CAD Flashcards
supplies oxygenated blood to the (posterior portion) back portion of the left atrium & ventricle
Left Circumflex Artery (LCA)
supplies oxygenated to the front portion of the ventricle to the septum of the heart
Left Anterior Descending Artery (LDA)
— supply oxygenated blood to the front portion of the right atrium
Right Marginal Artery (RMA)
supply oxygenated blood to the back poriton of the right ventricle
Posterior Descending Artery
form re-route when there is blockage so that the blood can reach other parts of the artery
collateral circulation
Vascular supply to the heart is impended by
Atheroma
Thrombosis
Spasm of the coronary artery
Accumulated fatty deposits and scar tissues
Atheroma
Atheroma leads to ________ and risk of ________
restriction in blood flow; thrombosis
patchy deposit of plaque
atheromas or atherosclerotic plaque
condition in which patchy deposit of plaque
(atheromas or atherosclerotic plaque) develop in the
wall of the medium and large sized arteries, leading to
reduced or blocked blood flow
Atherosclerosis
Atherosclerosis is a condition in which patchy deposit of plaque
(atheromas or atherosclerotic plaque) develop in the
wall of the medium and large sized arteries, leading to
reduced or blocked blood flow
T/F: Atherosclerosis can lead to stroke (in brain)
T
rupture, causing thrombosis
Unstable plaque
What do you give to patients with unstable plaque?
give antiplatelet medication just in case of rupturee (lead to coagulation/platelet adhesion)
T/F: Plaque rupture can cause MI
T
Blood clot
Thrombus
Fragment of blood clot travelling through vein
Emboli
Risk factors for CAD
atherosclerosis, htn, high cholesterol, diabetes, obesity, smoking + alcohol consumption
Etiology of CAD: Decrease blood flow to the myocardium
*Atherosclerosis
*Coronary spasm
*Traumatic Injury
*Embolic event
Etiology of CAD: Increased oxygen demand
*Diastole
*Systole
*Contractile state of the heart
*Increase in systolic wall tension
* Lengthening of ejection time
*Change in the heart rate
unbalanced oxygen supply and oxygen demand
Myocardial Ischemia
T/F: during MI, px can experience angina pectoris (chest pain)
T
Oxygen demand exceeds myocardial oxygen
supply
Myocardial Ischemia
Myocardial Ischemia may be silent if
the length is insufficient
* Afferent cardiac nerves are damages
* Inhibition of pain at the spinal or
supraspinal
Occurs when oxygen demand exceeds the oxygen supply
Myocardial Ischemia
T/F: during Myocardial infarction, heart muscles already died due lack of oxygenated blood for a long time
T
Transient chest discomfort that are
attributed to insufficient myocardial oxygen
Angina
Ordinary activity does not cause angina, such as walking and climbing stairs
Class I
Slight limitation of ordinary activity
Class II
Marked limitation of ordinary physical activity
Class III
Inability to carry on any physical activity without discomfort
Class IV
T/F: not all chest pain is classified as angina
T
Characterized by chest pain and breathlessness
on exertion, symptoms are relieved promptly
with rest
Stable Angina
Patient has a reproducible pattern of pain or
other symptoms
Stable Angina
Components to Consider in Anginal Pain
1.Quality of pain (suffocating type of pain)
2.Location of pain (chest pain)
3.Duration of pain (0.5 to 30 minutes)
4.Factor provoking pain
5.Factors that relieve pain
Symptoms of Stable Angina
Pressure over the sternum but not
always radiating
Pain usually lasting for 0.5 to 30 minutes
Precipitating factors include exercise, cold weather,
emotional stress
Relief occurs with rest and nitroglycerin
> 20 minutes occurring within a week of
presentation
Rest Angina
Previously diagnosed angina with distinctly more
frequency, longer duration or lower threshold
Increasing angina
-Rest Angina
-Increasing Angina
-decrease response to NTG
Unstable Angina
Nocturnal angina
Angina Decubitus
Angina Decubitus occurs when patient is in a
recumbent position
Coronary artery spasm that reduces blood flow
Prinzmetal Angina
Prinzmetal Angina is due to a
thrombi or plaque formation
Prinzmetal Angina occurs at
rest rather than exertion
ECG shows ST-elevation
Prinzmetal Angina
only occurs when patient is lying down; upright position, relieved
nocturnal
chest pain even if px is in upright position
prinzmetal
Diagnostic Test
*Resting ECG
*Exercise test
* Myocardial scintigraphy
* Stress Echocardiography
*Coronary Angiography (gold standard)
Treatment Goals for Angina
Prevent MI and death, thereby improving the patient’s
quality of life
Reduce symptomatology
Remove or reduce risk factors
Chronic Stable Angina treatment
*A – Aspirin and Antianginal Therapy
*B – Beta blocker and BP
*C – Cigarette smoking and Cholesterol
*D – Diet and Diabetes
*E – Education and Exercise
Recommendations
- Weight reduction/ maintenance
- Physical activity for 30 - 60 minutes/day x 7 day
- LDL-C <100mg/dL
*BP < 130mmHg
*No smoking and no environmental exposure to smoke
*Reduce intake of saturated fats
*If Diabetic HbA1c <7%
recommended physical activity for Chronic Stable angina
30 - 60 minutes/day x 7 day
recommended LDL-C for Chronic Stable angina
<100mg/dL
recommended BP for Chronic Stable angina
130mmHg
recommended Diabetic HbA1c for Chronic Stable angina
<7%
Management for Chronic Stable angina
*Anti-platelets/Anti-thrombotic
*ACEI’s and ARBS
*Statins
*Beta-blocker
*Calcium Channel Blocker
*Nitrates
Anti-Thrombotic Agents
Aspirin
Clopidogrel
COX- 2 Inhibitor
Acts via irreversible inhibition of platelet COX-1 and thus
thromboxane production
Aspirin
Aspirin’s Antiplatelet action is apparent within an hour of taking _________
300mg
Effect on platelet last for the lifetime of the platelet
Aspirin
Optimal maintenance dose for aspirin
75 -150mg/day
Lower dose of Aspirin have _________
limited cardiac risk protection
Higher dose of aspirin _______
increase risk for GI side effect
Inhibits ADP activation of platelet
Clopidogrel
Useful alternative to aspirin in patients who are allergic or cannot
tolerate aspirin
Clopidogrel
As effective as aspirin in patients with stable coronary disease
Clopidogrel
Usual dose is 300mg once then 75 mg daily
Clopidogrel
Less likely to cause gastric erosion and ulceration
Clopidogrel
Reduces the production of Prostacyclin
COX- 2 Inhibitor
More traditional non-selective NSAIDs increase
cardiovascular risk
COX- 2 Inhibitor
NSAID with high _______ specificity increase the risk of MI
COX-2
SHOULD BE AVOIDED IN CHRONIC STABLE
ANGINA
COX- 2 Inhibitor
Proven beneficial for post MI
ACE Inhibitor
Vasodilatory effect caused by the inhibition of the
production of Angiotensin II
ACE Inhibitor
Anti-inflammatory, anti-thrombotic and anti-proliferative
property
ACE Inhibitor
Reduces ROS production
ACE Inhibitor
Demonstrate the benefit of reducing cholesterol,
especially LDL-C, in patients with CHD
Statin
Earlier studies focused on patients with
“elevated” cholesterol, but all patients with
coronary risk factors benefit from reduction of
their serum cholesterol level
Statin
T/F: all patients with
coronary risk factors that is treated with statin benefit from reduction of their serum cholesterol level
T
statins reduce cardiovascular risk by
- Shift LDL cholesterol particle size to a larger particle, lesser atherogenic
- Improve endothelial function
- Prevention of pro-inflammatory mediators
- Possibly improve atherosclerotic plaque stability
No safe level for cholesterol for patients with CAD and there is a
continuum of risk down to very low cholesterol level
Statins
Level of LDL-C of __________ and total cholesterol__________ are
recommended for patients with established CVD
<2mmol/L; <4mmol/L
Considered first line agent in angina
Beta-Blocker
Reduce mortality both in patients who suffered from
previous MI and patients with HF
Beta-Blocker
Beta-Blocker reduce myocardial oxygen demand by blocking β- adrenergic receptor, there by ___________ (increasing/decreasing) the heart rate and
force of left ventricular contraction and lowering blood
pressure
decreasing
Beta Blockers are useful in
exertional angina
Patients treated optimally with B blockers should have a resting
heart rate of around
60 beats/minute
B blockers are used in caution in patients with _________
diabetes
Tendency to cause bronchospasm and peripheral
vascular spasm
Beta Blockers
Should not be stopped abruptly
Beta Blocker
Contraindicated in the rare Prinzmetal’s
angina where coronary spasm is a major
factor
Beta Blocker
Acts on a variety of smooth muscle and cardiac
tissue
Calcium Channel Blocker
______ have been
implicated in the exacerbation of angina
Calcium Channel Blocker
valuable in angina
Organic nitrates
Dilate vein → decrease preload
Nitrates
Dilate arteries to a lesser extent → decrease afterload
Nitrates
Promote flow in collateral coronary vessel, diverting
blood from the epicardium to the endocardium
Nitrates
Relax vascular smooth muscle by releasing nitric oxide
Nitrates
Tolerance is one of the main limitation
Nitrates
Nitrate preparation
*IV infusion
*Tablet / capsule
*Transdermal patch
* Sublingual tablet
* Spray
Exhibits the properties as nitrate
Nicorandil
Also activates ATP dependent potassium channel
Nicorandil
main benefit of nicorandil
Reduction in unplanned admission to hospital with chest
pain
Anti-ischemic agent
Ranolazine
T/F:Ranolazinen is not commonly used in the management of chronic stable angina
T
Inhibit inward sodium current during plata
Ranolazine