B P5 C40 Stable Ischemic Heart Disease

Question 1

SIHD is most commonly caused by atheromatous plaque that obstructs or gradually narrows the epicardial coronary arteries. However, other contributors, such as endothelial dysfunction, microvascular disease, and vasospasm, may also exist alone or in combination with coronary atherosclerosis and may be the dominant cause of myocardial ischemia in some patients

Pathophysiology of SIHD:

Answer 1

Vasospasm
Inflammation
Platelets and coagulation
Endothelial dysfunction
Microvascular dysfunction
Critical artery stenosis

Question 2

____________ angina is caused by redistribution of coronary blood flow to the splanchnic circulation, may be a marker of severe IHD.

Answer 2

Postprandial angina

Question 3

____________ angina is used to describe the ability of some patients to be able to exercise at higher intensity without angina after an intervening period of rest.

Answer 3

Warm-up angina

This attenuation of myocardial ischemia observed with repeated exertion has been postulated to be caused by ischemic preconditioning

Question 4

Common disorders that may simulate or coexist with angina pectoris are gastroesophageal reflux and disorders of esophageal motility, including diffuse spasm.To compound the difficulty in distinguishing between angina and esophageal pain, both may be relieved by _____. However, esophageal pain is often relieved by milk, antacids, foods, or occasionally warm liquids.

Answer 4

NTG

Question 5

_____ pain is steady, usually lasts 2 to 4 hours, and subsides spontaneously, without any symptoms between attacks. It is generally most intense in the right upper abdominal area but may also be felt in the epigastrium or precordium.This discomfort is often referred to the scapula and may radiate around the costal margin to the back.

Answer 5

BIliary pain

Question 6

The full-blown _____ syndrome (i.e., pain associated with tender swelling of the costochondral junctions) is uncommon, whereas costochondritis causing tenderness of the cos- tochondral junctions (without swelling) is relatively common

Answer 6

Tietze syndrome

Question 7

This condition may occur as a constant ache, worsened with neck movement, and sometimes results in a sensory deficit.

Answer 7

Cervical radiculopathy

Question 8

_____ pain suggests pulmonary infarction, and a history of exacerbation of the pain with inspiration, along with a pleural friction rub, if present, helps distinguish it from angina pectoris.

Answer 8

Pleuritic pain

Question 9

Recognition of _____ may be facilitated by the combination of chest pain not relieved by rest or nitroglycerin and exacerbated by movement, deep inspiration, and lying flat; a pericardial friction rub, which may be evanescent; and changes on the ECG (notably PR-segment depression or diffuse ST elevation).

Answer 9

Pericarditis

Question 10

Angina pectoris results from myocardial ischemia, which is caused by an imbalance between myocardial O2 requirements and myocardial O2 supply.

Factors that can elevate O2 requirements?
O2 supply is determined by?

Answer 10

Increases in:
Heart rate
Left ventricular (LV) wall stress
Contractility

O2 supply is determined by:
Coronary blood flow
Coronary arterial O2

Question 11

In _____ angina, the myocardial O2 requirement increases in the presence of a constant and usually restricted O2 supply.

The increased O2 requirement commonly stems from a physiologic response to exertion, emotional duress, or mental stress

Answer 11

Demand angina

Question 12

Stable angina may be caused by transient reductions in O2 supply, a condition sometimes termed _______________ angina, as a consequence of coronary vasoconstriction that results in dynamic stenosis.

Answer 12

Supply angina

In addition, endothelial damage in atherosclerotic coronary arteries decreases production of vasodilator substances such as nitric oxide, resulting in an abnormal vasoconstrictor response to exercise and other stimuli.

Question 13

Lipoprotein(a) (Lp[a]) is a highly heritable lipid-related risk factor that should be considered for measurement in selected individuals with _____.

Answer 13

Premature CAD
Strong family history of CAD
Reasonable to measure at least once among any individual with CAD

Question 14

Blood levels of _________________ are typically used to differentiate patients with acute MI from those with SIHD.

Answer 14

Cardiac troponins T and I

Question 15

Higher concentrations of these peptides are strongly associated with risk for cardiovascular events in those at risk for and with established CAD.

Answer 15

BNP and N-terminal pro-BNP

Question 16

The blood concentration of the acute-phase protein _____________ correlates with the risk for incident cardiovascular events in patients with SIHD or at risk for its development, prognostic value is additive to traditional risk factors, including lipids

Answer 16

HsCRP

In addition, hsCRP may be an important b marker reflecting residual risk among patients following ACS or with established SIHD who are treated to low LDL goals with lipid-lowering therapy. 25 , 26 Patients who achieve low LDL cholesterol levels (<70 mg/ dL) but with hsCRP levels above 2 mg/L are at higher risk for subsequent ischemic events than patients with low levels of both LDL and hsCRP.

Question 17

The most common abnormalities on the ECG in patients with SIHD are _____________

Answer 17

Nonspecific ST-T wave abnormalities with or without abnormal Q waves

Findings on the resting electrocardiogram (ECG) are normal in approximately half of patients with SIHD

Question 18

A ____________ ECG is a more favorable long-term prognostic sign in patients with suspected or definite CAD.

This also suggests the presence of _____ and is an unusual finding in a patient with an extensive previous MI

Answer 18

Normal resting

Normal resting LV function

Question 19

Various conduction disturbances, most frequently ______, may occur in patients with SIHD; are often associated with impairment of LV function, reflect multivessel CAD, poor prognosis

Answer 19

LBBB
LAFB

Question 20

____________ on the ECG is associated with a worse prognosis in patients with chronic stable angina

Answer 20

LV hypertrophy

This finding implies the presence of underlying hypertension, aortic stenosis, hypertrophic cardiomyopathy, or previous MI with remodeling and warrants further evaluation, such as echocardiography to assess LV size, wall thickness, and function.

Question 21

During an episode of angina pectoris, findings on the ECG become abnormal in 50% or more of patients with normal resting ECGs.

The most common finding is _____, although ST-segment elevation and normalization of previous resting ST-T wave depression or inversion (pseudonormalization) may develop.

Answer 21

ST-segment depression

Question 22

Assessment of global LV function is one of the most valuable aspects of echocardiography.

Identification of _____________ may be suggestive of CAD, whereas other findings such as valvular stenosis or pulmonary hypertension may suggest alternative diagnoses

Answer 22

Regional wall motion abnormalities

Question 23

The chest roentgenogram is generally _____________ in patients with SIHD

Answer 23

Normal limits

Question 24

_________ testing can provide useful information to establish the diagnosis and estimate the prognosis in patients with suspected stable angina.

Answer 24

Noninvasive stress testing

Question 25

The value of noninvasive stress testing is greatest when the pretest likelihood is ______________ because the test result is likely to have the greatest effect on the post-test probability of CAD.

Answer 25

Intermediate

Question 26

The _____________ is particularly helpful in patients with chest pain syndromes who are considered to have a moderate probability of CAD and in whom the resting ECG is normal, provided that they are capable of achieving an adequate workload.

Answer 26

Exercise ECG

Although the incremental diagnostic value of exercise testing is limited in patients in whom the estimated prevalence of CAD is high or low, the test provides useful additional information about the degree of functional limitation in both groups of patients and about the severity of ischemia and prognosis in patients with a high pretest probability of CAD. In

Question 27

Exercise testing in ______________ individuals without known CAD is not recommended, with the possible exception of asymptomatic individuals at high cardiac risk who plan to begin vigorous exercise.

Answer 27

Asymptomatic

Exercise testing is not required before initiating m ate exercise, even for high-risk individuals.

Question 28

One of the most important and consistent prognostic markers is ________ exercise capacity, regardless of whether it is measured by exercise duration or by workload achieved or whether the test was terminated because of dyspnea, fatigue, or angina.

Answer 28

Maximal exercise capacity

Question 29

Patients with high-risk stress test results should undergo either a ___________________ or ______________

Answer 29

Coronary computed tomography or angiography (CTA) or invasive angiogram.

Question 30

Patients in whom objective evidence of mild ischemia (e.g., 1-mm ST-segment depression) develops at a ____________________ do not require coronary arteriography before an adequate trial of medical therapy is first administered.

Answer 30

High workload (e.g., >9 to 10 minutes on a Bruce protocol)

Question 31

Long-acting beta-blocking agents, which should be omitted for ________________ before testing.

Answer 31

2 to 3 days

For long-acting nitrates, calcium antagonists, and short-acting beta blockers, discontinuing use of the medications the day before testing usually suffices.

If the test is being performed for risk stratification in a patient with known CAD, discontinuation of medications is not necessary.

Question 32

True or False

It is generally accepted that electrocardiographic stress testing is not as reliable in women

Answer 32

True

Question 33

_________________ with simultaneous ECG recording is generally considered to be superior to an exercise ECG alone in detecting CAD, in identifying multivessel CAD, in localizing diseased vessels, and in determining the magnitude of ischemic and infarcted myocardium.

Answer 33

Exercise myocardial perfusion imaging (MPI)

Exercise singlephoton emission computed tomography (SPECT) yields higher sensitivity and specificity than exercise electrocardiography alone

Stress MPI is particularly helpful in the diagnosis of CAD in patients with abnormal resting ECGs and in those in whom ST-segment responses cannot be interpreted accurately, such as patients with repolarization abnormalities caused by LV hypertrophy and those receiving digitalis.

Question 34

_________________ is particularly helpful in the diagnosis of CAD in patients with abnormal resting ECGs and in those in whom ST-segment responses cannot be interpreted accurately, such as patients with repolarization abnormalities caused by LV hypertrophy and those receiving digitalis.

Answer 34

Stress MPI

Question 35

Noninvasive test with highest sensitivity for the detection of CAD

Answer 35

CCTA

Sensitivity: 0.97
Specificity: 0.78

Question 36

Noninvasive test with highest specificity for the detection of CAD

Answer 36

PET and CMRI

PET
Specificity: 0.89, Sensitivity: 0.83

CMRI:
Specificity: 0.89, Sensitivity: 0.88

Question 37

A patient should be able to walk up ________________ flights of stairs without stopping to complete a standard exercise stress test.

Answer 37

Two flights of stairs

Question 38

________________ may be performed with exercise or pharmacologic stress with dobutamine and allows detection of regional ischemia by identifying wall motion abnormalities induced by ischemia.

Answer 38

Stress echocardiography

Stress echocardiography is also valuable in localizing and quantifying ischemic myocardium.

Numerous studies have shown that exercise echocardiography can detect the presence of CAD with an accuracy similar to that of stress MPI and is superior to exercise electrocardiography alone

The presence or absence of inducible regional wall motion abnormalities and the response of the ejection fraction to exercise or pharmacologic stress provide incremental prognostic information to that provided by the resting echo.

Question 39

Highest sensitivity and lowest sensitivities among non-invasive testing

Answer 39

Highest - CCTA
Lowest - Exercise ECG

Question 40

Highest and lowest specificity among non-invasive testing

Answer 40

Highest - PET/CTMRI
Lowest - Exercise ECG

Question 41

MPI can stratify patients into:

Answer 41

Low (<1% risk for future CV with a normal MPI study)
Intermediate (1% to 5%)
High (>5%)

Question 42

Risk stratification based on noninvasive testing:

HIGH RISK (>3% Annual Risk For Death or Myocardial Infarction)

Answer 42

Severe resting left ventricular dysfunction (LVEF <35%) not readily explained by noncoronary causes

Resting perfusion abnormalities involving ≥10% of the myocardium without previous known MI

High-risk stress findings on the ECG, including
* ≥2-mm ST-segment depression at low workload or persisting into recovery
* Exercise-induced ST-segment elevation
* Exercise-induced VT/VF

Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress ≥10%)

Stress-induced perfusion abnormalities involving ≥10% of the myocardium or stress segmental scores indicating multiple vascular territories with abnormalities

Stress-induced LV dilation

Inducible wall motion abnormality (involving >2 segments or 2 coronary beds)

Wall motion abnormality developing at a low dose of dobutamine (≤10 mg/kg/min) or at a low heart rate (<120 beats/min)

Multivessel obstructive CAD (≥70% stenosis) or left main stenosis (≥50% stenosis) on CCTA

Question 43

Risk stratification based on noninvasive testing:

INTERMEDIATE RISK (1-3% Annual Risk For Death or Myocardial Infarction)

Answer 43

1. Mild to moderate resting LV dysfunction (LVEF of 35%-49%) not readily explained by noncoronary causes
2. Resting perfusion abnormalities involving 5%-9.9% of the myocardium in patients without a history or previous evidence of MI
3. ≥1-mm ST-segment depression occurring with exertional symptoms
4. Stress-induced perfusion abnormalities encumbering 5%-9.9% of the myocardium or stress segmental scores (in multiple segments) indicating one vascular territory with abnormalities but without LV dilation
5. Small wall motion abnormality involving one to two segments and only one coronary bed
6. One-vessel CAD with ≥70% stenosis or moderate CAD stenosis (50%- 69% stenosis) in ≥2 arteries on CCTA

Question 44

Risk stratification based on noninvasive testing:

LOW RISK (<1% Annual Risk For Death or Myocardial Infarction)

Answer 44

1. Low-risk treadmill score (score ≥5) or no new ST-segment changes or exercise-induced chest pain symptoms when achieving maximal levels of exercise
2. Normal or small myocardial perfusion defect at rest or with stress encumbering ≥5% of the myocardium*
3. Normal stress or no change in limited resting wall motion abnormalities during stress
4. No coronary stenosis >50% on CCTA

Question 45

Screening of asymptomatic individuals at _____ risk for CAD using CAC can be useful to guide decisions about initiation and titration of preventive therapies such as statins and aspirin

Answer 45

Intermediate

Question 46

CAC screening does not have a role in the diagnosis of obstructive CAD among ______________ patients.

Answer 46

Symptomatic

Screening of asymptomatic individuals at intermediate risk for CAD can be useful to guide decisions about initiation and titration of preventive therapies such as statins and aspirin

Question 47

___________ is a noninvasive method for angiography of the coronary arterial tree and quantification of ventricular function.

Answer 47

Coronary CTA

Compared with nuclear MPI, a comprehensive anatomic evaluation with coronary CTA offers superior accuracy for the prediction of an abnormal invasive fractional flow reserve (FFR)

Question 48

The accuracy of coronary CTA for estimating the severity of luminal stenosis is limited in patients with __________________

Answer 48

• Tachycardia unable to be controlled adequately with beta blockers
• Heavy coronary calcification
• Region of previously placed coronary stents

For these reasons, stress testing with adjunctive imaging is preferred over CTA for patients with known CAD.

Question 49

An important advantage of CTA over stress testing is the ability to _______________________

Answer 49

Detect nonobstructive plaque

Question 50

In the randomized _____ trial among 10,003
symptomatic patients without known CAD, coronary CTA was compared with functional testing as an initial evaluation strategy.

Clinical outcomes and costs were similar in the CTA and functional testing arms over a median follow-up of 2 years.

Patients randomized to coronary CTA underwent more cardiac catheterizations but were less likely to be found to have no obstructive disease on invasive angiography.

An important finding from this study was the low rate of cardiovascular events in both treatment arms, highlighting the possibility that deferral of all testing may be reasonable for many lower-risk individuals.

Answer 50

PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain)

Question 51

Low- to intermediate-risk patients with chest pain were randomized to evaluation with coronary CTA (n = 2,073) versus standard care (n = 2,073).

Coronary CTA compared with standard care was associated with a nonsignificant increase in coronary revascularization procedures and a nonsignificant reduction in CHD death or MI in the short-term. At a median follow-up of nearly 5 years, CTA was associated with a reduction in CHD death or MI vs. standard care. Benefit was largely due to a reduction in nonfatal MI. Although CTA was associated with an increase in invasive therapy and revascularization in the short-term, there was no difference in invasive therapy and revascularization between treatment arms at 5 years. Since there was no difference in overall revascularization rates, long-term benefit from CTA may have been due to lifestyle modification and statin therapy.

Answer 51

SCOT HEART (Scottish Computed Tomography of the HEART)

Question 52

The clinical strength of CT angiography remains its ability to exclude significant CAD with a high negative predictive value and identify low-risk patients with no stenosis and no plaque.

Among the many important implications of the _____________ trial, one is that a strategy using coronary CTA as the initial diagnostic test for patients with angina to exclude severe left main disease before initiating medical therapy for angina can support good outcomes without a need for invasive management

Answer 52

ISCHEMIA

Question 53

___________ has emerged as highly useful for assessment of myocardial viability because of evidence demonstrating its ability to predict functional recovery after percutaneous or surgical revascularization and good correlation with PET

Answer 53

CMRI

Offers accurate characterization of LV function, as well as delineation of patterns of myocardial disease that are often useful in discriminating ischemic from nonischemic myocardial dysfunction.

Question 54

Resting abnormalities considered as high risk based on non-invasive testing

Answer 54

Severe resting left ventricular dysfunction (LVEF <35%) not readily explained by noncoronary causes

Resting perfusion abnormalities involving ≥10% of the myocardium without previous known MI

Multivessel obstructive CAD (≥70% stenosis) or left main stenosis (≥50% stenosis) on CCTA

Question 55

Stress abnormalities considered as high risk based on non-invasive testing

Answer 55

High-risk stress findings on the ECG, including
• ≥2-mm ST-segment depression at low workload or persisting into recovery
• Exercise-induced ST-segment elevation
• Exercise-induced VT/VF

Severe stress-induced LV dysfunction (peak exercise LVEF <45% or drop in LVEF with stress ≥10%)

Stress-induced perfusion abnormalities involving ≥10% of the myocardium or stress segmental scores indicating multiple vascular territories with abnormalities

Stress-induced LV dilation

Inducible wall motion abnormality (involving >2 segments or 2 coronary beds)

Wall motion abnormality developing at a low dose of dobutamine (≤10 mg/kg/min) or at a low heart rate (<120 beats/min)

Question 56

Precise assessment of the anatomic severity of CAD still requires ______________

Answer 56

Invasive coronary angiography

It should be remembered that myocardial ischemia may occur in the absence of epicardial CAD

The proportion of individuals who reported angina but had no obstructive disease on coronary angiography approached 50%.

Question 57

High-grade lesions _____________ are particularly high risk.

Answer 57

High grade lesions of the left main coronary artery or its equivalent, as defined by severe proximal LAD and proximal left circumflex CAD

Question 58

Mortality without revascularization in patients with severe left main CAD was approximately _________________

Answer 58

15 - 20%

Question 59

Coronary angiography is not a reliable indicator of the _____ significance of the stenosis

Answer 59

Functional significance

Question 60

This approach (Angiography) may lead to significant _________________ of the severity and extent of atherosclerosis.

Answer 60

Underestimation

Question 61

The most serious limitation to the routine use of coronary angiography for prognosis in patients with SIHD is its inability to identify _________________________, such as MI or sudden death

Answer 61

Which coronary lesions can be considered to be at high risk for future events

Question 62

Most acute MIs emanate from antecedent coronary stenoses that obstruct ______________ of the luminal diameter

Answer 62

less than 50%

Question 63

IVUS provide a more comprehensive evaluation of the enhanced the detection and quantification of coronary atherosclerosis, as well helping to characterize the _____________________ of the coronary atheroma to rupture

Answer 63

Vulnerability

Question 64

IVUS continues to have a role in assessing _____________________.

Answer 64

Left main coronary stenoses
Bifurcation lesions
Optimizing stent deployment

Question 65

_________ uses light technology that provides much higher resolution images of the coronary atheroma (10 to 15 microns, versus 100 to 150 microns with IVUS) but penetration is limited to 1 to 3 mm in depth; useful for measuring fibrous cap thickness and endothelial coverage of stent struts

Answer 65

OCT

Question 66

The major current clinical role for OCT is evaluating patients with acute MI and no evidence of coronary obstruction by angiography, where OCT may detect _____________ and ___________ unrecognized on the coronary angiogram.

Answer 66

Occult plaque rupture and spontaneous coronary dissection

Question 67

______________ the most important invasive tool to complement coronary angiography, providing a functional assessment of the hemodynamic impact of a coronary stenosis.

Answer 67

FFR

The primary role of FFR is in g ing decisions regarding percutaneous coronary intervention (PCI) for stenoses that appear intermediate in severity by angiography.

Question 68

_________ ratio of pressure distal to a stenosis/pressure before the stenosis under conditions of maximal hyperemia, which is usually achieved with adenosine.

Answer 68

FFR

A stenosis with an FFR value <0.75 is highly likely to be associated with ischemia on nuclear perfusion imaging, whereas stenoses with FFR >0.8 are rarely associated with ischemia; 0.75 to 0.8 represents a “grey zone.”

Question 69

A stenosis with an FFR value <____ is highly likely to be associated with ischemia on nuclear perfusion imaging, whereas stenoses with FFR >_____ are rarely associated with ischemia; _____ represents a “grey zone.”

Answer 69

Ischemia: < 0.75
Grey zone: 0.75-0.80
Rarely assoc. with ischemia: > 0.80

Question 70

Alternative to FFR that does not require administration of a vasodilator and thus avoids adverse effects from adenosine and is simpler to perform in the catheterization laboratory

Answer 70

IFR

An iFR of >0.89 is commonly used as an analogous threshold to FFR >0.8 as a threshold above which PCI can be deferred.

Question 71

An iFR of >____ is commonly used as an analogous threshold to FFR >0.8 as a threshold above which PCI can be deferred.

Answer 71

iFR >0.89 = FFR >0.80

Question 72

_______ can be performed to exclude hemodynamically significant diffuse CAD that is underappreciated by angiography.

Answer 72

FFR and iFR

Question 73

_______ can be used to interrogate the coronary microcirculation

Answer 73

CFR and IMR

Question 74

___________ can be given at low doses to assess coronary endothelial function and at higher dosages to evaluate for coronary spasm.

Answer 74

Acetylcholine

Question 75

Most coronary artery ectasia and/or aneurysms are caused by ____________________, and the rest are caused by congenital anomalies and inflammatory conditions such as Kawasaki disease.

Answer 75

Coronary atherosclerosis (50%)

Question 76

Despite the absence of overt obstruction, ________ of patients with multivessel fusiform coronary artery ectasia or aneurysms have demonstrated evidence of cardiac ischemia.

Answer 76

70%

Question 77

Coronary ectasia should be distinguished from discrete coronary artery aneurysms, which are almost never found in arteries without _________________, are most common in the _______ coronary artery, and are usually associated with extensive CAD.

Answer 77

Severe stenosis

LAD

These discrete atherosclerotic coronary artery aneurysms do not appear to rupture, and they do not warrant resection.

Question 78

In patients with chronic occlusion of a major coronary artery but without MI, collateral-dependent myocardial segments show almost normal baseline blood flow and O2 consumption but severely limited ____________

Answer 78

Flow reserve

This finding helps explain the ability of collateral vessels to protect against resting ischemia but not against exerciseinduced angina.

Question 79

Up to ______ of patients with a history of stable angina experience angina one or more times per week.

Answer 79

30%

Question 80

The ________________ is a pragmatic integer score based on nine routinely assessed clinical characteristics (age, diabetes, hypertension, smoking, peripheral arterial disease, prior stroke, prior coronary artery bypass grafting (CABG), history of heart failure, and renal dysfunction) that demonstrated a graded relationship with the risk for cardiovascular death, MI, or ischemic stroke

Answer 80

TIMI Risk Score for Secondary Prevention (TRS 2°P)

Question 81

The ___________ risk score estimates net clinical outcome (balancing reductions in ischemia with increases in bleeding) with extending the duration of dual antiplatelet therapy from 12 to 30 months after stenting.

Answer 81

DAPT risk score

Question 82

The _______________ was developed as a weighted integer score to predict new coronary thrombotic events (MI or stent thrombosis) in patients who had undergone PCI.

Answer 82

PARIS risk score

The PARIS risk variables are similar to those in the TRS 2 including:

• PCI for acute coronary syndrome
• Revascularization before the qualifying PCI
• Diabetes mellitus
• Renal dysfunction
• Current smoking

Question 83

The __________________ scores a simple five-item risk score, using age, creatinine clearance, hemoglobin, white blood cell count, and previous spontaneous bleeding, that predicts out-of-hospital bleeding during DAPT.

Answer 83

PRECISE-DAPT

Question 84

Comprehensive management of SIHD has five aspects:

Answer 84

(1) Identification and treatment of associated diseases that can precipitate or worsen angina and ischemia
(2) Improvement of coronary risk factors
(3) Application of pharmacologic and nonpharmacologic interventions for secondary prevention
(4) pharmacologic management of angina
(5) Revascularization by catheter-based PCI or by CABG

Question 85

Medical therapies to have been shown to reduce mortality or morbidity in patients with SIHD

Answer 85

Aspirin
Statins
ACEi
Ezetimibe
PCSK9 inhibitors
High-dose eicosapentaenoic acid (EPA)

Question 86

In stable patients with LV dysfunction following MI, __________________ and _________________ reduce both mortality and the risk for repeat MI, and these agents are recommended in all such patients, with or without chronic angina, along with aspirin, statins, and in selected individuals aldosterone antagonists.

Answer 86

ACE inhibitors and Beta-blocking agents

Question 87

Among 9361 patients with hypertension and a high risk indicator other than diabetes, patients randomized to a systolic blood pressure target <120 mm Hg compared with <140 mm Hg had a significantly reduced rate of the primary endpoint of acute coronary syndrome, stroke, heart failure, or death as well as all-cause mortality

Answer 87

Systolic Blood Pressure Intervention Trial (SPRINT),

Question 88

Intensive versus moderate-dose statin therapy in patients with established IHD have provided evidence of greater reduction in major cardiovascular events with _______________ compared with moderate-dose statin therapy.

Answer 88

Intensive

Results from secondary prevention trials of patients with a history of SIHD, unstable angina, or previous MI have provided convincing evidence that effective lipid-lowering therapy significantly improves overall survival and reduces cardiovascular mortality in patients with CAD, regardless of baseline cholesterol levels. 8

Question 89

Two large clinical outcome trials of PCSK9 inhibitors in patients post-ACS or with chronic CAD

Answer 89

SIHD
In the FOURIER trial that included 27,564 patients with SIHD treated with maximally tolerated statin, compared with placebo, evolocumab reduced the primary outcome of MACE at 48 weeks from 11.3% to 9.8% (HR 0.85; 95% CI, 0.79 to 0.92), with no significant difference in all-cause mortality

ACS
The ODDYSSEY OUTCOMES trial of 18,924 patients with ACS in the prior 1 to 12 months, addition of alirocumab to statin therapy resulted in a significant 15% relative reduction in the composite MACE outcome and a similar 15% relative reduction in all-cause mortality

Question 90

If the patient is falls into a very high-risk category and LDL-C remains ≥70 mg/dL (1.8 mmol/L) on statin + ezetimibe (or the patient is intolerant to one or both of these therapies), a ______________ is recommended.

Answer 90

PCSK9 inhibitor

Question 91

Very high risk of atherothrombotic events is defined by

Answer 91

• Multiple prior atherosclerotic vascular events

or

• One prior event with multiple high-risk conditions such as ≥65 years, family history of premature CAD, prior CABG/PCI, diabetes mellitus, hypertension, chronic kidney disease, current smoking, LDL ≥100 mg/dL, or HF.

Question 92

PCSK9 inhibitors lower _______

Answer 92

Lp(a)

Question 93

The ESC takes an even more aggressive position on adding additional agents to statins, recommending ezetimibe and/or PCSK9 for high-risk individuals with LDL-C _______________

Answer 93

≥55 mg/dL (1.4 mmol/L)

Question 94

Severe hypertriglyceridemia (TG >500 mg/dL) merits treatment to prevent _____________, whereas treatment of moderate TG elevation (150 to 500 mg/dL) can be considered to _______________

Answer 94

Pancreatitis

Lower ASCVD risk

Question 95

Thus, although a near normal HbA 1C level (i.e., below 6.5% [53 mmol/L]) is optimal to minimize microvascular complications, for older patients and those with preexisting CV disease a less stringent HbA 1C target of _______ is recommended

Answer 95

≤8%

Question 96

The American Diabetes Association Standards of Medical Care in Diabetes 2020 recommend ___________ as the first-line therapy for all patients with type 2 diabetes mellitus.

Thereafter, among patients with established atherosclerotic cardiovascular disease, a ____________________ with demonstrated cardiovascular disease benefit is recommended as part of the patient’s glucose-lowering regimen independent of the A 1C concentration.

Answer 96

Metformin
SGLT2 inhibitor or GLP-1 receptor agonist

In contrast, the European Society of Cardiology guidelines recommend either a SGLT2 inhibitor or GLP-1 receptor agonist as first-line monotherapy for patients with atherosclerotic vascular disease or at high CV risk

Question 97

_______________, may be substituted for aspirin in patients with aspirin hypersensitivity or in those who cannot tolerate aspirin

Answer 97

Clopidogrel

Question 98

____________ more effective than weight loss drugs and has been demonstrated to prevent incident CVD events, but data are limited in patients with established IHD

Answer 98

Bariatric surgery

Question 99

Clopidogrel versus aspirin in patients with cerebral, peripheral, or coronary disease

Treatment with clopidogrel resulted in a modest 8.7% relative reduction in the risk for vascular death, ischemic stroke, or MI (P = 0.043) over a period of 2 years

Answer 99

CAPRIE trial (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events)

Question 100

Randomly assigned 15,603 patients with either clinically evident cardiovascular disease or multiple risk factors to receive clopidogrel (75 mg per day) plus low-dose aspirin (75 to 162 mg per day) or placebo plus low-dose aspirin and followed them for a median of 28 months. The primary efficacy end point was a composite of myocardial infarction, stroke, or death from cardiovascular causes.

In this trial, there was a suggestion of benefit with clopidogrel treatment in patients with symptomatic atherothrombosis and a suggestion of harm in patients with mul- tiple risk factors. Overall, clopidogrel plus aspirin was not significantly more effective than aspirin alone in reducing the rate of myocardial infarction, stroke, or death from cardiovascular causes

Answer 100

CHARISMA (Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization Management and Avoidance)

Question 101

The 2016 DAPT guideline from the ACC/AHA recommended that the standard duration of DAPT be at least ___________ for most patients receiving stents for SIHD

Answer 101

6 months

Patients who are at higher risk of atherothrombotic events with acceptable bleeding risk may be considered for durations of DAPT longer than 6 to 12 months.

Question 102

Oral anticoagulants (OAC) may be used in patients with SIHD either for secondary prevention of atherothrombosis or because of other indications for chronic anticoagulation, including

Answer 102

Atrial fibrillation
Venous thromboembolic disease, V Mechanical heart valves

Question 103

Among patients without an indication for OAC for another indication, the addition of a low-dose of the direct OAC rivaroxaban to low-dose aspirin significantly reduced the risk of major cardiovascular events seen in what trial

Answer 103

Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial

27395 patients with stable atherosclerotic vascular disease of whom 24824 patients had stable CAD were randomized to receive rivaroxaban 2.5 mg twice daily by mouth plus aspirin or rivaroxaban 5 mg twice daily, or aspirin alone

In the cohort with SIHD, compared with the aspirin-only group, those allocated to rivaroxaban plus aspirin experienced a 26% relative reduction in the risk of cardiovascular death, MI, or stroke (P < 0.001). Major bleeding was increased with rivaroxaban-plus-aspirin (3% versus 2%, P < 0.001). In contrast, rivaroxaban 5 mg twice daily without aspirin did not significantly reduce the rate of major cardiovascular events but did increase the risk of bleeding. 150 Rivaroxaban plus aspirin also reduced mortality when compared with aspirin alone

Question 104

When triple therapy is necessary, recommendations include

Answer 104

(1) limiting exposure to triple therapy to the shortest possible duration
(2) targeting the lower range of international normalized ratio (INR) for warfarin
(3) avoiding the more potent P2Y 12 antagonism of prasugrel and ticagrelor (i.e., clopidogrel is preferred in combination with OAC
(4) routinely administering proton pump inhibitors to prevent GI bleeding

Question 105

__________ reduce death and recurrent MI in patients who have experienced MI and are useful for managing angina.

Answer 105

Beta blockers

Question 106

not indicated for the treatment of angina, these drugs appear to have important benefits in reducing the risk

Answer 106

ACEi and ARBs

Reductions in LV hypertrophy, progression of a rosis, plaque rupture, and thrombosis, in addition to a potentially favorable influence on myocardial O 2 supply-and-demand relationships, cardiac hemodynamics, sympathetic activity, and coronary endothelial function

Question 107

In the __________, ramipril significantly decreased the risk for major vascular events by a relative 22% in 9297 patients with atherosclerotic vascular disease or diabetes mellitus

Answer 107

HOPE (Heart Outcomes Prevention Evaluation) study

Question 108

_________ trial similarly showed a 20% relative reduction in the risk for cardiovascular death, MI, or cardiac arrest in 13,655 patients with stable CAD in the absence of heart failure.

Answer 108

EUROPA (European Trial on Reduction of Cardiac Events with Perindopril in Stable CAD)

Question 109

True or False

ACE inhibitors are recommended for ALL patients with CAD and LV dysfunction and for those with hypertension, diabetes, or chronic kidney disease.

Answer 109

True

Question 110

True or False

ACE inhibitors may be considered for OPTIONAL USE in all other patients with SIHD, including those with a normal LV ejection fraction and well-controlled cardiovascular risk factors

Answer 110

True

Question 111

In patients with established vascular disease or high-risk diabetes, ________________ appear to provide similar secondary prevention benefits as ACE inhibitors, and thus are suitable alternatives for patients intolerant to ACE inhibitors.

Answer 111

Angiotensin receptor blockers (ARBs)

Question 112

_____________ cornerstone of therapy for angina; modestly effective antihypertensives and antiarrhythmics; also been shown to reduce mortality and reinfarction in patients after MI and to reduce mortality in patients with heart failure with reduced ejection fraction

Answer 112

Beta blockers

Question 113

Beta-blocking agents reduce m cardial O2 demand primarily during _________________, when surges of increased sympathetic activity occur.

Answer 113

Activity or excitement

Beta blockade reduces myocardial O 2 requirements, primarily by slowing the heart rate; the slower heart rate in turn increases the duration of diastole, with a corresponding increase in the time available for coronary perfusion. In addition, these drugs reduce exercise-induced increases in blood pressure and contractility.

Question 114

Beta-blocking agents may reduce blood flow to most organs by means of the combination of ______________

Answer 114

Unopposed alpha-adrenergic vasoconstriction and beta2 receptor blockade

Complications are relatively minor, but in patients with peripheral vascular disease, the reduction in blood flow to skeletal muscles with the use of nonselective beta-blocking agents may decrease maximal exercise capacity

Noncardioselective beta blockers may precipitate episodes of Raynaud phenomenon in patients with this condition. Reduced flow to the limbs may also occur in patients with peripheral vascular disease.

Question 115

Abrupt withdrawal of beta blockers after prolonged administration can result in increased ______________ in patients with chronic stable angina.

Answer 115

Total ischemic activity

Question 116

Chronic beta blocker therapy can be safely discontinued by slowly withdrawing the drug in a stepwise manner over the course of _____________

Answer 116

2 to 3 weeks

If abrupt withdrawal of beta blockers is required, patients should be instructed to reduce exertion and manage angina episodes with sublingual nitroglycerin and/or substitute a calcium antagonist.

Question 117

Ideal candidates for use of beta blocking agents for angina

Answer 117

• Prominent relationship of physical activity to attacks of angina
• Coexistent hypertension
• History of supraventricular or ventricular arrhythmias
• Previous MI
• LV systolic dysfunction
• Mild to moderate heart failure symptoms (NYHA functional classes II, III)
  *Prominent anxiety state

Question 118

Poor candidates for use of beta blocking agents for angina

Answer 118

• Asthma or reversible airway component in patients with chronic lung disease
• Severe LV dysfunction with severe heart failure symptoms (NYHA functional class IV)
• History of severe depression
• Raynaud phenomenon
• Symptomatic peripheral vascular disease Severe bradycardia or heart block
• Diabetes with frequent hypoglycemic episodes

Question 119

__________________ inhibit movement of calcium ions through slow channels in cardiac and smooth muscle membranes by noncompetitive blockade of voltage-sensitive L-type calcium channels.

Answer 119

Calcium antagonists

Question 120

The three major classes of calcium antagonists are the

Dihydropyridines (____________ is the prototype)
Phenylalkylamines (____________ is the prototype)
Modified benzothiazepines (________is the prototype).

Answer 120

Nifedipine
Verapamil
Diltiazem

Question 121

The two predominant effects of calcium antagonists result from _________________ and ________________

Answer 121

Blocking the entry of calcium ions
Slowing recovery of the channel.

Question 122

________________ in patients with angina pectoris is related to the reduction in myocardial O 2 demand and the increase in O 2supply that they induce

Answer 122

Calcium antagonists

Each relaxes vacular smooth muscle in the systemic arterial and coronary arterial beds. In addition, blockade of the entry of calcium into myocytes results in a negative inotropic effect, which is counteracted to some extent by peripheral vascular dilation and by activation of the sympathetic nervous system in response to drug-induced hypotension.

Question 123

_____________ a dihydropyridine, is a particularly effective dilator of vascular smooth muscle and is a more potent vasodilator than diltiazem or verapamil; beneficial effects in the treatment of angina result from its capacity to reduce myocardial O2 requirements because of its afterload-reducing effect and to increase myocardial O 2 delivery as a result of its dilating action on the coronary vascular bed

Answer 123

Nifedipine

Question 124

In rare cases in patients with __________________, nifedipine aggravates angina, presumably by lowering arterial pressure excessively with subsequent reflex tachycardia.

Answer 124

Extremely severe fixed coronary obstructions

Question 125

Nifedipine has been reported to worsen heart failure in patients with preexisting __________________ and is contraindicated in patients who are hypotensive or have ________________

Answer 125

Chronic heart failure
Severe aortic valve stenosis

Question 126

_______________ dilates systemic and coronary resistance vessels and large coronary conductance vessels. It slows the heart rate and reduces myocardial contractility.

Answer 126

Verapamil

Verapamil slows the heart rate and AV conduction. Therefore, it is contraindicated in patients with preexisting AV nodal disease, sick sinus syndrome, or systolic heart failure.

Question 127

A rare side effect of Verapamil is ________________, which appears after 1 to 9 months of therapy.

Answer 127

Gingival hyperplasia

Question 128

_____________ intermediate between those of nifedipine and verapamil.In clinically useful doses its vasodilator effects are less profound than those of nifedipine, and its cardiac depressant action on the sinoatrial and AV nodes and myocardium is less than that of verapamil.

Answer 128

Diltiazem

Question 129

_______________ less lipid soluble than n ine, has a slow, smooth onset and ultralong duration of action (plasma half-life of 36 hours). It causes marked coronary and peripheral dilation and is useful in the treatment of patients with angina accompanied by hypertension

Answer 129

Amlodipine

Question 130

Amlodipine should not be coadministered with _______________ as it increases drug levels of this statin and may increase risk for myopathy.

Answer 130

Simvastatin

Question 131

________________ half-life similar to that of nifedipine (2 to 4 hours) but appears to have greater vascular selectivity.

Answer 131

Nicardipine

Question 132

relax vascular smooth muscle; evident in systemic (including coronary) arteries and veins, but they appear to be predominant in the venous circulation. The venodilator effect reduces ventricular preload, which in turn reduces myocardial wall tension and O2 requirements.

Answer 132

Nitrates

By reducing the heart’s mechanical activity, volume, and O2 consumption, nitrates increase exercise capacity in patients with IHD

Thus, in patients with stable angina, nitrates improve exercise tolerance and time to ST-segment depression during treadmill exercise tests

Question 133

________________ remains the drug of choice for the treatment of acute angina episodes

Answer 133

Sublingual nitrate

Question 134

Piperazine derivative; shift myocardial substrate uptake from fatty acid to glucose and thus was considered to be a potential myocardial metabolic modulator; reduction in calcium overload in ischemic myocytes via inhibition of the late inward sodium current (INa)

Answer 134

Ranolazine

Simvastatin should not be co-administered with ranolazine in doses greater than 20 mg daily.

Question 135

Specific and selective inhibitor of the If ion channel, the principal determinant of the sinoatrial node pacemaker current; reduces the spontaneous firing rate of sinoatrial pacemaker cells and thus slows the heart rate through a mechanism that is not associated with negative inotropic effects.

Answer 135

Ivabardine

This agent does not currently have a role in patients with SIHD.

Question 136

Nicotinamide ester that dilates peripheral and coronary resistance vessels via action on ATP-sensitive potassium channels and possesses a nitrate moiety that promotes systemic venous and coronary vasodilation

Has been associated with ulcerations of the GI tract.

Answer 136

Nicorandil

Question 137

Inhibit fatty acid metabolism and reduce the frequency of angina without hemodynamic effects in patients with chronic stable angina.

Answer 137

Trimetazidine

Question 138

___________________ are preferred for patients with suspected Prinzmetal (variant) angina

Answer 138

Calcium antagonists or long-acting nitrates

Question 139

Considerations may be used to guide decisions regarding the indications for (as well as the approach to) revascularization:

Answer 139

(1) the presence and severity of symptoms
(2) physiologic significance of the coronary lesions and other anatomic considerations
(3) results of functional testing
(4) the presence of LV dysfunction
(5) other medical conditions that influence the risks associated with percutaneous or surgical revascularization and longevity after revascularization

Question 140

Presence and Severity of Symptoms

Coronary revascularization (catheter-based or surgical) should be considered if ischemic symptoms

Answer 140

Persist after intensification of medical therapy and impair functional status or quality of life

If unacceptable side effects or the patient’s therapeutic preferences limit antianginal therapy

Question 141

Significance of Coronary Lesions

_____________ stenosis of an epicardial coronary artery is considered to be anatomically significant ( ________ for left main coronary stenosis).

Answer 141

≥70%

≥50%

Question 142

Randomized trial of PCI versus medical therapy in patients without left main CAD or LV dysfunction revealed that, contrary to conventional wisdom, no anatomic subset of CAD stenosis severity (including patients with 70% to 90% narrowing and >90% narrowing of the LAD coronary artery) benefitted from PCI versus medical therapy with respect to long-term clinical events.

Answer 142

COURAGE trial

Question 143

Identify the trial

Severe ischemia, more extensive CAD, and proximal LAD stenosis did not identify patients with clinical benefit from revascularization

Answer 143

ISCHEMIA trial

Question 144

Patients were randomly assigned to convetional PCI guided by visual assessment of the angiogram, or FFR-guided PCI (with PCI performed only in lesions in which the FFR was 0.8 or less).

The results showed a lower 2-year rate of death or MI with the FFRguided strategy.

From 2 years to 5 years, the risks with the two strategies were similar.Therefore, at 5 years, outcomes in the two treatment groups were also similar; however, the FFR-guided group had a lower number of stented arteries and less resource use.

Answer 144

FAME trial

Recall FAME 2 and 3 trials

Question 145

The three major determinants of risk in patients with CAD are ______________________

Answer 145

LV function, the burden of ischemia, and extent of coronary disease

Question 146

The greatest survival benefits of ____________, as well as symptomatic and functional improvements, are evident in patients with impaired LV function (generally defined as an ejection fraction <0.40)

Answer 146

CABG

Question 147

Patients with diabetes are at substantially higher risk for complications after ______

Answer 147

PCI

Possible explanations for the higher rate of adverse outcomes include a greater burden of coronary atherosclerosis, an altered vascular biologic response to balloon and/or stent injury, rapid progression of disease in nonrevascularized segments, and higher platelet reactivity.

Question 148

The diabetic atherosclerotic milieu is characterized by a __________________, decreased fibrinolytic activity, increased proliferation, and inflammation.

Answer 148

Procoagulant state

Restenosis is more frequent in patients with diabetes, as is disease progression.

Question 149

______________ trial is the largest trial of coronary revascularization performed in patients with CKD

C tion and revascularization were performed in 85% and 50% of patients in the invasive therapy group versus 32% and 20% in the conservative arm. Multivessel CAD was present in 51% and nonobstructive CAD in 26% in the invasive arm. Among those undergoing revascularization, PCI was performed in 85% and CABG in 15%. The primary outcome of death or MI at 3 years did not differ between the treatment arms (36.4% versus 36.7%; adjusted HR, 1.01; 95% CI, 0.79 to 1.29). However, the stroke rate was higher (HR 3.76; 95% CI, 1.52 to 9.32) as was the composite of death or new dialysis initiation (HR 1.48; 95% CI, 1.04 to 2.11) with invasive therapy.

Answer 149

ISCHEMIA-CKD trial

Question 150

In patients with severe CKD, coronary revascularization may be best reserved for patients with _____________ and perhaps in those with LV dysfunction.

Answer 150

ACS or refractory symptoms

Question 151

In patients with severe CKD, coronary revascularization may be best reserved for patients with _____________ and perhaps in those with LV dysfunction.

Answer 151

ACS or refractory symptoms

Question 152

The technical goal of bypass surgery is to achieve, whenever possible, _________________ by grafting all coronary arteries of sufficient caliber that have physiologically significant proximal stenoses.

Answer 152

Complete revascularization

Question 153

____________ performed by using a standard median sternotomy, with generally small skin incisions, and stabilization devices to reduce motion of the target vessels while anastomoses are performed without CPB.

Answer 153

Off pump CABG

Findings from three major trials of off-pump versus on-pump CABG have produced similar findings with more incomplete revascularization and a higher need for repeat revascularization with the off-pump technique.

Question 154

Trial of OPCAB versus CABG in 2203 patients, in particular, there was also worse graft patency, and a higher incidence of death, MI, or repeat revascularization at 1 year among patients who underwent off-pump CABG (9.9% versus 7.4%, respectively, P = 0.04).

Answer 154

ROOBY (Randomized On/Off Bypass) trial

Question 155

4752 patients randomly assigned to OPCAB versus traditional CABG, there was no significant difference in the rates of death, stroke, MI, renal failure, or repeat revascularization

Answer 155

CORONARY (CABG Off or On Pump Revascularization Study) trial

Question 156

The current standard for bypass grafting advocates routine use of an _____ for grafting the LAD coronary artery and supplemental _____ to other vessels

Answer 156

IMA: LAD

SVG: other vessels

Question 157

Current professional society guidelines recommend use of bilateral IMA grafts as reasonable (class IIa) in ______________________

Answer 157

Younger patients in the absence of excessive risk of sternal complications

Question 158

The _____ conduit may be emerging as the preferred second arterial conduit after the IMA

Answer 158

Radial artery

Question 159

Patency of venous and arterial grafts

Answer 159

VENOUS:
Early occlusion: 8-12%
1 year: 15-30%
Annual occlusion rate after 1st yr: 2%- 4% (6-10 yr)

ARTERIAL:
Patent upto 5 years

Question 160

_____ grafts are more susceptible to failure due to competitive flow from native blood vessels than SVGs; thus, these grafts should not be used to revascularize borderline stenoses without clear evidence of flow limitation.

Answer 160

Arterial grafts

Question 161

In a patient-level analysis of six randomized trials, patients treated with __________________ compared with saphenous vein grafts had a significantly lower rate of the composite of death, MI, or repeat revascularization at five years (HR 0.67; 95% CI,,0.49 to 0.90), as well as a higher rate of great patency.

Answer 161

Radial-artery grafts

Question 162

In the parallel RAPCO-Saphenous Vein Graft (SVG) trial (n = 225), 10-year patency was ____ for the radial artery versus 71% for the SV (HR for graft failure 0.40; 95% CI, 0.15 to 1.00) and survival was 73% for the radial artery versus 65% for the SV (HR 0.76; 95% CI, 0.47 to 1.22) (

Answer 162

85%

Question 163

Early occlusion (before hospital discharge) occurs in ____________ of venous grafts, and by 1 year, 15% to 30% of vein grafts have become occluded.

Answer 163

8% to 12%

Question 164

After the first year the annual occlusion rate is _______ and rises to approximately 4% annually between years 6 and 10.

Answer 164

2%

Question 165

_____________ are more susceptible to failure due to competitive flow from native blood vessels than SVGs; thus, arterial grafts should not be used to revascularize borderline stenoses without clear evidence of flow limitation.

Answer 165

Arterial grafts

Question 166

Late patency of grafts is related to ______________________ as determined by the diameter of the coronary artery into which the graft is inserted, the size of the distal vascular bed, and the severity of coronary atherosclerosis distal to the site of insertion of the graft.

Answer 166

Coronary arterial runoff

The highest graft patency rates are found when the lumina of vessels distal to the graft insertion are larger than 1.5 mm in diameter, perfuse a large vascular bed, and are free of atheroma obstructing more than 25% of the vessel lumen. For saphenous veins, optimal patency rates are achieved with a lumen of 2.0 mm or larger.

Question 167

Late patency of grafts is related to:

Answer 167

(1) Coronary arterial runoff as determined by the diameter of the coronary artery into which the graft is inserted

(2) Size of the distal vascular bed

(3) Severity of coronary atherosclerosis distal to the site of insertion of the graft

Question 168

The highest graft patency rates are found when the lumina of vessels distal to the graft insertion are _____.

For saphenous veins, optimal patency rates are achieved with a lumen of _____ mm or larger.

Answer 168

ARTERIAL GRAFT
> 1.5 mm in diameter
Perfuse a large vascular bed
Free of atheroma obstructing > 25% of the vessel lumen

VENOUS GRAFT
> 2.0 mm

Question 169

The rate of disease progression appears to be highest in arterial segments already showing evidence of disease, and it is between three and six times higher in grafted native coronary arteries than in nongrafted native vessels.

Lesions in the native vessel that are _______________ and _______________ in diameter are at increased risk for progressing to total occlusion.

Answer 169

Long (>10 mm)

Greater than 70%

Question 170

In patients with 3V CAD undergoing CABG, the completeness of revascularization is a significant determinant of the relief of symptoms at 1 year and over a 5-year period.

After 5 years, approximately ___% of surgically treated patients can be predicted to be free of an ischemic event, sudden death,o ccurrence of MI,or recurrence of angina; approximately ___% remain free for approximately 10 years and around 15% for 15 or more years.

Answer 170

After 5 years: 75%

After 10 years: 50%

> 15 years: 15%

Question 171

The efficacy of aspirin therapy for maintaining early graft patency when started ____________________ preoperatively

Answer 171

Within 24 hours

Question 172

______________ statin therapy is indicated for post-CABG patients

Answer 172

High-intensity

Question 173

Patients with _________________ have an increasing magnitude of benefit from CABG over medical therapy.

Patients with left main and/or three-vessel CAD and, in particular those with _________________, should be considered candidates for CABG to prolong life, whereas similar data support the benefits of CABG in ___________ patients with multivessel CAD if revascularization is needed

Answer 173

More extensive and severe CAD

Multivessel CAD and LV systolic dysfunction

Diabetic

CABG is indicated, regardless of symptoms, for patients with CAD in whom survival is likely to be prolonged.

Question 174

True or False

All the major randomized trials have demonstrated greater relief of angina, better exercise performance, and a lower requirement for antianginal medications at 5 years in surgically treated than in medically treated patients.

Answer 174

All the major randomized trials have demonstrated greater relief of angina, better exercise performance, and a lower requirement for antianginal medications at 5 years in surgically treated than in medically treated patients.

Question 175

Subgroup analyses revealed several high-risk criteria that identify patients who are likely to sustain a more substantial survival benefit:

Answer 175

(1) left main CAD
(2) single- or double-vessel CAD with proximal LAD disease
(3) LV systolic dysfunction
(4) a composite evaluation that indicates high risk, including severity of symptoms, high-risk exercise tolerance test, history of previous MI, and the presence of ST depression on the resting ECG.

Question 176

The diagnostic criteria for MI in the setting of CABG have been revised and are now based on elevation of cardiac troponin or a myocardial creatine kinase-MB (CK-MB) isoenzyme level more than ________________ in association with new pathologic Q waves, objective evidence of new myocardial dysfunction or graft occlusion based on noninvasive imaging or angiography

Answer 176

10 times the upper limit of normal

Question 177

Postulated mechanisms for neurologic abnormalities after cardiac surgery include _____.

Answer 177

• Emboli from atherosclerosis of the aorta or other large arteries (potentially precipitated by aortic cross-clamping)
• Emboli from the CPB machine circuit and its tubing
• Intraoperative hypotension, particularly in patients with preexisting hypertension.

Question 178

Cerebrovascular Injury post CABG that is associated with major neurologic deficits, stupor, and coma

Answer 178

Type I

Question 179

Injury that is characterized by deterioration in intellectual function and memory. The incidence of neurologic abnormalities is variably estimated, depending on how the deficits are defined

Answer 179

Type II

Postulated mechanisms include emboli from atherosclerosis of the aorta or other large arteries (potentially precipitated by aortic cross-clamping), emboli from the CPB machine circuit and its tubing, and intraoperative hypotension, particularly in patients with preexisting hypertension.

Older age, in addition to other comorbid conditions (particularly diabetes), and intraoperative manipulation of the aorta are powerful predictors of the neurologic sequelae of CPB, including stroke, delirium, and neurocognitive dysfunction. In most but not all studies, atherosclerosis of the proximal aorta has also been a strong predictor of stroke, as has the use of an intra-aortic balloon pump.

Question 180

This arrhythmia is of the most frequent complications of CABG.

It occurs in up to 40% of patients, primarily within 2 to 3 days; associated with a twofold to threefold increase in postoperative stroke

Answer 180

Atrial Fibrillation

Older age, hypertension, previous atrial fibrillation, and heart failure are associated with a higher risk for the development of atrial fibrillation after cardiac surgery.

Question 181

Prophylactic use of _____________ reduces the frequency of postoperative atrial fibrillation; such drugs should be administered routinely before and after CABG to patients without contraindications

Answer 181

Beta-blocking agents

Amiodarone is also effective in prophylaxis against postoperative atrial fibrillatio

Question 182

Patients with preoperative renal dysfunction and a serum creatinine level that rises to _________ appear to be at increased risk for the need for hemodialysis and may be candidates for alternative approaches to revascularization.

Answer 182

> 2.5 mg/dL

Question 183

In the randomized _______ trial of predominantly on-pump CABG versus medical therapy in 1212 patients with CAD amenable to revascularization and an ejection fraction of 35% or less in the absence of left main CAD or severe (class III) angina, the rate of death from any cause at an average of 56 months after randomization was 36% in patients assigned to CABG and 41% in those assigned to medical therapy (HR, 0.86; 95% CI, 0.72 to 1.04; P = 0.12).

However, the combined endpoint of death or hospitalization for cardiovascular causes was significantly lower (58%) in the CABG group than in the medical therapy group

Answer 183

STITCH

Moreover, in the STITCH Extension Study (STICHES), in which follow-up was extended to 10 years, a significant benefit with respect to mortality emerged favoring the CABG

arm (58.9% versus 66.1%; HR 0.84; 95% CI, 0.73 to 0.97; P = 0.02)

Question 184

Describes prolonged but temporary p ischemic LV dysfunction without myocardial necrosis

Answer 184

Myocardial stunning

Question 185

Persistent LV dysfunction due either to chronically reduced myocardial perfusion or to repetitive stunning

Answer 185

Myocardial hibernation

Question 186

Late redistribution or redistribution with second tracer injection suggest viability

Answer 186

Regional blood flow

Question 187

Mismatch between flow (low) snd metabolism (active) suggests viability

Answer 187

Myocardial metabolism

Question 188

An estimated 5% to 10% of isolated CABG surgeries are cardiac reoperations, with the major indication for reoperation being late disease of _______________________

Answer 188

Saphenous vein grafts

An added factor underlying recurrent s toms is progression of disease in native vessels between the first and second operations. S

Question 189

In the SYNTAX trial conducted between 2005 and 2007, 1800 patients with three-vessel or left main CAD were randomly assigned to undergo CABG or PCI.

The primary outcome measure was a noninferiority comparison of the two groups for major adverse cardiac or cerebrovascular events (i.e., death from any cause, stroke, MI, or repeat revascularization) during the 12-month period after randomization.

At 12 months, the rate of the primary outcome was significantly higher in the PCI group in large part because of an increased rate of repeat revascularization with a s ilar rate of death and MI between the two groups. However, stroke was significantly more likely to occur with CABG

At 5 years, rates of MI and repeat revascularization were significantly lower in the CABG group whereas all-cause mortality did not differ significantly between groups.

Answer 189

SYNTAX trial

While 10-year mortality did not differ between PCI and CABG for patients with left main CAD, a survival advantage was suggested with CABG for patients with multivessel CAD

Question 190

_________ should remain the standard of care for patients with complex coronary lesions (high or intermediate SYNTAX scores), whereas for patients with less complex CAD (low SYNTAX scores) or left main CAD (with low or intermediate SYNTAX scores), PCI remains an acceptable alternative.

Answer 190

CABG

Question 191

Patients with multivessel disease were randomly assigned to an initial treatment strategy of CABG (n = 914) or PTCA (n = 915) and were followed for an average of 5.4 years

Among diabetic patients who were being treated with insulin or oral hypoglycemic agents at base line, a subgroup not specified by the protocol, five-year survival was 80.6 percent for the CABG group as compared with 65.5 percent for the PTCA group (P = 0.003).

Answer 191

BARI trial

As compared with CABG, an initial strategy of PTCA did not significantly compromise five-year survival in patients with multivessel disease, although subsequent revascularization was required more often with this strategy. For treated diabetics, five-year survival was significantly better after CABG than after PTCA.

Question 192

1900 patients with diabetes and multivessel CAD who were randomly assigned to either DES treatment or CABG showed a convincing clinical benefit from CABG versus PCI. In particular, the trial findings showed significant reductions in all-cause mortality and the composite of death or MI in CABG-treated diabetic patients.

Answer 192

FREEDOM trial

A potential a tage of CABG over PCI is that bypass grafts to the mid-coronary vessel both treat the culprit lesion (regardless of anatomic complexity) and may afford prophylaxis against new proximal disease progression

Question 193

____________ is regarded as the preferred revascularization approach in patients with multivessel CAD and diabetes when reduction of clinical events is the principal goal of treatment

Answer 193

CABG

Question 194

Randomly assigned 2368 patients with both type 2 diabetes and heart disease to undergo either prompt revascularization with intensive medical therapy or intensive medical therapy alone and to undergo either insulin-sensitization or insulin-provision therapy. Primary end points were the rate of death and a composite of death, myocardial infarction, or stroke (major cardiovascular events).

At 5 years, rates of survival did not differ significantly between the revascularization group (88.3%) and the medical-therapy group (87.8%, P=0.97) or between the insulin-sensitization group (88.2%) and the insulin-provision group (87.9%, P=0.89).

In the CABG stratum, the rate of major cardiovascular events was significantly lower in the revascularization group (22.4%) than in the medical-therapy group

Answer 194

BARI 2D trial (A Randomized Trial of Therapies for Type 2 Diabetes and Coronary Artery Disease)

Overall, there was no significant difference in the rates of death and major cardiovascular events between patients undergoing prompt revascularization and those undergoing medical therapy or between strategies of insulin sensitization and insulin provision.

Question 195

In patients with single-vessel disease in whom revascularization is deemed necessary and the lesion is anatomically suitable, ____ is almost always preferred over CABG.

Answer 195

In patients with single-vessel disease in whom revascularization is deemed necessary and the lesion is anatomically suitable, PCI is almost always preferred over CABG.

Question 196

PCI and CABG offer _________ in patients without highly complex CAD (e.g., patients with SYNTAX score <22)

Answer 196

Similar survival

Question 197

______ for unprotected left main disease is an alternative to CABG (class I) in patients for whom the coronary anatomy is consistent with a low risk of PCI procedural complications and a high likelihood of good long-term outcome (e.g., a low SYNTAX score of ≤22, ostial or trunk left main CAD)

Answer 197

PCI

Question 198

Syndrome of angina or angina-like chest discomfort with no obstructive coronary disease

Answer 198

INOCA (Ischemia with No Obstructive Coronary Artery Disease)

Question 199

Potential explanations for angina in the absence of flow-limiting CAD that have historically been offered include

Answer 199

Misinterpretation of the coronary angiogram
Potential misdiagnosis of flush (or stump) coronary occlusions at sites of major arterial bifurcations
Coronary vasospasm
Increased subendocardial pressure leading to coronary artery compression
Hyperdynamic ventricular contraction with an elevated ejection fraction resulting in a supply-demand imbalance.

Question 200

Patients with chest pain and normal findings on coronary arteriography may represent as many as ________ of those undergoing coronary arteriography

Answer 200

10% to 30%

Question 201

The Coronary Vasomotion Disorders International Study Group definition of microvascular angina include:

Answer 201

(1) symptoms suggestive of myocardial ischemia
(2) objective evidence of myocardial ischemia
(3) absence of obstructive CAD (no stenosis with >50% diameter reduction and/or FFR >0.80)
(4) documentation of reduced CFR and/or inducible microvascular spasm

Question 202

In the CorMicA trial, _____ was the most common abnormality detected when integrated invasive functional assessments were performed among patients with INOCA.

Answer 202

Microvascular dysfunction

Question 203

__________________ was characterized by high vascular tone at rest, potentially due to capillary rarefaction, fibrosis, and LV hypertrophy, whereas _____________ the more common endotype, was characterized by normal vascular tone at rest.

Answer 203

Structural microvascular dysfunction (MVD)

Functional MVD

Question 204

Approximately _________ of patients with chest pain and normal coronary angiographic findings have positive exercise test results

Answer 204

20% to 30%

Question 205

Comprehensive invasive assessment of patients with evidence for myocardial ischemia on noninvasive testing can provide diagnostic information in more than 75% of patients without obstructive CAD. Such a comprehensive invasive assessment may include ____.

Answer 205

(1) FFR or IFR to evaluate diffuse epicardial obstructive disease that was not apparent from the angiogram
(2) Endothelial function, and spasm testing with acetylcholine;
(3) CFR and/or IMR testing with adenosine;
(4) IVUS to assess for diffuse structural abnormalities and myocardial bridging

Question 206

Used to diagnose microvascular dysfunction in the absence of epicardial CAD

Answer 206

Coronary Flow Reserve
Index of Microvascular Resistance

Question 207

Used to diagnose endothelial dysfunction

Answer 207

Endothelial function testing

Question 208

Used to identify hemodynamic impact of diffuse coronary stenoses

Answer 208

FFR and iFR

Question 209

Used for the clinical syndrome in which one or more of the pathophysiologic features just discussed result in LV dysfunction and heart failure symptoms.

Answer 209

Ischemic CMP

Question 210

The cause of chronic mitral regurgitation in patients with CAD is multifactorial, and the geometric determinants are complex; these include:

Answer 210

(1) Papillary muscle dysfunction from ischemia and fibrosis in conjunction with a wall motion abnormality

(2) Changes in LV shape in the region of the papillary muscle

(3) Dilation of the mitral annulus

Question 211

Although atherosclerosis is by far the most common cause of CAD, other conditions may also be responsible. These include congenital abnormalities in the origin or distribution of the coronary arteries, the most important of which are _____.

Answer 211

(1) Anomalous origin of a coronary artery (usually the left) from the pulmonary artery

(2) Origin of both coronary arteries from either the right or the left sinus of Valsalva

(3) Coronary arteriovenous fistula

Question 212

_________ defined as a segment of the ventricular wall that exhibits paradoxical (dyskinetic) systolic expansion.

Answer 212

LV aneurysm

Question 213

Localized myocardial rupture in which the hemorrhage is limited by pericardial adhesions, and they have a mouth that is considerably smaller than the maximal diameter

Answer 213

False aneurysm

Question 214

More than 80% of LV aneurysms are located ____________ near the apex.

They are often associated with total occlusion of the __________ and poor collateral blood supply.

Answer 214

Anterolaterally
LAD coronary artery

Question 215

Approximately 5% to 10% of aneurysms are located _________.

Threefourths of patients with LV aneurysms have multivessel CAD.

Answer 215

Posteriorly

Question 216

Approximately 50% of patients with moderate or large aneurysms have symptoms of ___________ , with or without associated angina, approximately 33% have severe angina alone, and approximately 15% have symptomatic ventricular arrhythmias that may be intractable and life-threatening

Answer 216

Heart failure

Question 217

Clues to the presence of an aneurysm include

Answer 217

Persistent ST-segment elevations on the resting ECG (in the absence of chest pain)
Characteristic bulge of the silhouette of the left ventricle on a chest roentgenogram

Question 218

________________ do not rupture, and operative excision may be carried out to improve the clinical manifestations, most often heart failure but sometimes also angina, embolization, and life-threatening tachyarrhythmias

Answer 218

True LV aneurysms

Question 219

Clues in the detection of LV aneurysm

Answer 219

ECG: Persistent ST-segment elevations on the resting ECG (in the absence of chest pain)

CXR: bulge and marked calcification of the silhouette of the LV

2DED:
Color flow: flow “in and out” of the aneurysm, as well as abnormal flow within the aneurysm
Doppler: “to-and-fro” pattern with characteristic respiratory variation in the peak systolic velocity

Question 220

____ ventricular restoration has the potential to reverse the adverse remodeling, realign contractile fibers, and decrease LV wall stress and has thus been of interest as a possible intervention to mitigate the progression of ischemic cardiomyopathy.

Answer 220

Anterior

Question 221

Several inherited connective tissue disorders are associated with myocardial ischemia, including:

Answer 221

Marfan syndrome (causing aortic and coronary artery dissection)

Hurler syndrome (causing coronary obstruction),

Ehlers-Danlos syndrome (causing coronary artery dissection)

Pseudoxanthoma elasticum (causing accelerated CAD).

Question 222

Emerging data suggests that _____ may be an important cause of this syndrome (SCAD) and screening of the renal arteries with angiography or CTA is recommended. Other contributing factors include _____.

Answer 222

Fibromuscular dysplasia

Estrogen use and hypertension

Question 223

In the acute phase of SCAD, a _____ strategy is recommended as PCI failure rates are high, iatrogenic dissection is common, and complete healing may lead to a favorable outcome without intervention.

In one study, angiographic healing was apparent in 95% of patients undergoing repeat angiography more than 30 days post-spontaneous dissection

Answer 223

Conservative strategy

Question 224

Connective tissue diseases or autoimmune forms of vasculitis, including _____, or vasculopathy, such as _____, can involve the coronary arteries

Answer 224

Polyarteritis nodosa
Giant cell (temporal) arteritis

Scleroderma

Question 225

_____, a mucocutaneous lymph node syndrome, may cause coronary artery aneurysms and IHD in children

Answer 225

Kawasaki disease

Question 226

_____ is seen at autopsy in approximately 20% of patients with rheumatoid arthritis but is rarely associated with clinical manifestations

Answer 226

Coronary arteritis

Question 227

In patients with SLE, CAD has been attributed to _____.

Answer 227

Vasculitis
Immune complex–mediated endothelial damage
Coronary thrombosis from antiphospholipid Ab Accelerated atherosclerosis

Question 228

_____ syndrome, characterized by arterial and venous thrombosis and the presence of antiphospholipid antibodies, may be associated with MI, angina, and diffuse LV dysfunction.

Answer 228

Anti-phospholipid syndrome

Question 229

Luetic aortitis may also produce myocardial ischemia by causing _____.

Answer 229

Coronary ostial obstruction

Question 230

Takayasu arteritis is associated with angina, MI, and cardiac failure in patients younger than 40 years.

Coronary blood flow may be decreased by involvement of the _____, but disease in distal coronary segments is rare. The average age at the onset of symptoms is 24 years, and the event-free survival rate 10 years after diagnosis is approximately 60%. CT angiography has been shown to be useful in detecting involvement of the coronary arteries in Takayasu arteritis.

Answer 230

Ostia or proximal segments of the coronary arteries

Question 231

The occurrence of CAD and morbid cardiac events in young individuals after mediastinal irradiation is highly suggestive of a cause-and-effect relationship. Pathologic changes include _____.

Answer 231

Adventitial scarring
Medial hypertrophy with severe intimal atherosclerotic disease

Question 232

In patients without risk factors who receive an intermediate total dose of _____ Gy, the risk for cardiac death and MI is low.

Answer 232

30-40 Gy

Question 233

Question 234

Question 235

Question 236

Question 237

Question 238