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RACP Written 2018 > Cardiology - Ischaemic Heart Disease > Flashcards

Cardiology - Ischaemic Heart Disease Flashcards

1
Q

Fractional Flow Reserve

  • how is it done?
  • Cut-offs?
A

Adenosine is used to induce maximal hyperaemia
= gold standard for VESSEL SPECIFIC ISCHAEMIA

FFR <0.8 = ISCHAEMIA

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2
Q

Fractional Flow Reserve: benefit when used during PCI

A

In multivessel disease during PCI it reduced MI and death

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3
Q

In the pathogenesis of atherosclerosis:

Which apolipoprotein combines with LDL, where and what do they do?

A

LDL combines with Apolipoprotein B in the INTIMA and binds to extracellular matrix

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4
Q

In the pathogenesis of atherosclerosis:

What are foam cells?

A

Foam cells develop when MONOCYTES take up lipoprotein particles by endocytosis

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5
Q

In the pathogenesis of atherosclerosis:

How is cholesterol transferred from cell to HDL?

A

via the ABC (ATP Binding Cassette) transporters

ABC-A1 gene transfers to nascent HDL (mutated in Tangier’s with VERY LOW HDL)

ABC-G1 gene transfers to mature HDL

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6
Q

In the pathogenesis of atherosclerosis:

Role of ABC-A1 gene?

A

Transfers cholesterol from cell to nascent HDL

mutated in Tangier’s with VERY LOW HDL

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7
Q

In the pathogenesis of atherosclerosis:

Role of ABC-G1 gene?

A

Transfers cholesterol from cell to mature HDL

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8
Q

Which ABC gene transfers cholesterol from cell to NASCENT HDL?

A

ABC-A1

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9
Q

Which ABC gene transfers cholesterol from cell to MATURE HDL?

A

ABC-G1

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10
Q

What is mutated in Tangier’s?

A

ABC-A1 gene resulting in VERY LOW HDL

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11
Q

What does HDL do with the cholesterol it picks up?

A

HDL delivers cholesterol to hepatocytes via Scavenger Receptor B1

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12
Q

What produces PDGF?

And what does PDGF do in the pathogenesis of atherosclerosis?

A

PDGF = Platelet Derived Growth Factor

It is produced by activated platelets, macrophages and endothelial cells.

It stimulates smooth muscle cells in tunica media to migrate to intima

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13
Q

In the pathogenesis of atherosclerosis:

What does TGF-beta do?

A

Stimulates smooth muscle cells to make collagen

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14
Q

In the pathogenesis of atherosclerosis:

What makes plaques prone to rupture?

A
  • thin fibrous caps
  • large lipid cores
  • high macrophage content
  • outward remodelling
  • spotty calcification rather than dense
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15
Q

Which coronary arteries are typically effected in stable angina?

A

Stable angina is usually angina secondary to atherosclerosis of EPICARDIAL arteries

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16
Q

What is microvascular angina?

A

Angina with no flow-limiting obstruction in the epicardial arteries

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17
Q

Is microvascular angina more common in males or females?

A

Females

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18
Q

How do you diagnose microvascular angina?

A

Coronary reactivity tests with vasoactive agents: ie:

  • intracoronary adenosine
  • intracoronary acetylcholine
  • intracoronary nitroglycerides
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19
Q

How do you manage microvascular angina?

A

Nitrates
Betablockers
CCBs
Statins

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20
Q

Who do you see ABNORMAL CARDIAC NOCICEPTION in, and how do you treat?

A

Abnormal cardiac nociception is a type of angina with no flow-limiting obstruction in epicardial arteries (LIKE microvascular but NOT)
Seen in FEMALES
Trial treatment with IMIPRAMINE

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21
Q

Link between CRP and Stable Angina?

A

If the CRP level in stable angina is elevated it is an INDEPENDENT RISK FACTOR

Can help reclassify it as ‘intermediate risk’

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22
Q

ECG features that increase risk of adverse events in STABLE ANGINA?

A

LVH

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23
Q

When do you use Exercise Stress Test for chest pain?

A

If intermediate pre-test probability 10 - 90%

24
Q

How good is Exercise Stress Testing in coronary artery disease?

A

Sensitivity 80%, Specificity 70%

If POSITIVE and MALE >50yrs with a typical history of pain IN THE TEST then likelihood of CAD is 98%

25
Q

What is Exercise Stress Test MOST SENSITIVE for?

A

Triple vessel disease

26
Q

What coronary artery might result in a FALSE NEGATIVE on your Exercise Stress Test?

A

Left Circumflex

27
Q

Ideal goal when doing an Exercise Stress Test?

A

To exercise 6 - 12 minutes to achieve 85% of age-predicted max-heart rate (220-age)

28
Q

What is the DUKE TREADMILL SCORE and what is it based on?

A

Provides 5yr mortality

Based on:

  • development of symptoms
  • degree of ST depression
  • exercise duration
29
Q

In the first minute of stopping an Exercise Stress Test, what increases your mortality?

A

If your heart rate recovery is <12bpm in the first minute then INCREASED mortality

30
Q

What meets criteria for a positive Exercise Stress Test?

A 
>3mm ST depression
>2mm ST elevation
SBP >230mmHg
Fall of SBP >20mmHg
HR DECREASES >20% of starting rate
Arrythmia
31
Q

Contraindications to an Exercise Stress Test?

A
  • Aortic Stenosis
  • LBBB
  • MI <7 days ago
  • Rest angina <48 hours ago
  • Uncontrolled BP
32
Q

Problem with WOMEN doing an Exercise Stress Test?

A

Women have a high rate of FALSE POSITIVES

BUT if the woman is LOW RISK then the Exercise Stress Test is similar to a nuclear med myocardial perfusion scan

33
Q

Risk of doing an Exercise Stress Test?

A

1 in 10,000 mortality

1 in 10,000 non-fatal events

34
Q

Is an stress echo or exercise stress test more sensitive?

A

A stress echo is more sensitive because it assesses if stress causes regions of AKINESIS or DYSKINESIS

35
Q

In nuclear stress tests what is used to stress the heart?

How do they work?

A

DOBUTAMINE: increases myocardial oxygen demand

ADENOSINE or DIPYRIDAMOLE:
Temporarily increases flow in nondiseases segments to cause flow disparity

36
Q

Which medication used in nuclear stress tests increases myocardial oxygen demand?

A

Dobutamine

37
Q

Which medication used in nuclear stress tests temporarily increases flow in nondiseases segments to cause flow disparity

A

Adenosine or Dipyridamole

38
Q

What classifies a MARKEDLY POSITIVE nuclear exercise test?

A

Lung uptake of thallium
Ischaemia in >2 vascular territories
EF <35%

39
Q

What classifies as MARKEDLY POSITIVE exercise echo?

A

EF <35% at rest
Fall in EF with stress
Ischaemia in >2 vascular territories

40
Q

The severity of coronary artery narrowing WHERE is associated with a higher risk in stable angina?

A

Left main

LAD proximal to origin of first septal artery

41
Q

In treating STABLE ANGINA:

Should you use a statin?

A

YES!

  • stabilises plaque
  • Reduces risk of MI and death (25 - 30%)
  • reduces LDL (25 - 30%)
  • reduces TGAs (5 - 30%)
  • INCREASES HDL (5-9%)
42
Q

How do nitrates work?

A

Relax vascular smooth muscle by releasing NITRIC OXIDE that binds to GUANYLYL CYCLASE in smooth muscle and INCREASES cGMP

Results in:

  • systemic venodilation with reduced LV EDV and pressure
  • increased collateral flow
  • dilation of epicardial vessels
43
Q

What do nitrates result in?

A

Increases Exercise TOLERANCE

but NOT mortality benefit

44
Q

Effect of nitrates on bleeding?

A

Antithrombotic effect

Because NO-dependent activation of platelet guanylyl-cyclase, impaired intraplatelet calcium flux and platelet activation

45
Q

Which five medication classes work as anti-anginals? (excluding perhexiline)

A 
Nitrates
Betablockers
CCBs (nondihydropyridine)
Ranolazine
Nicorandil
46
Q

Which calcium channel blockers can you use for their anti-anginal effect?

A

Non-dihydropyridine CCBs: verapamil and diltiazem

47
Q

How does ranolazine work as an antianginal?

A

Selective inhibitor of late inward sodium channel in myocardium
–> prevents calcium overload via Na/Ca exchange

48
Q

When is ranolazine contraindicated?

A
  • hepatic impairment
  • QTc prolongation
  • use with CYP3A4 inhibitors
49
Q

How does nicorandil work as an antianginal?

A

Opens ATP-sensitive K channels in myocyte to cause reduction of free intracellular calcium

50
Q

When do you revascularise in stable angina?

A

If symptoms persist despite medical treatment

51
Q

At which SYNTAX SCORE is coronary artery disease considered severe?

A

> 22

52
Q

Benefit of PCI in treatment of stable angina?

A

More effective for RELIEF
BUT
No better than medical treatment for mortality or MI

53
Q

How many BMS have restenosis in 6 months?

A

20%

54
Q

How many DES have restenosis in 6 months?

A

<10%

55
Q

What increases your risk of restenosis after revascularisation?

A
  • diabetes
  • small arteries or incomplete dilation
  • longer stent
56
Q

When do we use CABG in preference to stenting in coronary artery disease?

A
  • left main disease
  • three vessel disease
  • LV dysfunction
  • diabetes IF MULTI-VESSEL
57
Q

Benefit and Risks of CABG compared to stenting?

A

Benefit:

  • mortality <1%
  • occlusion much lower, with 10-20% in 1st year and <2% per year afterwards

Bad:

  • recurrence of angina in 25% by 3 years
  • higher stroke risk than PCI

RACP Written 2018 (167 decks)

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