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ICM > 3: Chronic Ischemic Heart Disease > Flashcards

3: Chronic Ischemic Heart Disease Flashcards

1
Q

traditional risk factors for atherosclerotic vascular disease

A
  • age (men > 45; women > 55)
  • family history (first degree relative) - males 30)
  • sedentary lifestyle
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2
Q

before exam look at this slide

A

graphs and relative risk increases based on risk factors

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3
Q

what two risk factors, if had together, significantly increase risk of fatal or non-fatal MI?

A

DM + previous MI

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4
Q

what is metabolic syndrome?

A

any 3 of the following:

  • HTN (>/= 130/85)
  • abdominal obesity (waist circumference > 40cm men; >35 cm women)
  • HDL /= 150
  • fasting plasma glucose >/= 100
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5
Q

what is metabolic syndrome associated with?

A

inflammation (vasculitis)
coagulation abnormalities
progression to T2DM

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6
Q

manifestations of CAD

A
  • chronic stable angina
  • unstable angina
  • MI
  • ischemic cardiomyopathy (CHF)
  • sudden cardiac death
  • silent ischemia
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7
Q

what physical findings may appear during periods of ischemia?

A

an S4 heart sound (not always though)

also may show an S3 if they have CHF/dilated cardiomyopathy

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8
Q

what tests do you get for eval of ischemic heart disease in the office?

A
  • office and ambulatory BP
  • fasting lipid profile
  • BMI calculation
  • fasting plasma glucose (OGTT)
  • chemistries
  • CBC
  • stress testing
  • measure of LV function (important prognostic value; tells you how to treat patient)
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9
Q

questions you need to ask for chest pain history

A
  • location
  • character
  • radiation
  • intensity
  • duration
  • frequency
  • associated symptoms
  • exacerbating/relieving factors
  • pattern over time
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10
Q

presentation of stable angina pectoris (6 things)

A
  • visceral discomfort
  • diffuse and sub-sternal pain
  • dyspnea, diaphoresis, nausea, light-headed
  • provoked by physical exertion, emotional upset, rarely heavy meals, working in cold
  • onset over several minutes
  • relieved by rest, sublingual NTG
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11
Q

difference between atypical angina and typical angina

A

missing one of the following:

  • substernal pain
  • brought on by exertion
  • relieved by rest or NTG
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12
Q

less common sites of pain with MI

A
  • right side
  • epigastrium
  • jaw
  • back
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13
Q

where might you see pain referred in angina?

A

lower jaw (not upper jaw)

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14
Q

Canadian CV society classification of angina

A

Class I: no angina
Class II: angina on more than usual activity
Class III: angina on less than usual activity
Class IV: angina at rest or on any activity

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15
Q

angina equivalents

A
  • arm/back/lower jaw pain
  • dyspnea on exertion
  • postprandial symptoms
  • nocturnal angina
  • nausea
  • diaphoresis
  • fatigue
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16
Q

why is nocturnal angina really bad?

A

at night is when the body has the lowest metabolic demand and blood flow should be best - if angina still occurs then, means the patient is critically ill

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17
Q

what other options are there for a chest pain ddx?

A
  • CAD/MI
  • aortic: dissection, ulcer, hematoma
  • pericarditis
  • pulm: embolism, pneumonia, pleurisy
  • esophageal: spasm, inflam, stricture, GERD, achalasia
  • musculoskeletal
  • anxiety
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18
Q

in what group of people is it more common to see TIA sx or claudication pain?

A

smokers

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19
Q

ddx: how does pericarditis differ?

A 
variable duration 
sharp 
positional (relieved by sit up + lean forward) 
pleuritic 
worse with inspiration
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20
Q

ddx: how does aortic dissection differ?

A

excruciating, ripping, sudden pain
anterior
radiates to back
unequal pulse?

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21
Q

ddx: how does PE differ?

A

sudden onset dyspnea and pleuritic pain

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22
Q

ddx: how does musculoskeletal pain differ?

A

sudden onset
fleeting
reproduced by palpation

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23
Q

ddx: how does GERD differ?

A

burning
substernal
epigastric 10-60minutes
related to meals

24
Q

ddx: how does psychological differ?

A 
tightness
aching
with dyspnea 
non-exertional 
lasts more than 30 min
25
Q

when do we feel chest pain? aka pathophysiology of ischemia

A

imbalance between supply and demand:

supply:
- stenosis
- spasm
- anomaly
- anemia

demand:
- tachycardia
- aortic stenosis
- HTN urgency
- LVH

26
Q

causes of non-atherosclerotic CAD

A
  • coronary vasospasm
  • anomalous coronary arteries
  • coronary arteritis (Kawasaki)
  • coronary dissection
  • myocardial bridge
  • coronary embolization
27
Q

what is myocardial bridge?

A

piece of myocardium over a coronary artery

  • incidental finding
  • doesn’t normally cause angina
  • don’t do anything about it
28
Q

novel risk factors for atherosclerotic disease

A
  • chronic inflammation (RA)
  • elevated hsCRP
  • homocys
  • chronic kidney disease
  • coagulation abnormalities
  • chronic infection?
29
Q

myocardial ischemia: secondary causes

A
  • severe anemia
  • hypoxemia
  • uncontrolled HTN
  • severe LVH
  • uncontrolled tachycardia (SVT, WPW)
  • thyrotoxicosis
30
Q

resting EKG in ischemic heart disease

A
  • may be normal in 50%
  • most common finding is non-specific ST-T changes
  • conduction abnormalities such as LBBB, LAFB (marker for poor prognosis)
31
Q

importance of pretest probability: what groups do you do stress tests for and which do you not?

A
  • asymptomatic patients with or w/o some risk factors: don’t do
  • opposite end of spectrum- already diagnosed CAD: don’t do
  • DON’T DO FOR UNSTABLE SYMPTOMS

-only use it for patients in the middle ground gray zone - medium risk category w/ some clinical sx and some risk factors

32
Q

stress test modalities

A
  • exercise stress EKG

- stress imaging modalities

33
Q

how is the stress provided in a stress test?

A 
treadmill 
pharmacologic (dobutamine, vasodilators)
34
Q

whenever you do a pharmacological stress test, what do you also always have to add?

A

imaging- chances to see things on EKG with this type of test is low

35
Q

what imaging modalities are used for stress test?

A
  • echo (treadmill, dobutamine)
  • nuclear (treadmill, vasodilators, or rarely dobutamine)
  • MRI
36
Q

stage I of standard Bruce protocol for stress test

A
  • office work
  • light housework
  • golf (walking with bag)
37
Q

stage II of standard Bruce protocol for stress test

A
  • light factory work
  • stairs
  • bicycle riding (10 mph)
38
Q

stage III of standard Bruce protocol for stress test

A
  • heavy factory work

- running (10min/mile)

39
Q

stage IV of standard Bruce protocol for stress test

A
  • running (8min/mile)
  • stairs with heavy weight
  • boxing
40
Q

at what percent stenosis does a person with CAD get symptoms?

A

70% occluded- this is when you get a drop in flow

41
Q

what is the evolution of abnormalities in ischemia?

A
  1. decreased relaxation (diastolic dysfxn)
  2. systolic dysfxn
  3. decreased filling
  4. decreased ST
  5. angina
42
Q

approximately what percent of patients with angina also experience episodes of silent ischemia?

A

50%

43
Q

what do you do in evaluating IHD

A
  • confirm diagnosis of CAD
  • assess functional limitations
  • assess status of modifiable risk factors
  • assess burden of ischemia:
    • how much muscle is at risk?
    • how many vessels involved?
    • how severe is ischemia?
  • assess LV function
44
Q

pros and cons of exercise stress EKG

A

pros:
- low cost, versatility, validated, no need for IV access, fairly sensitive and specific

cons:
- high false positive in females, unreliable with abnormal resting EKG, false negative (failure to achieve HR)

45
Q

stress EKG: what counts as ST segment changes

A

greater than 1mm horizontal or down-sloping ST depression is diagnostic of ischemia

  • magnitude: more is worse
  • duration: longer is worse
  • timing: earlier is worse
  • number of leads: more is worse
  • associated angina, drop in BP, arrhythmia

greater than 1mm ST elevation

46
Q

coronary artery disease: high risk groups?

A
  • left main stenosis > 50%
  • 3 vessel disease, especially with LV dysfxn
  • 2 vessel disease involving proximal LAD
  • multi-vessel disease in diabetics
  • impaired LV function
47
Q

stress test findings suggestive of high risk

A
  • inability to complete stage II of Bruce protocol
  • angina at a low workload (less than 6 METs)
  • failure to achieve 80% of target HR or HR>120
  • fall in BP > 10 with progressive exercise (accompanied by other evidences of ischemia)
  • ischemic ST depression
  • ST elevation more than 1mm (non infarct lead)
  • sustained ventricular tachycardia
48
Q

findings with ischemic ST depression

A
  • greater than or = 2mm (esp downsloping)

- occurring at a low workload or HR (5 min into recovery

49
Q

grading functional capacity with METs

A

10 - good capacity

50
Q

what is 1 MET?

A

oxygen consumption of a 40 y/o, 70kg man in resting state

51
Q

indications for stress imaging

A
  • unable to exercise
  • abnormal baseline EKG
  • known CAD (prior infarct, revascularized/cath)
52
Q

describe the regadenosan, adenosine or dipyridamole

A

coronary vasodilatation in normal segments, diseased segment (s) unable to dilate leading to relative hypoperfusion

53
Q

stress imaging findings suggestive of high risk

A
  • perfusion defects in multiple coronary territories
  • large reversible perfusion defect in single territory (LAD)
  • transient ischemic LV dilatation
  • increased lung uptake (with abnormal perfusion)
  • abnormal LV function (EF
54
Q

indications for coronary angiography in stable CAD

A
  • persistent sx despite medical therapy (min 2)
  • non-invasive test results suggesting high risk
  • equivocal or non-diagnostic non-invasive test results
  • high risk occupation
55
Q

initial management of IHD

A
  • aspirin 81 mg daily
  • sublingual NTG as needed
  • lipid lowering therapy
  • instructions on healthy lifestyle
  • activity dictated by symptoms
  • report any change in symptoms immediately

ICM (26 decks)

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