4: Ischemic Heart Disease

Question 0

Affected coronary vessels

Answer 0

LAD>RCA>LCA

RCA: posterior, inferior wall
LCA: lateral wall
LAD: anterior wall

Question 1

Ischemic Heart disease

Answer 1

Mismatch between demand and supply

Question 2

MC congenital anomaly on coronary artery causing IHD

Answer 2

LAD is originating from Pulmonary artery

Question 3

MCC of IHD

Answer 3

Atherosclerosis

Question 4

Risk

Answer 4

Male: over 45
Female: over 50 postmenopausal
Diabetes
HTN
Smoking (takes 15yrs for risk to come down)
Inflammation (vasculitis)*- it makes thrombus dangerous, makes it easier to rupture
Hyperhomocystinimia

Question 5

IHD- spectrum

Answer 5

Angina (ischemia)

MI (permanent damage to cardiac muscle)

Question 6

Stable angina- info

Answer 6

Substernal pain (can present as squeeze, pressure, weight on chest)
Pain lasts for few mins (up to 5 mins), crescendo, decrescendo
Any stress in life will bring up the pain (anger, sex, etc)
Rest makes it better
Nitrates (reduce the pain for angina, might not for MI)
Subendocardial damage
Raveen’s sign

Question 7

Angina decubitus

Answer 7

lying down causes pain

1: increased intrathoracic pressure and heart needs to pump harder, higher demand for O2
2: Sleep
3: Respiratory system dysfunction during sleep

Question 8

Unstable angina- UA/NSTEMI (non-ST elevated MI)

Answer 8

1: Accelerating (Diabetic. with less and less activity)
2: New onset (suddenly started. Faster pathogenesis than atherosclerosis)
3: Resting
Thrombus formation or Ruptured plaque (non-occlusive)
Subendocardial damage

Question 9

Prinzmetal angina

Answer 9

No previous history
Younger pts (30-40)
While they are sleeping
Vaso-spasm (hyper-responsive smooth muscle and some chemical causes it)
Transmural damage
MC in RCA (LCA is more affected by ischemia)

Question 10

Investigation- angina

Answer 10

EKG (show nothing)*
Stress induced EKG changes (let pts exercise while on EKG-> ST depression more than 1mm over 0.8 sec on more than one LEAD)- stop with more than 2mm depression or arrhythmia!! (MC done test)
Coronary angiography (GOLD STANDARD)- done in 4 cases;
1: tx dont improve the angina
2: stress test is unconclusive
3: pts keep coming back with typical angina sx but stress test is negative
4: if the pts is in charge of ppl’s lives (i.e. airplane pilot, surgeon etc)
Lipids
TL 50
HTN retinopathy (AV nicking)
Xanthoma

Question 11

ST depression

Answer 11

due to Injury current caused by subendocardial ischemia.

Current going away from the LEAD, thus depression

Question 12

ST elevation

Answer 12

in case of MI/ Prinzmetal

Intramural ischemia sending the current toward LEAD thus elevation.

Question 13

Pts unable to exercise for stress test

Answer 13

Pharmacologic stress test
Decrease the supply of blood to heart
Dipyridamole, Dopamine

Question 14

Treatment- angina

Answer 14

Reassurance (angina is better than MI)
Encourage to stop smoking
Sx management
Reduce stress
MONA;**
Morphene
Oxygen (dont give if O2 saturation is good)
Nitrate (give pulsating headache, reflex tachycardia, tolerance development [nitrate free window keeps efficacy]) +Beta blocker (on on asthma, COPD, AV block. in that case, give Cachannel blocker [beta blocker is better since it increase the diastolic time which increase the time for coronary vessels to receive more blood)
Aspirin (or other anti-platelet drugs like clopidogrel, anti-coagulation like Heparin, fundaperinux which do not cause HIT)

Question 15

Prinzmetal- tx

Answer 15

Nitrate
Cachannel blocker
PCI (percutaneous intervention)- drug eluting stent (Saerolimus, Paclitaxil), stent (for a year, clopidogrel and aspirin, and life time of aspirin afterward) [restenosis can happen, temporary]
Cabbage (coronary artery bipass graft) [permanent, risk of stroke]
DO Cabbage if:**
-3 or more vessels involved
-Left main vessel involved
-Diabetics
-Ejection fraction <50%

Question 16

MI-sx

Answer 16

Chest pain lasts more than 30mins**
Pain- Nitrates and rest wont cure it
Sympathetic stimulation (anterior wall)- tachycardia
Parasympathetic stimulation (inferior wall)- bradycardia

Question 17

MI- Investigation

Answer 17

1: Chest pain more than 30 mins
2: ST elevation (in more than 2 LEADs)
3: Bio-markers (Troponin the most reliable)

EKG:

1: ST elevation on certain LEADs (left bundle block-> anterior cause)
2: Q wave develops (hr to days)
3: T wave inversion
4: ST elevation on opposite LEADs

Akinesia or Dyskinesia can be seen

Question 18

LEADs

Answer 18

Lateral: V5, V6, I, aVL
Anterior: V1, V2, V3, V4
Inferior: aVF, II, III

Question 19

MI- tx

Answer 19

Nitrate
Oxygen
Aspirin
Thrombo-lytic (p-TA, alte-plas) [any chance of bleeding contraindicate it]

Question 20

MI- tx; timeline

Answer 20

Thrombo-lytic (30mins-2hrs)* efficacy goes down after 2hrs and ineffective after 12hrs
PCI: door to surgery in 90mins*

Question 21

MI- complication

Answer 21

V-fibrillation
Dressler’s syndrome (many weeks later)
Necrosis; Mitral regurgitation, interseptal rupture, lateral free wall rupture (cardiac tamponade)