coronary artery disease

Question 1

CAD in general

Answer 1

-blood vessel disorder in the general category of atherosclerosis
-affects perfusion
-impairs CO

Question 2

Atherosclerosis

Answer 2

-starts as soft deposits of fat that harden with age
-Atheromas (fatty deposits) form in coronary arteries = CAD

Other names for CAD
-ASHD = arteriosclerotic heart disease
-CVHD = cardiovascular heart disease
IHD = ischemic heart disease
CHD = coronary heart disease

Question 3

development of CAD

Answer 3

-fatty deposit in intima of artery
-endothelial injury and inflammation play a role

3 stages
-fatty streak
-fibrous placque
-complicated lesion

Question 4

Fatty streak

Answer 4

-earliest lesion
-lipid fills smooth muscle cells –> yellow
-starts at age 20 and gets worse
-treatment to lower LDL may slow progression

Question 5

Fibrous plaque

Answer 5

-beginning of progressive change in endothelium around 30 yrs old
-LDLs and growth factors stimulate smooth muscel proliferation and arterial wall thickens
-cholesterol and other lipids move into intima
-collagen covers and forms grayish or whitish fibrous plaque with smooth or rough jagged edges
-Narrow lumen reduces blood flow

Question 6

Complicated lesion

Answer 6

-fibrous plaque grows –> continued inflammation leads to plaque instability, ulceration, and rupture
-platelets accumulate resulting in thrombus that further narrows artery
-activation of platelets causes expression of glcoprotein IIb/IIIa receptors to bind fibrinogen, increasing the size of thrombus

Question 7

collateral circulation

Answer 7

-blood takes detour to get around blockage
-contributing factors = predisposition for angiogenesis and presence of chronic ischemia

usually works pretty well except during exercise

Question 8

Nonmodifiable risk factors for CAD

Answer 8

age (45 for men; 55 for women)
gender (men get it earlier, but women die more)
Ethnicity (black women)
Family history
Genetics (genes controlling lipid metabolism)

Question 9

modifiable risk factors

Answer 9

High serum lipids
-keep cholesterol under 200
-keep HDL over 40
-keep LDL under 130
-keep fasting triglycerides under 150

Question 10

How to make treatment plan for someone with high LDL

Answer 10

based on 10-yr and lifetime risk of CVD or stroke

based on
-age
-gender
-race
-tobacco
-diabetes
-BP
-BP drugs
-total cholesterol and HDL level

Question 11

Endothelial injury causes what?

Answer 11

left ventricular hypertrophy and reduced stroke volume

Question 12

Tobacco use

Answer 12

-nicotine increases catecholamines which raise HR, BP, and vasoconstriction
-tobacco smoke increases LDLs, decreases HDLs, and increases O2 radicals which causes inflammation and thrombosis
-Carbon monoxide in tobacco smoke reduces O2 carrying capacity of Hgb

-second hand smoke increases CAD risk by 25-30%

Question 13

Physical inactivity and Obesity as risk factors

Answer 13

If you exercise:
-better lipid metabolism
-more HDL
-better O2 extraction by muscles

Obesity
-bad if BMI > 30
-bad if waist >40” (M) or 35” (F)
-causes high LDL, triglycerids, and HTN
-causes insulin resistance
-apple figure is worse than pear

Question 14

Diabetes and metabolic syndrome as contributing factors

Answer 14

Diabetes
-increased endothelial dysfunction
-altered lipid metabolism –> higher cholesterol and triglycerides

Metabolic syndrome
-catch-all for central obesity, HTN, abnormal serum lipds, and high fasting blood glucose
-all related to insulin resistance

Question 15

Psychologic states as risk factors

Answer 15

Type A personality
-stress
-depression/anxiety
-hostility/anger

lack of support = SNS stimulation = catecholamines = endothelial injury, high HR, high force of heart beat = increased O2 demand

Stress can also alter coagulation

Question 16

increased homocysteine levels and substance use as risk factors

Answer 16

Homocysteine
-made from breakdown of AA methionine
-damages endothelium, promotes plaque build up, enhances clotting

Substances
-coke and meth result in coronary artery spasms –> chest pain and MI

Question 17

FITT formula

Answer 17

frequency, intensity, type, and time

Question 18

Nutrition recommendations

Answer 18

-more complex carbs, fiber, and omega-3 fatty acid
-less sat fats, cholesterol, and alc/simple sugars

Question 19

Lipid-lowering drug therapy

Answer 19

-important to have lipid profile screened

Statin therapy recommended if:
-known CVD
-LDL cholesterol > 190
-age 40-75 with DM and LDL 70-189
-age 40-75 with LDL 70-189 and 10 yr risk of CVD 7.5%

-drug treatment is lifelong
-should also change diet, weight, and activity
-reassess after 6 weeks and tweak drugs as needed

Question 20

Drugs that restrict lipoprotein production

Answer 20

HMG-CoA reductase inhibitors: statins
-inhibit cholesterol synth, lower LDL and CRP, raise HDL
-one of them might damage liver

Niacin
-lowers LDL and triglyceride by inhibiting synth
-increases HDL
-side effects = flushing, pruritus, GI issues, otho-hypo

Fibric acid derivatives (Lopid)
-reduces triglycerides and increases HDL
-increases bleeding with warfarin and effects of antihyperglycemic drugs

Question 21

Drugs that increase lipoprotein removal

Answer 21

Bile acid sequestrants
-increase conversion of cholesterol to bile acids
-reduces total cholesterol and LDL
-GI side effects and reduced absorption of other drugs

Proprotein Convertase Subtilisin/Kexin 9 Inhibitors
-block PCSK9 to lower LDL
-liver is able to get rid of LDL better
-used with diet therapy and max statins

Question 22

Drugs that decrease cholesterol absorption

Answer 22

Ezetimibe (Zetia)
-decrease absorption of dietary and biliary cholesterol
-combine with statin

Question 23

Antiplatelet therapy

Answer 23

lowdose aspirin (81 mg)
-good for 50-70 yr olds
-contraindicated with risk for bleeding
-Clopidogrel (Plavix) if aspirin intollerant

Question 24

Gerontologic Considerations

Answer 24

Increased incidence and mortality a/w CAD in older adults

Strategies to reduce risk and treat CAD are effective
-Treat: HTN and increased lipids
-stop smoking and exercise more

More likely to change when hospitalized or have chest pain.