Acute Coronary Syndrome 1

Question 1

Recall 3 key points regarding the prevalence and significance of ischemic heart disease.

Answer 1

CV disease is the #1 cause of death in the world
death from ischemic heart disease is declining in the US due to improved prevention and therapy
the societal cost burden of ischemic heart disease is significant and increasing

Question 2

How might a patient present with stable ischemic heart disease?

Answer 2

absence of symptoms
predictable, chronic angina pectoris
intact fibrous cap
minimal platelet activation

Question 3

What are clinical indications suggestive of unstable inschemic heart disease?

Answer 3

rapidly progressive anginal symptoms
elevated cardiac biomarkers
ECG changes

Question 4

Contrast the pathophysiology of stable angina and acute coronary syndrome.

Answer 4

the first is obstructive or non-obstructive coronary artery disease, intact fibrous cap and min platelet activation or thrombus

the second is obstructive coronary artery disease, plaque rupture or erosion, followed by platelet activation, inflammation and thrombus

Question 5

What are the 1st line treatments for someone with chronic stable angina?

Answer 5

lifestyle modification, B-blocker, CCB and nitrate therapy

Question 6

What is the options for patients with stable angina who are refractory medical therapy?

Answer 6

percutaneous (stenting) or surgical coronary artery revascularization may be considered

Question 7

Under what circumstance should coronary artery bypass surgery be considered.

Answer 7

patient is refractory to medical therapy AND has three vessel disease with depressed left ventricular function and has no contra indications

if surgery is not possible, multi-vessel percutaneous stenting may be considered

Question 8

Define the classes that can be used to describe the severity of angina pectoris.

Answer 8

I. only with strenuous, rapid or prolonged exertion
II. slight limitation of ordinary activity
III. marked limitation of ordinary activity
IV inability to carry on any physical activity without discomfort, angina may be present at rest

Question 9

Presence of Q waves suggest what?

Answer 9

suggest prior myocardial.

Question 10

__________ with exercise is most diagnostic of significant, obstructive coronary artery disease.

Answer 10

horizontal or down-sloping depression or elevation of the S-T segment with exercise is most diagnostic of significant, obstructive coronary artery disease

Question 11

What can increase the predictive value of an electrocardiographic stress test?

Answer 11

increasing the prevalence of the disease- consider risk factors to stratify the population

or combination with non-invasive imaging methods (nuclear scintigraphy or echocardiography)

Question 12

What characteristic of heart tissue does nuclear stress imaging highlight?

Answer 12

radionuclide tracer is taken up by myocardium in proportion to blood flow, can highlight ischemic portions of the heart

Question 13

High risk coronary artery disease is likely when: (4)

Answer 13

onset of chest pain and or EKG changes of M ischemia occurs at a low level of physical exertion
exercise-induced hypertension occurs
malignant ventricular arrhythmias occur
large areas of myocardium demonstrate reduced perfusion or contractility using imaging

Question 14

Name agents that can be used instead of exercise in a stress test.

Answer 14

coronary vasodilators- adenosine and dipyridamole and hyper contractility agents such as dobutamine

Question 15

Describe fractional flow reserve.

Answer 15

coronary guide wire mounted with a transducer placed across the lesion can pressure difference can be diagnostic of functional obstruction

Question 16

Non invasive testing can establish a diagnosis but it can also help to define _____

Answer 16

prognosis

Question 17

The most important part of the clinical evaluation of a patient with suspected ischemic heart disease is what.

Answer 17

detailed history

Question 18

What method is the gold standard for establishing diagnosis and assessing the severity of CAD?

Answer 18

invasive cardiac catherization

Question 19

What approaches could you use to address symptom relief with acute coronary syndrome.

Answer 19

meds like B bluchers, CCBs and nitrates

ballon angioplasty, stenting and surgical bypass

Question 20

What approaches could use to prolong a patients like that has acute coronary syndrome?

Answer 20

lifestyle modifications
anti-platelet medications (aspirin, clopiogrel and prasrugrel)
PB recution and plaque modifying meds ACE I or statins

Question 21

Because of the diffuse nature of CAD, stenting and angioplasty have been able to offer symptom relief but not________ with stable ischmemic heart disease

Answer 21

reduce total rates of MI or death in patients with stable ischemic heart disease

Question 22

The risk of repeat revascularization following PCI is highest in those with ?

Answer 22

diabetes

long stunted segments, multiple overlapping stents and small diameter vessels

Question 23

What are the 3 types of acute coronary syndrome?

Answer 23

unstable angina

non ST elevated myocardial infarction (NSTEMI) and STelevation myocardial infarction (STEMI)

Question 24

How do you differentiate NSTEMI and STEMI from unstable angina?

Answer 24

with serum biomarkers of myocardial cell necrosis such as troponin I and troponin T

Question 25

Angina at rest implies what?

Answer 25

unstable plaque and platelet based pathology

Question 26

Both unstable angina and NSTEMI are triggered by what?

Answer 26

plaque rupture that results in a transient and or incompletely occlusive thrombus

Question 27

If not treated quickly, ST-segment elevation will usually be followed by development of Q waves which implies what?

Answer 27

competed transmural necrosis

Question 28

The site of myocardial infarction is most commonly in the ___ portion of the coronary arteries, which may be related to the differences in mechanical stress in these locations.

Answer 28

proximal portion

Question 29

Plaque rupture exposes several chemical factors on the vessel wall including (3).

Answer 29

tissue factor
collagen
vonWillebrand factor

Question 30

_____ and _____ are both potent inhibitors of platelet activation are reduced int eh vicinity of atherosclerotic plaque.

Answer 30

NO and prostacyclin

Question 31

TIMI score is based on 7 clinical variables.

Answer 31

age >65
presence of at least 3 risk factors for CAD
prior coronary stenosis of >50
present ST segment deviation
two angina episodes in prior 24hrs
elevated serum cardiac biomarkers
use of aspirin in prior seven days