Cardiovascular System

Question 1

What are (7) major risk factors for stable angina? Which is the worst?

Answer 1

1. Diabetes (worst one)
2. Hyperlipidemia
3. Hypertension
4. Cigarette smoking
5. Age
6. FHx of CAD or MI
7. Low levels of HDL

Question 2

Below what EF leads to increased mortality risk in CAD?

Answer 2

EF <50%

Question 3

What vessel involvements in stable angina have an increased mortality risk?

Answer 3

1. LMCA - supplies ~2/3 of heart

2. 2 or 3-vessel involvement

Question 4

What are the clinical features of stable angina?

Answer 4

1. Chest pain / substernal pressure sensation <10-15m, usually more pressure than sharp, gradual onset
2. Worse with exertion / increased oxygen demands
3. Relieved with rest / NG
4. No change with position / breathing / chest wall tenderness

Question 5

What diagnostic tools are used to evaluate for stable angina and what is seen on those tools?

Answer 5

Physical Exam: normal
Resting ECG: normal
Stress test: ECG, ECHO
Cardiac catheterization w/coronary angiography

Question 6

What wave signs on an EKG escalate a stable angina to an unstable angina?

Answer 6

ST-segment or T-wave abnormalities

Question 7

What is the highest sensitivity exam in evaluating for CAD if the resting ECG is normal?
What does it involve?
When is it contraindicated?
What happens if the exam is positive?

Answer 7

Stress ECG

• ECG done before, during, and after a treadmill
• exercise induced ischemia causes subendocardial ischemia leading to ST-depression
• Contraindicated: baseline ECG abnormalities (LBBB, LVH)
• If (+) –> cardiac cath

Question 8

When is a stress ECHO indicated and what does it involve?

What happens if the exam is positive?

Answer 8

• If resting ECG is normal and CAD is suspected.
• More sensitive for detecting ischemia, can assess LV size / function, dx valvular disease, identify CAD w/pre-existing ECH abnormalities
• ECHO performed before and after exercise, after may show wall motion abnormalities like akinesis or hypokinesis not present at rest
• If (+) –> cardiac cath

Question 9

What is a stress myocardial perfusion imaging and what is it used for?

Answer 9

IV radioisotope injection during exercise that evaluates uptake of the isotope by viable myocytes during exercise

Question 10

What are the differences between the (3) medications used in pharmacological stress test administration?

Answer 10

• Adenosine, Dipyridamole (used in perfusion imaging): causes generalized coronary vasodilation, so diseased arteries receive less flow when the whole cardiac system is also vasodilated
• Dobutamine (used in stress ECHO): increases HR, BP, cardiac contractility

Question 11

What is the most definitive test for CAD?

Answer 11

Coronary catheterization with coronary angiography

Question 12

When is a stress test considered to be positive?

Answer 12

1. ST-Depression
2. Chest pain
3. Hypotension
4. Significant arrhythmias

Question 13

What are the (2) types of conditions termed “Syndrome X” and what do they involve?

Answer 13

1. Metabolic Syndrome X: 1+ HCh, HTG, impaired glucose tolerance, DM, hyperuricemia, HTN
2. Syndrome X: exertional angina w/normal CA (chest pain w/ exercise, but normal cardiac cath), exercise testing / nuclear imaging show MI

Question 14

What medication used in CAD treatment is proven to decrease morbidity and reduce risk of MI?

Answer 14

Aspirin

Question 15

What medications are indicated in the treatment of ACS?

Answer 15

1. Aspirin
2. Lipid-lowering agents
3. B-blockers
4. Nitrates
5. CC-blockers

Question 16

What (2) types of lipid-lowering agents are used in ACS treatment and why?

Answer 16

1. HMG-CoA reductase inhibitors (statins) lower LDL

2. PCSK9 inhibitors lower LDL even more; use in conjunction with statins for LDL level >70

Question 17

When is revascularization indicated?

Answer 17

Stable angina refractory to medical therapy and symptom control

Question 18

What is the pathophysiology of unstable heart angina? What happens to oxygen demand?

Answer 18

Unchanged oxygen demand; decreased oxygen supply due to reduced resting coronary flow

Question 19

What are the (3) types of patients who may have unstable angina?

Answer 19

1. Patients with chronic angina with increasing frequency, duration, intensity of chest pain
2. Patients with new onset angina that is severe + worsening
3. Patients with angina at rest

Question 20

What is the difference between unstable angina and NSTEMI?

Answer 20

Cardiac enzymes; NSTEMI has elevated troponin or CK-MB

Question 21

What are the mortality-lowering medications used in the treatment of unstable angina?

Answer 21

1. Duel anti-platelet therapy (aspirin + P2Y12 inhibitor - clopidogrel, ticagrelor, prasugrel) x9-12 mo
2. Heparin (LMWH)
3. BB unless CI

Question 22

What other medical management is indicated in the treatment of unstable angina?

Answer 22

1. Aspirin
2. Heparin
3. P2Y12 inhibitor
4. BB
5. Nitrates
6. Glycoprotein IIb/IIIa inhibitors as adjuncts
7. High-intensity statin
8. Oxygen
9. Replace electrolytes (K+, Ca+)
10. Morphine

Question 23

What are the indications for revascularization in unstable angina after evaluation?

Answer 23

1. After patient responds to medical therapy and a stress test is complete
2. If sx persist after medications and/or ECG continues to show signs of ischemia >48h
3. Hemodynamic instability, ventricular arrthymias, new MR, new septal defect

Question 24

What angina classically appears at night, at rest, and are associated with ventricular arrhythmias? What is the pathophysiology? How is it diagnosed? How is it treated?

Answer 24

Variant (Prinzmetal) angina - transient vasospasm on top of atherosclerotic lesions
Dx: transient ST-elevation on ECG when chest pain occurs, coronary angiography shows vasospasm after IV ergonovine or acetylcholine administration to provoke vasoconstriction
Tx: vasodilators (CCB, nitrates), RF modifications

Question 25

What is the most common cause of myocardial infarction?

Answer 25

Acute coronary thrombosis: atheromatous plaque ruptures into vessel lumen, thrombus forms, leads to occlusion

Question 26

What are the common clinical symptoms of myocardial infarction? What about other symptoms?

Answer 26

``` Most common: - Intense substernal chest pain, crushing - Radiation to neck, jaw, arms, back, occasional epigastric - May not respond to NG **may be asymptomatic in ~33% of patients (women, elderly, post-op, diabetic) Other: - dyspnea - sweating - weakness/fatigue - n/v - sense of impending doom - fainting ```

Question 27

How is a myocardial infarction diagnosed? What is seen on the diagnostic tests and what do they indicate?

Answer 27

ECG: - peaked T waves: occur early on, may be missed - ST-segment elevation: transmural injury, acute infarct - Q waves: necrosis, occurs later - T-wave inversion: nonspecific - ST-segment depression: subendocardial injury Cardiac Enzymes: - troponins: (+) 3-5h, peak 12-24h, normalize 5-14d; repeat Q6H for 18-24h **may be falsely elevated in renal failure, must trend - CK-MB: (+) 4-8h, peak 24h, normalize 48-72h; repeat Q8H for 24h

Question 28

When are nitrates and diuretics contraindicated in myocardial infarction? Why?

Answer 28

- Contraindicated in RV wall infarct with inferior lead changes - HPN, elevated JVP, hepatomegaly, clear lungs - May lead to cardiovascular collapse

Question 29

What are the only (4) medications that have been shown to reduce mortality in treatment of MI?

Answer 29

1. Aspirin 2. Ticagrelor 3. BB 4. ACEi

Question 30

What do the following ECG changes indicate about the location of a myocardial infarct? 1. V1-V4: ST elevation (acute), Q waves (late) 2. V1,V2: large R wave, ST depression, prominent T 3. I, aVL: Q waves (late) 4. II, III, aVF: Q waves (late)

Answer 30

ECG changes in ischemia 1. Anterior infarct 2. Posterior infarct 3. Lateral infarct 4. Inferior infarct

Question 31

Which medication used in the ACS treatment combination has a common side effect of dyspnea?

Answer 31

Ticagrelor

Question 32

Which medication used in the ACS treatment combination reduces remodeling of the heart post-MI?

Answer 32

BB

Question 33

Which statin gives the best results as shown in the PROVE IT-TIMI 22 trial?

Answer 33

Atorvastatin

Question 34

What is the mechanism of action of nitrates when used in ACS treatment?

Answer 34

Venodilation to reduce oxygen demand on the heart through reduced preload

Question 35

Which BB shows the greatest decreased in MI mortality?

Answer 35

Carvedilol

Question 36

Which medication is used in unstable angina and STEMI/NSTEMI, but not used in stable angina?

Answer 36

Heparin

Question 37

What are the (3) methods of revascularization? Within how long of ACS presentation should they be initiated?

Answer 37

1. Percutaneous Coronary Intervention (PCI): 90 min **preferred method of treatment 2. Thrombolytic therapy: 6 hrs up to 24hrs 3. Coronary Artery Bypass Grafting (CABG): used in multi-vessel disease

Question 38

When are thrombolytics indicated? Which is the best? What are absolute contraindications?

Answer 38

- (Alteplase) Indicated if ST elevation in 2+ contiguous leads with pain onset <6h prior, not responsive to NG - CI: trauma (head or CPR), previous stroke, recent invasive surgery, dissecting aortic aneurysm, active bleeding/ bleeding diarrhea

Question 39

What are the (6) main categories of complications after acute MI?

Answer 39

1. Pump failure (CHF) 2. Arrhythmias 3. Recurrent infarction 4. Mechanical/anatomical 5. Acute pericarditis 6. Dressler syndrome

Question 40

What is the most common cause of in-hospital mortality after acute MI? How is it treated?

Answer 40

CHF - treat mild cases with medications (ACEi, diuretic) - severe cases may lead to cardiogenic shock

Question 41

``` How are the following arrhythmias that may present after an acute MI managed and treated? PVC AFib VTach VFib PSVT Sinus tach Sinus brady Asystole AV block ```

Answer 41

PVC: observation AFib: ? VTach: antiarrhythmic (stable), electrical cardioversion (unstable) VFib: immediate defibrillation + CPR PSVT: ? Sinus tach: treat underlying cause (pain, anxiety, fever, etc.) Sinus brady: observation, consider atropine if severe Asystole: treat as VFib unless obvious; transcutaneous pacing AV block: 2 degree anterior - emergent pacemaker, 2D inferior - IV atropine or temporary pacemaker

Question 42

How is recurrent MI within 24h treated?

Answer 42

Repeat thrombolysis or urgent catheterization and PCI; continue medical management

Question 43

What mechanical complications after acute MI occur on the following timeline? What are their treatments? 1-4d to 2wk Within 10d

Answer 43

1-4d: free wall rupture - hemodynamic stabilization, pericardiocentesis (due to hemopericardium and cardiac tamponade), surgical repair <10d: IV septum rupture - emergent surgery

Question 44

What mechanical complication has most likely occurred if a patient presents with a new murmur after an acute MI? How do you diagnosis it? How is it treated?

Answer 44

Papillary muscle rupture -> acute MR Dx: immediate ECHO Tx: emergent surgery with mitral valve replacement, sodium nitroprusside to decrease afterload, intra-aortic balloon pump (IABP)

Question 45

What ventricular mechanical complications may occur after acute MI? When is surgery indicated?

Answer 45

``` Ventricular pseudoaneurysm (surgical emergency): incomplete free wall rupture - contained by pericardium, likely to become full free wall rupture Ventricular aneurysm: medical management ```

Question 46

What is the likely diagnosis if a patient presents weeks to months after an acute MI with fever, malaise, pericarditis, leukocytosis, and pleuritis? What is the pathophysiology? What is the treatment?

Answer 46

Dressler syndrome; immunological | Tx: aspirin, ibuprofen

Question 47

What are the main steps in evaluating a patient presenting with chest pain?

Answer 47

1. Rule out life threatening causes (ACS, aortic dissection, pericarditis w/cardiac tamponade, PE, tension pneumothorax, esophogeal rupture) 2. Assess vitals 3. Focused history (OLDCARTS) 4. Focused physical exam 5. Ancillary tests (ECG, cardiac enzymes, CXR, PE r/o) 6. DDx (CV, Pulm, GI, MSK, Psych, Drugs)

Question 48

In evaluation for chest pain, what factor makes it more likely to be cardiac in nature? What factors make it less likely to be cardiac origin?

Answer 48

More likely: relieved with nitroglycerin | Less likely: pain is positional, pleuritic, reproduced with chest wall palpation