CAD Flashcards
Metabolic syndrome
3/5 criteria Abdominal obesity (>= 102 cm men, >= 88 cm in men) TG > 175 HDL < 40 men, < 50 women BP > 130/85 Fasting glucose >= 100
Indication for stress EKG in asymptomatic
CLass IIb
Intermediate risk, particularly when starting exercise program
Indication for asymptomatic stress test with imaging
May be considered when DM, strong FH CHD, previous assessment suggests high risk such as CAC score > 400
Very high risk ASCVD
History of ASCVD
>= 2 events or 1 events and >=2 conditions
Events for ACSVD very high risk
ACS < 12 mo
h/o MI or stroke
Symptomatic PAD
Conditions for ASCVD very high risk
Smoker, DM, HTN LDL >= 100 on max therapy >= 65 Heterozygous FH h/o CABG or PCI CKD GFR 15-59 CHF
Very high risk ASCVD LDL goal
<70
History of ASCVD, not very high risk LDL goal
Lower by 50%
LDL >= 190, primary prevention goal
Lower by 50% or LDL < 100
DM + ASCVD risk > 20% treatment
High intensity statin
DM + ASCVD risk < 20% treatment
Look at risk enhancers
If yes -> high intensity
If not -> moderate
DM risk enhancers for primary prevention
DM2 for 10 yrs, DM1 for 20 yrs Ur albumin >= 30 mcg/mg creat eGFR < 60 Retinopathy, neuropathy ABI < 0.9
LDL < 190, non-DM management age 0-19
Lifestyle
Statin if FH
LDL < 190, non-DM management age 20-39
Lifestyle
If early ASCVD and LDL > 160 -> statin
LDL < 190, non-DM management age 40-75
Risk calculator
ASCVD risk >= 20% treatment
High intensity statin
ASCVD risk <= 5%
Lifestyle
ASCVD risk 5-20% treatment
Borderline, look at risk enhancers
If yes -> moderate statin
If uncertain and 7.5-20 -> CAC
High intensity statin reduction
> =50%
Moderate intensity statin reduction
30-50%
Low intensity statin reduction
<30%
Aspirin primary prevention indication
Class IIb
ASCVD > 20%, maybe >10%, not increased bleeding risk
Duke treadmill score
Maximum exercise time in minutes - 5(ST segment deviation in mm) - 4(angina index)
High risk duke treadmill score
<= - 10
Low risk duke treadmill score
> = 5
Class I for coronary angiography
High likelihood of severe CAD
Unacceptable symptoms despite GDMT
High risk CAD (>3% risk of death or MI / year) at rest
EF < 35%
>10% myocardium perfusion abnormality without prior history or evidence of MI
Multivessel disease or LM 50% on CCTA
High risk CAD (>3% risk of death or MI / year) on stress
> = 2 mm ST depression on stress EKG
Stress induced LV dysfunction (EF < 45 or drop 10)
10% myocardium or multiple territory induced perfusion abn
Stress induced LV dilatation
Induced WMA >2 seg or 2 coronary beds
WMA at low dose of dobutmaine <10 or HR <= 120
AUC for coronary angiography
- Symptomatic with high pretest probability of CAD without stress test
- Intermediate risk stress imaging
- Discordant clinical and stress result
- Equivocal / non-diagnostic stress
- CCTA: symptomatic with >= 50% / possibly obstructive stenosis
Class I for CABG in SIHD, improves survival
Left main
3VD
2VD with proximal LAD
Post arrest with ischemia mediated VT
Class IIa CABG in SIHD
1 vessel with proximal LAD
Class IIa for FFR in SIHD
Intermediate lesions 50-70%
Class I for PCI in SIHD
1+ significant stenosis, unacceptable angina despite GDMT (excluding improved survival with CABG)
Low SYNTAX score
0-22
Intermediate SYNTAX score
23-32
High SYNTAX score
> 33
Class IIa LM PCI in SIHD
Low risk SYNTAX
STS >= 5%
LM in SIHD treatment
CABG for most PCI in low risk and complexity class IIa
3VD in SIHD treatment
CABG for most
PCI if low risk, SYNTAX <= 22, non-DM
2VD in SIHD treatment
PCI or CABG
1VD in SIHD treatment
PCI
High risk MPI stress findings
- > 12% myocardial defect
- Severe reversible defect
- Abnormal EF
- Increased lung uptake of tracer
- Transient ischemic dilation (TID)
Duke treadmill score
Exercise duration (minutes) - (4 x angina index) - (5 x maximum ST deviation)
Angina index
0 - no angina
1 - angina that doesn’t limit exercise
2 - angina limiting exercise
Low risk DTS
> = 5
5 year survival 97%
Intermediate risk DTS
-10 to +4
90% 5 year survival
High risk DTS
-11 or lower
65% 5 year survival
Strongest predictors of post-STEMI mortality
Age > 75
SBP < 100
Carotid duplex before CABG if
>65 L main PAD Smoking Stroke/TIA Carotid bruit
Coronary flow reserve
For microvascular dysfunction
Ratio of intracoronary mean velocity with hyperemia / baseline
CFR response to IC adenosine < 2.5
non-endothelial microvascular dysfunction
CFR decreased coronary diameter in response to IC acetylcholine
macrovascular dysfunction
CFR increased coronary diameter in response to IC NG
non endothelial macrovascular dysfunction
Atheroembolic embolization / cholesterol emboli
livedo reticularis, eosinophils in urine with renal dysfunction
Cholesterol emboli management
Aggressive secondary prevention
