Chronic Ischemic Heart Disease

Question 1

What are causes of Angina?

Answer 1

• demand is increased: coronary artery unable to deliver adequate flow because of fixed obstrucction is present (exertional angina, emotional upset derived angina)
• demand is normal supply decreased because a primary event occurs in the artery system (large artery spasm, plaque rupture, microvascular plugging)

Question 2

• Chesst pain that is squeezing, grip like, suffocating, heavy but not sharp, stabbing or related to breathing
• levine sign
• alternate: pressure, tightness, heavy
• some are atypical: nausea, burning or atypical location, or even sharp
• women more likely atypical

Answer 2

Angina

Question 3

what are other cardiac conditions that may intensify ischemia?

Answer 3

1. Anemia
2. Fever and infection
3. tachyarrhythmias
4. emotional stress
5. hypoxemia

Question 4

Initial lab tests for Angina?

Answer 4

• CBC, lytes, BUN and creatinine
• UA for analysis of glucose and microalbuminuria
• fasting glucose or A1c
• fasting lipid panel
• resting ECG
• CXR when signs or symptoms of cardiac or pulmonary disease are presetn
• resting ECHO (when a systolic murmur or CHF is present or when active pain is present)

Question 5

What are indications for Angiography?

Answer 5

• CCS class III OR IV angina
• high risk results of noninvasive stress testing
• sudden death or ventricular arrhythmia with angina
• angian and signs of CHF
• clinical findings suggesting severe CAD
• EF < 50% by noninvasive imaging and angina
• patients with inconclusive noninvasive testing and angina

Question 6

• Reduces short and long term odds of MI in pts with unstable angina
• 33% reduction in patients with stable angina
• ASA and clopidogrel of often used in this type of therapy

Answer 6

CAD: antiplatelet therapy

Question 7

for is recommended for secondary prevention?

Answer 7

• Lipid lowering angents
• lifestyle changes, diet changes, agressive lipid lowering with statins
• LDL should be lowered to < 70

Question 8

• Effective in blunting HR, BP and contractility and thus reduce oxygen consumption during stress or exercise
• effective as first line therapy in control of exertional angina
• effective in reducing post MI mortality up to 3yrs posst MI
• use for long term in pts with LVEF < 40%
• titrate to resting HR of 55-60
• contraindicated in asthma, COPD, severe bradycardia, SSS
• fatigue, depression, nightmares, impotece are side effect

Answer 8

CAD: Beta blockers

Question 9

• Inhibit transmembrane calcium flux across different types of channels
• generally recommended as an alternative to beta blockers or to be used in combo
• all have some negative inotropic effects
• of equal efficacy to BBs for angina relief
• better for vasospastic angina
• short acting forms not recommended
• side effects: CHF, edema, hypotension, constipation

Answer 9

calcium channel blockers

Question 10

• Endothelium independent vasodilators that lower oxygen and demand and increase perfusion
• effective in reducing exertional angina but can cause reflex tachycardia
• work well in combination with BB
• tolerance develoops rapidly without daily nitrate free intervals
• headache most common side effect
• cannot be used within 24 hours of sildenafil use
• ALL CAD pts should be instructed in the use

Answer 10

Nitrates for CAD

Question 11

• MOA is not certain
• alternative to standard therapy
• studies performed are with the drug as an add on to at least one conventional anti-anginal agent
• in these studies there was improved exercise time, reduced episodes of angina and decreased use of NTG

Answer 11

Ranlozine

Question 12

Indications for revascularization for chronic stable angina?

Answer 12

CABG for:

• Left main stenosis
• 3 vessel disease (in patient with reduced LVEF or treated diabetes
• 2 vessel disease with proximal LAD stenosis and LV dysfunction

PTCA or CABG for:

• Various levels of severity of CAD who have angina that cannot be successfully controlled by medication or have high risk noninvasive stress test results

PCI

• Reduces angina
• does not reduce mortality in stable patients vs. medical mangement
• PCI does not lower the long term risk for subsequent MI

Question 13

Pathways to ACS?

Answer 13

Spontaneous rupture of coronary plaque

• Rupture to complete vessel occulsion
• rupture to partial occlusion causing narrowing of the lumen

Coronary vasoconstriction
chronic CAD witha supply demand imbalance

Question 14

diagnosis of unstable angina?

Answer 14

• New onset angina of less than two months duration that is severe and frequent >3 days
• Crescendo Angina (more frequent, more prolonged, lower threshold)
• rest angina
• initial biomarkers are negative

Question 15

Thearpy for unstable angina for those admitted to the hospital or chest pain center?

Answer 15

• assessment of risk
• bed rest
• sedation as needed
• ECG monitoring, serial 12 lead ECGs
• serial evaluation of cardiac biomarkers
• anti-thrombotic (heparin or LMWH)
• antiplatelet agents (dual antiplatelet therapy)
• beta blockers scheduled
• nitrates as needed for pain

Question 16

30% mortality rate

• 70% of mortality occurs outside the hospital
• survival is age related
• about 4% of those discharged from the hospital will die in the first post -MI year

About 50% of cases have some precipitating event: exercise, stress, other illness or surgery, early morning

Answer 16

Acute ST elevation myocardial infarction

Question 17

what are some associated symptoms of chest pain?

Answer 17

• nausea or cold sweats
• tired or weak
• sick feeling
• dyspnea
• anxiety/ fear of death

Question 18

What would and ECG of acute ischemia show?

Answer 18

• New ST elevation > 0.2mV in two or more contiguous leads V2-V3 at the J point or > 0.1mV in other leads
• new ST depression or T-wave changes in two or more contiguous leads

Question 19

What would ED therapy look like for an Acute MI?

Answer 19

Oxygen

• Used routinely but not much evidence it actually helps unless there is pulmonary congestion or a O2 saturation < 90%

IV access
ASA chew tablets if not already done in the ambulance
Nitroglycerin

• SL for initial presentation of pain
• IV initially for all patients with definite ongoing ischemia, CHF or hypertension

Question 20

• Most effective therapy and generally applicable to patients not candidates for thrombolysis
• more effective than thrombolysis for opening occluded arteries
• better than thrombolysis when used in experienced labs
• not universally available

Answer 20

Primary angioplasty