 1. 2 3. 4.

Answer 29

1. CK-MB (creatine kinase myocardial band) rise within 4-8 hrs, peaks 12-20 hours returns to normal within 2-3 days 2. Troponin rise within 4 hours return to normal within 7-14 days 3. CBC to assess for anemia 4. BMP to assess renal function for drug dosing

Question 30

MI ECG Patterns: 1. 2. 3. 4.

Answer 30

ST elevation = infarction ST depression = ischemia Q waves appear at the site of previous infarction T wave inversion = recent MI or ischemia

Question 31

STEMI

Answer 31

transmural infarction of the myocardium full thickness of the muscle usually a complete occlusion of a main artery ST elevation on ECG **REQUIRES IMMEDIATE PCI OR THROMBOLYTICS**

Question 32

NSTEMI (5)

Answer 32

not a full thickness infarction partial or very distal blockage of an artery cardiac enzymes will be elevated may see ST depression on ECG **NO THROMBOLYTICS- risk>benefit **

Question 33

STEMI: Classic evolution of ECG changes involves.....

Answer 33

peaked T waves, ST elevation, to q wave development, to t wave inversion *q waves dont occur 30-50% of the time*

Question 34

STEMI management

Answer 34

all pts with suspected MI should receive aspirin immediately- chew reperfusion therapy for all pts who seek medical attention within 12 hours of onset of symptoms -primary PCI or fibrinolytic therapy -PCI is preferable if FMC to balloon time is <90 min

Question 35

Management of all ACS

Answer 35

1. MONA: morphine, oxygen, nitroglycerin, aspirin 2. P2T12 inhibitor > clopidogrel 3. Anticoag- cont until PCI 4. BB IF NO ACUTE HF 5. ACEI - esp in DM or LVEF <40% 6. statin (atorvastatin 80 mg regardless of LDL) 7. ambulation after 24 hours

Question 36

For STEMI management, if patients receive fibrinolytic therapy, they should be transferred for ____________ within 24 hours. Risks of fibrinolytic therapy: 1.

Answer 36

PCI 1. bleeding

Question 37

What are the absolute contraindications for fibrinolytic therapy?

Answer 37

history of hemorrhagic CVA CVA within a year known intracranial neoplasm known internal bleeding suspected aortic dissection

Question 38

What are the relative contraindications for fibrinolytic therapy?

Answer 38

BP > 180/110 Other brain pathology Major surgery within 3 weeks Recent trauma or internal bleeding (2-4 weeks) CPR > 10 minutes Active PUD Pregnancy Hx of severe HTN Current use of anticoagulant with INR > 2

Question 39

Indications for Cardiac Catheterization in a pt. with NSTEMI/UA

Answer 39

Recurrent angina/ischemia at rest or with low level activity Elevated troponin ST-segment depression Recurrent ischemia with heart failure High-risk stress test results EF < 40% Hemodynamic instability Sustained V-tach PCI within 6 months Prior CABG

Question 40

What are complications of MI?

Answer 40

1. Post infarction ischemia 2. Arrythmia - sinus brady, SVT (less serious) -ventricular arrythmias- serious 3. Myocardial dysfunction 4. Mechanical defect (papillary muscle rupture/dysfunction) 5. Myocardial rupture 6. LV aneurysm 7. Dressler syndrome -pericarditis 8. Mural thrombus