Coroanry Artery Disease And Angina (Johnston) Flashcards
Coronary vasoconstriction, stenosis, platelets releasing 5-HT and TxA2 are examples of __ angina
Supply
Exercise, stress, emotion, fever, and thyrotoxicosis can cause ___ angina
Demand
Can also add in LVH d/t AS and ANemia (low O2 carrying capacity)
What are some mechanical consequences of ischemia?
Heart failure (LVF or RVF or both)
Angina, if ischemia is prolonged or develop coronary occlusion, may lead to myocardial necrosis
Segmental akinesis, bulging (dyskinesis)
What are some biochemical consequences of ischemia?
FA’s cant be oxidized
Increased lactate production
Reduced pH with metabolic acidosis
What are some electrical consequences of ischemia?
T wave inversion
Transient displacement of ST segment
Depression-Subendocardial
Elevation-Subepicardial
Electrical instability; VT, VF
Anterior wall infarction d/t LAD is best seen in what leads?
V1-V7 (Johnston slide)
Inferior wall infarction (RV infarction) d/t RCA is best seen in what leads?
II, III, aVF; V3R-V6R
Lateral wall infarction d/t left circumflex artery is best seen in what leads?
I, aVL, V5-V6
Posterior wall infarction d/t posterior descending a. (RCA branch) is best seen in what leads?
V1-V3
T wave inversion seen in diffuse myocardial ischemia is known as ___
NSTEMI
Mitral regurgitation d/t dysfunction of papillary muscle is usually indicative of this lesion:
RCA lesion
What are some non chest pain symptoms of chronic ischemic heart disease?
Dyspnea Non chest locations of discomfort (exertional or rest) Mid-epigastric or abdominal Diaphoresis Excessive fatigue and weakness Dizziness and syncope
___ is d/t ischemia, but described as dyspnea, fatigue, faintness and gastric eructation’s (belching).
Anginal equivalent
The pathogenesis of Anginal equivalent is due to ischemia causing an elevated LV filling pressure that leads to pulmonary edema and seen in these types of pts:
Diabetic
Elderly
Women
What are some signs of risk factors for angina?
Xanthelastama (soft, yellowish spots on eyelids) Xanthomas Diabetic skin lesions Nicotine stains Pale Absent peripheral pulses
What conditions can mimic angina in the absence of Coronary Artery Disease?
Aortic stenosis
Aortic insufficiency
Pulmonary HTN
Hypertrophic cardiomyopathy
The symptoms of this pathology is characterized by New or Worsening chest pain where the tempo has changed, its more severe, prolonged, and more frequent. It may occur at rest and cause the pt to awake from sleep and the pain can last longer than 20 minutes. This type of pt has to use more medication for relief and there is no evidence of myocyte necrosis
Unstable angina
Chest pain with elevation of cardiac enzymes and without elevation is said to have a ___
NSTEMI
During an anginal attack (stable angina), what is the most common change seen on EKG?
Most common change is ST depression (subendocardial injury-ischemia). May also show old MI
In unstable angina/NSTE ACS, what correlates with prognosis?
Magnitude of ST segment depression
If ST depressed 1 mm or greater in 2 or more leads- almost 4x likely to die within 1 year
If 2 mm or greater ST depression, almost 6x likely to die within a year
If ST depression > 2 mm or more in more than 1 region of ECG, mortality is 10-fold
When is troponin I detected in NSTEMI? CK-MB?
Troponin I in 2-4 hrs
CK-MB after 3-6 hrs
What BNP levels (increased/decreased) are associated with increased mortality in NSTE ACS?
Increased
What are some signs of high risk for coronary events?
Positive stress test at low work load
ST depression greater than 5 min after test completion
Decrease in BP- systolic fall > 10 mm Hg during exercise
VT during exercise
Reduced EF during exercise (stress echo)
When is stress testing contraindicated?
Recent MI or acute MI Unstable arrhythmias Acute PE Aortic dissection Unstable angina Severe aortic stenosis Decompensated HF Endocarditis DVT
Nuclear myocardial perfusion imaging is useful in these pathologies:
LBBB
LVH
Digitalis effect
This test is done with exercise or dobutamine and detects wall motion abnormality and EF
Stress ECG
This test can detect coronary calcification and specificity only 50% in identifying pts with obstructive CAD
CCTA
On CXR, what conditions will you see cardiomegaly?
HTN
VHD
Cardiomyopathy
Pericardial effusion
What is the gold standard test for the anatomic definition of CAD?
Coronary angiography (Cardiac catheterization)
PCI-90% successful; stent insertion
CABG-for L main disease or 3 vessel disease
What are some pharmacological therapies to prevent MI/death/reduce symptoms?
Aspirin B blocker ACEi Statins Nitrates CCB
When are B blockers contraindicated?
Decompensated HF, hypotension, advanced AV block
Can potentially make HF worse
ACEi can be useful in decreasing cardiovascular mortality in these types of pts:
Diabetic (renal protective) and pts with LV systolic dysfunction
What do nitrates do to preload?
Decrease preload (venodilation)
This CCB decreases has a negative inotropic effect and should be used with caution
Verapamil
This CCB inhibits inward Na current and decreases intracellular calcium
Ranolazine
When should CABG be employed?
For L main or 3 vessel CAD multiverse with LV EF < 50%
When should PCI be employed?
1 or 2 vessel disease
What does the ekg show in variant angina or prinzmetal angina?
Transient ST elevation during chest pain in absence of severe CAD
What should you treat Variant/prinzmetal angina with?
DHP CCB –> Amlodipine
Relieved by nitro
What is the risk of plaque rupture in chronic stable angina?
Low risk of plaque rupture (small lipid core and thick fibrous cap)
Chronic stable angina=consequence of imbalance between O2 supply-demand
