B P5 C40 Stable Ischemic Heart Disease Flashcards
1
Q
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:
A
Vasospasm
Inflammation
Platelets and coagulation
Endothelial dysfunction
Microvascular dysfunction
Critical artery stenosis
2
Q
____________ angina is caused by redistribution of coronary blood flow to the splanchnic circulation, may be a marker of severe IHD.
A
Postprandial angina
3
Q
____________ 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.
A
Warm-up angina
This attenuation of myocardial ischemia observed with repeated exertion has been postulated to be caused by ischemic preconditioning
4
Q
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.
A
NTG
5
Q
_____ 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.
A
BIliary pain
6
Q
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
A
Tietze syndrome
7
Q
This condition may occur as a constant ache, worsened with neck movement, and sometimes results in a sensory deficit.
A
Cervical radiculopathy
8
Q
_____ 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.
A
Pleuritic pain
9
Q
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).
A
Pericarditis
10
Q
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?
A
Increases in:
Heart rate
Left ventricular (LV) wall stress
Contractility
O2 supply is determined by:
Coronary blood flow
Coronary arterial O2
11
Q
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
A
Demand angina
12
Q
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.
A
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.
13
Q
Lipoprotein(a) (Lp[a]) is a highly heritable lipid-related risk factor that should be considered for measurement in selected individuals with _____.
A
Premature CAD
Strong family history of CAD
Reasonable to measure at least once among any individual with CAD
14
Q
Blood levels of _________________ are typically used to differentiate patients with acute MI from those with SIHD.
A
Cardiac troponins T and I
15
Q
Higher concentrations of these peptides are strongly associated with risk for cardiovascular events in those at risk for and with established CAD.
A
BNP and N-terminal pro-BNP
16
Q
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
A
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.
17
Q
The most common abnormalities on the ECG in patients with SIHD are _____________
A
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
18
Q
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
A
Normal resting
Normal resting LV function
19
Q
Various conduction disturbances, most frequently ______, may occur in patients with SIHD; are often associated with impairment of LV function, reflect multivessel CAD, poor prognosis
A
LBBB
LAFB
20
Q
____________ on the ECG is associated with a worse prognosis in patients with chronic stable angina
A
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.
21
Q
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.
A
ST-segment depression
22
Q
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
A
Regional wall motion abnormalities
23
Q
The chest roentgenogram is generally _____________ in patients with SIHD
A
Normal limits
24
Q
_________ testing can provide useful information to establish the diagnosis and estimate the prognosis in patients with suspected stable angina.
A
Noninvasive stress testing
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.
Intermediate
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.
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
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.
Asymptomatic
Exercise testing is not required before initiating m ate exercise, even for high-risk individuals.
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.
Maximal exercise capacity
29
Patients with high-risk stress test results should undergo either a ___________________ or ______________
Coronary computed tomography or angiography (CTA) or invasive angiogram.
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.
High workload (e.g., >9 to 10 minutes on a Bruce protocol)
31
Long-acting beta-blocking agents, which should be omitted for ________________ before testing.
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.
32
True or False
It is generally accepted that electrocardiographic stress testing is not as reliable in women
True
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.
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.
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.
Stress MPI
35
Noninvasive test with highest sensitivity for the detection of CAD
CCTA
Sensitivity: 0.97
Specificity: 0.78
36
Noninvasive test with highest specificity for the detection of CAD
PET and CMRI
PET
Specificity: 0.89, Sensitivity: 0.83
CMRI:
Specificity: 0.89, Sensitivity: 0.88
37
A patient should be able to walk up ________________ flights of stairs without stopping to complete a standard exercise stress test.
Two flights of stairs
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.
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.
39
Highest sensitivity and lowest sensitivities among non-invasive testing
Highest - CCTA
Lowest - Exercise ECG
40
Highest and lowest specificity among non-invasive testing
Highest - PET/CTMRI
Lowest - Exercise ECG
41
MPI can stratify patients into:
Low (<1% risk for future CV with a normal MPI study)
Intermediate (1% to 5%)
High (>5%)
42
Risk stratification based on noninvasive testing:
HIGH RISK (>3% Annual Risk For Death or Myocardial Infarction)
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
43
Risk stratification based on noninvasive testing:
INTERMEDIATE RISK (1-3% Annual Risk For Death or Myocardial Infarction)
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
44
Risk stratification based on noninvasive testing:
LOW RISK (<1% Annual Risk For Death or Myocardial Infarction)
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
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
Intermediate
46
CAC screening does not have a role in the diagnosis of obstructive CAD among ______________ patients.
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
47
___________ is a noninvasive method for angiography of the coronary arterial tree and quantification of ventricular function.
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)
48
The accuracy of coronary CTA for estimating the severity of luminal stenosis is limited in patients with __________________
* 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.
49
An important advantage of CTA over stress testing is the ability to _______________________
Detect nonobstructive plaque
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.
PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain)
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.
SCOT HEART (Scottish Computed Tomography of the HEART)
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
ISCHEMIA
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
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.
54
Resting abnormalities considered as high risk based on non-invasive testing
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
55
Stress abnormalities considered as high risk based on non-invasive testing
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)
56
Precise assessment of the anatomic severity of CAD still requires ______________
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%.
57
High-grade lesions _____________ are particularly high risk.
High grade lesions of the left main coronary artery or its equivalent, as defined by severe proximal LAD and proximal left circumflex CAD
58
Mortality without revascularization in patients with severe left main CAD was approximately _________________
15 - 20%
59
Coronary angiography is not a reliable indicator of the _____ significance of the stenosis
Functional significance
60
This approach (Angiography) may lead to significant _________________ of the severity and extent of atherosclerosis.
Underestimation
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
Which coronary lesions can be considered to be at high risk for future events
62
Most acute MIs emanate from antecedent coronary stenoses that obstruct ______________ of the luminal diameter
less than 50%
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
Vulnerability
64
IVUS continues to have a role in assessing _____________________.
Left main coronary stenoses
Bifurcation lesions
Optimizing stent deployment
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
OCT
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.
Occult plaque rupture and spontaneous coronary dissection
67
______________ the most important invasive tool to complement coronary angiography, providing a functional assessment of the hemodynamic impact of a coronary stenosis.
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.
68
_________ ratio of pressure distal to a stenosis/pressure before the stenosis under conditions of maximal hyperemia, which is usually achieved with adenosine.
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.”
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.”
Ischemia: < 0.75
Grey zone: 0.75-0.80
Rarely assoc. with ischemia: > 0.80
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
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.
71
An iFR of >____ is commonly used as an analogous threshold to FFR >0.8 as a threshold above which PCI can be deferred.
iFR >0.89 = FFR >0.80
72
_______ can be performed to exclude hemodynamically significant diffuse CAD that is underappreciated by angiography.
FFR and iFR
73
_______ can be used to interrogate the coronary microcirculation
CFR and IMR
74
___________ can be given at low doses to assess coronary endothelial function and at higher dosages to evaluate for coronary spasm.
Acetylcholine
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.
Coronary atherosclerosis (50%)
76
Despite the absence of overt obstruction, ________ of patients with multivessel fusiform coronary artery ectasia or aneurysms have demonstrated evidence of cardiac ischemia.
70%
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.
Severe stenosis
LAD
These discrete atherosclerotic coronary artery aneurysms do not appear to rupture, and they do not warrant resection.
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 ____________
Flow reserve
This finding helps explain the ability of collateral vessels to protect against resting ischemia but not against exerciseinduced angina.
79
Up to ______ of patients with a history of stable angina experience angina one or more times per week.
30%
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
TIMI Risk Score for Secondary Prevention (TRS 2°P)
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.
DAPT risk score
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.
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
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.
PRECISE-DAPT
84
Comprehensive management of SIHD has five aspects:
(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
85
Medical therapies to have been shown to reduce mortality or morbidity in patients with SIHD
Aspirin
Statins
ACEi
Ezetimibe
PCSK9 inhibitors
High-dose eicosapentaenoic acid (EPA)
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.
ACE inhibitors and Beta-blocking agents
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
Systolic Blood Pressure Intervention Trial (SPRINT),
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.
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
89
Two large clinical outcome trials of PCSK9 inhibitors in patients post-ACS or with chronic CAD
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
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.
PCSK9 inhibitor
91
Very high risk of atherothrombotic events is defined by
* 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.
92
PCSK9 inhibitors lower _______
Lp(a)
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 _______________
≥55 mg/dL (1.4 mmol/L)
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 _______________
Pancreatitis
Lower ASCVD risk
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
≤8%
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.
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
97
_______________, may be substituted for aspirin in patients with aspirin hypersensitivity or in those who cannot tolerate aspirin
Clopidogrel
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
Bariatric surgery
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
CAPRIE trial (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events)
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
CHARISMA (Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization Management and Avoidance)
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
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.
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
Atrial fibrillation
Venous thromboembolic disease, V Mechanical heart valves
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
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
104
When triple therapy is necessary, recommendations include
(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
105
__________ reduce death and recurrent MI in patients who have experienced MI and are useful for managing angina.
Beta blockers
106
not indicated for the treatment of angina, these drugs appear to have important benefits in reducing the risk
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
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
HOPE (Heart Outcomes Prevention Evaluation) study
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.
EUROPA (European Trial on Reduction of Cardiac Events with Perindopril in Stable CAD)
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.
True
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
True
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.
Angiotensin receptor blockers (ARBs)
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
Beta blockers
113
Beta-blocking agents reduce m cardial O2 demand primarily during _________________, when surges of increased sympathetic activity occur.
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.
114
Beta-blocking agents may reduce blood flow to most organs by means of the combination of ______________
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.
115
Abrupt withdrawal of beta blockers after prolonged administration can result in increased ______________ in patients with chronic stable angina.
Total ischemic activity
116
Chronic beta blocker therapy can be safely discontinued by slowly withdrawing the drug in a stepwise manner over the course of _____________
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.
117
Ideal candidates for use of beta blocking agents for angina
* 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
118
Poor candidates for use of beta blocking agents for angina
* 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
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.
Calcium antagonists
120
The three major classes of calcium antagonists are the
Dihydropyridines (____________ is the prototype)
Phenylalkylamines (____________ is the prototype)
Modified benzothiazepines (________is the prototype).
Nifedipine
Verapamil
Diltiazem
121
The two predominant effects of calcium antagonists result from _________________ and ________________
Blocking the entry of calcium ions
Slowing recovery of the channel.
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
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.
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
Nifedipine
124
In rare cases in patients with __________________, nifedipine aggravates angina, presumably by lowering arterial pressure excessively with subsequent reflex tachycardia.
Extremely severe fixed coronary obstructions
125
Nifedipine has been reported to worsen heart failure in patients with preexisting __________________ and is contraindicated in patients who are hypotensive or have ________________
Chronic heart failure
Severe aortic valve stenosis
126
_______________ dilates systemic and coronary resistance vessels and large coronary conductance vessels. It slows the heart rate and reduces myocardial contractility.
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.
127
A rare side effect of Verapamil is ________________, which appears after 1 to 9 months of therapy.
Gingival hyperplasia
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.
Diltiazem
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
Amlodipine
130
Amlodipine should not be coadministered with _______________ as it increases drug levels of this statin and may increase risk for myopathy.
Simvastatin
131
________________ half-life similar to that of nifedipine (2 to 4 hours) but appears to have greater vascular selectivity.
Nicardipine
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.
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
133
________________ remains the drug of choice for the treatment of acute angina episodes
Sublingual nitrate
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)
Ranolazine
Simvastatin should not be co-administered with ranolazine in doses greater than 20 mg daily.
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.
Ivabardine
This agent does not currently have a role in patients with SIHD.
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.
Nicorandil
137
Inhibit fatty acid metabolism and reduce the frequency of angina without hemodynamic effects in patients with chronic stable angina.
Trimetazidine
138
___________________ are preferred for patients with suspected Prinzmetal (variant) angina
Calcium antagonists or long-acting nitrates
139
Considerations may be used to guide decisions regarding the indications for (as well as the approach to) revascularization:
(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
140
Presence and Severity of Symptoms
Coronary revascularization (catheter-based or surgical) should be considered if ischemic symptoms
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
141
Significance of Coronary Lesions
_____________ stenosis of an epicardial coronary artery is considered to be anatomically significant ( ________ for left main coronary stenosis).
≥70%
≥50%
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.
COURAGE trial
143
Identify the trial
Severe ischemia, more extensive CAD, and proximal LAD stenosis did not identify patients with clinical benefit from revascularization
ISCHEMIA trial
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.
FAME trial
Recall FAME 2 and 3 trials
145
The three major determinants of risk in patients with CAD are ______________________
LV function, the burden of ischemia, and extent of coronary disease
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)
CABG
147
Patients with diabetes are at substantially higher risk for complications after ______
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.
148
The diabetic atherosclerotic milieu is characterized by a __________________, decreased fibrinolytic activity, increased proliferation, and inflammation.
Procoagulant state
Restenosis is more frequent in patients with diabetes, as is disease progression.
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.
ISCHEMIA-CKD trial
150
In patients with severe CKD, coronary revascularization may be best reserved for patients with _____________ and perhaps in those with LV dysfunction.
ACS or refractory symptoms
151
In patients with severe CKD, coronary revascularization may be best reserved for patients with _____________ and perhaps in those with LV dysfunction.
ACS or refractory symptoms
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.
Complete revascularization
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.
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.
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).
ROOBY (Randomized On/Off Bypass) trial
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
CORONARY (CABG Off or On Pump Revascularization Study) trial
156
The current standard for bypass grafting advocates routine use of an _____ for grafting the LAD coronary artery and supplemental _____ to other vessels
IMA: LAD
SVG: other vessels
157
Current professional society guidelines recommend use of bilateral IMA grafts as reasonable (class IIa) in ______________________
Younger patients in the absence of excessive risk of sternal complications
158
The _____ conduit may be emerging as the preferred second arterial conduit after the IMA
Radial artery
159
Patency of venous and arterial grafts
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
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.
Arterial grafts
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.
Radial-artery grafts
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) (
85%
163
Early occlusion (before hospital discharge) occurs in ____________ of venous grafts, and by 1 year, 15% to 30% of vein grafts have become occluded.
8% to 12%
164
After the first year the annual occlusion rate is _______ and rises to approximately 4% annually between years 6 and 10.
2%
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.
Arterial grafts
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.
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.
167
Late patency of grafts is related to:
(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
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.
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
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.
Long (>10 mm)
Greater than 70%
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.
After 5 years: 75%
After 10 years: 50%
>15 years: 15%
171
The efficacy of aspirin therapy for maintaining early graft patency when started ____________________ preoperatively
Within 24 hours
172
______________ statin therapy is indicated for post-CABG patients
High-intensity
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
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.
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.
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.
175
Subgroup analyses revealed several high-risk criteria that identify patients who are likely to sustain a more substantial survival benefit:
(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.
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
10 times the upper limit of normal
177
Postulated mechanisms for neurologic abnormalities after cardiac surgery 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
* Intraoperative hypotension, particularly in patients with preexisting hypertension.
178
Cerebrovascular Injury post CABG that is associated with major neurologic deficits, stupor, and coma
Type I
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
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.
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
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.
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
Beta-blocking agents
Amiodarone is also effective in prophylaxis against postoperative atrial fibrillatio
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.
>2.5 mg/dL
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
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)
184
Describes prolonged but temporary p ischemic LV dysfunction without myocardial necrosis
Myocardial stunning
185
Persistent LV dysfunction due either to chronically reduced myocardial perfusion or to repetitive stunning
Myocardial hibernation
186
Late redistribution or redistribution with second tracer injection suggest viability
Regional blood flow
187
Mismatch between flow (low) snd metabolism (active) suggests viability
Myocardial metabolism
188
An estimated 5% to 10% of isolated CABG surgeries are cardiac reoperations, with the major indication for reoperation being late disease of _______________________
Saphenous vein grafts
An added factor underlying recurrent s toms is progression of disease in native vessels between the first and second operations. S
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.
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
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.
CABG
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).
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.
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.
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
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
CABG
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
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.
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.
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.
196
PCI and CABG offer _________ in patients without highly complex CAD (e.g., patients with SYNTAX score <22)
Similar survival
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)
PCI
198
Syndrome of angina or angina-like chest discomfort with no obstructive coronary disease
INOCA (Ischemia with No Obstructive Coronary Artery Disease)
199
Potential explanations for angina in the absence of flow-limiting CAD that have historically been offered include
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.
200
Patients with chest pain and normal findings on coronary arteriography may represent as many as ________ of those undergoing coronary arteriography
10% to 30%
201
The Coronary Vasomotion Disorders International Study Group definition of microvascular angina include:
(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
202
In the CorMicA trial, _____ was the most common abnormality detected when integrated invasive functional assessments were performed among patients with INOCA.
Microvascular dysfunction
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.
Structural microvascular dysfunction (MVD)
Functional MVD
204
Approximately _________ of patients with chest pain and normal coronary angiographic findings have positive exercise test results
20% to 30%
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 ____.
(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
206
Used to diagnose microvascular dysfunction in the absence of epicardial CAD
Coronary Flow Reserve
Index of Microvascular Resistance
207
Used to diagnose endothelial dysfunction
Endothelial function testing
208
Used to identify hemodynamic impact of diffuse coronary stenoses
FFR and iFR
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.
Ischemic CMP
210
The cause of chronic mitral regurgitation in patients with CAD is multifactorial, and the geometric determinants are complex; these include:
(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
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 _____.
(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
212
_________ defined as a segment of the ventricular wall that exhibits paradoxical (dyskinetic) systolic expansion.
LV aneurysm
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
False aneurysm
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.
Anterolaterally
LAD coronary artery
215
Approximately 5% to 10% of aneurysms are located _________.
Threefourths of patients with LV aneurysms have multivessel CAD.
Posteriorly
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
Heart failure
217
Clues to the presence of an aneurysm include
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
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
True LV aneurysms
219
Clues in the detection of LV aneurysm
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
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.
Anterior
221
Several inherited connective tissue disorders are associated with myocardial ischemia, including:
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).
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 _____.
Fibromuscular dysplasia
Estrogen use and hypertension
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
Conservative strategy
224
Connective tissue diseases or autoimmune forms of vasculitis, including _____, or vasculopathy, such as _____, can involve the coronary arteries
Polyarteritis nodosa
Giant cell (temporal) arteritis
Scleroderma
225
_____, a mucocutaneous lymph node syndrome, may cause coronary artery aneurysms and IHD in children
Kawasaki disease
226
_____ is seen at autopsy in approximately 20% of patients with rheumatoid arthritis but is rarely associated with clinical manifestations
Coronary arteritis
227
In patients with SLE, CAD has been attributed to _____.
Vasculitis
Immune complex–mediated endothelial damage
Coronary thrombosis from antiphospholipid Ab Accelerated atherosclerosis
228
_____ syndrome, characterized by arterial and venous thrombosis and the presence of antiphospholipid antibodies, may be associated with MI, angina, and diffuse LV dysfunction.
Anti-phospholipid syndrome
229
Luetic aortitis may also produce myocardial ischemia by causing _____.
Coronary ostial obstruction
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.
Ostia or proximal segments of the coronary arteries
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 _____.
Adventitial scarring
Medial hypertrophy with severe intimal atherosclerotic disease
232
In patients without risk factors who receive an intermediate total dose of _____ Gy, the risk for cardiac death and MI is low.
30-40 Gy
233
234
235
236
237
238
