Dz of CV System (Ch1)

Question 1

Clinical presentation of CAD

Answer 1

Asx
Stable angina pectoris
Unstable angina pectoris
MI - NSTEMI or STEMI
Sudden cardiac death

Question 2

LDL goal for CAD pts

Answer 2

LDL less than 100 mg/dL

Question 3

Typical anginal chest pain

Answer 3

substernal
worse with exertion
better with rest or nitroglycerin

Question 4

Uses of stress testing

Answer 4

confirm dx of angina

evaluate response of therapy in patients with documented CAD

Identify pts with CAD who may have high risk of acute coronary events

Question 5

S/S of a positive stress test

Answer 5

ST segment depression
CP
hypotension
significant arrhythmias

Question 6

Metabolic syndrome X

Answer 6

any combination of hypercholesterolemia, hypertriglyceridemia, impaired glucose tolerance, diabetes, hyperuricemia, htn

key underlying factor is insulin resistance d/t obesity

Question 7

Syndrome X

Answer 7

Exertional angina with normal coronary arteriogram: pt presents with CP after exertion but have no coronary stenoses at cardiac catheterization

exercise testing and nuclear imaging show evidence of MI

prognosis is excellent

Question 8

Types of stress tests and their method of detecting ischemia

Answer 8

Exercise ECG: ST segment depression

Exercise or dobutamine echocardiogram: wall motion abnormalities

Exercise or dipyridamole perfusion study (thallium/technetium): decreased uptake of the nuclear isotope during exercise

Question 9

Cardiac catheterization

Answer 9

Most accurate method of determining a specific cardiac diagnosis

Provides information on hemodynamics, intracardiac pressure measurements, cardiac output, O2 saturation, etc

Coronary angiography almost always performed as well for visualization of coronary arteries

Question 10

Indications for cardiac catheterization

Answer 10

after positive stress test

Acute MI with intent of performing angiogram and PCI

Pt w/ angina in any of the following: when noninvasive tests are nondiagnostic, angina that occurs despite medical therapy, angina that occurs soon after MI, any angina that is a diagnostic dilemma

if pt is severely symptomatic and urgent diagnosis and management are necessary

Evaluation of valvular disease, and to determine the need for surgical intervention

Question 11

Coronary arteriography (angiography)

Answer 11

Most accurate method of identifying presence and severity of CAD

standard test for delineating coronary anatomy

Main purpose is to identify patients with severe coronary disease to determine whether revascularization is needed

Revascularization with PCI involving a balloon and/or stent can be performed at the same time as the diagnostic procedure

Coronary stenosis greater than 70 percent may be significant (i.e. it can produce angina)

Question 12

Standard of care for stable angina

Answer 12

aspirin

beta-blocker - specifically atenolol and metoprolol

Question 13

Side effects of nitrates

Answer 13

“SHOT”

Syncope
Headache
Orthostatic hypotension
Tolerance

Question 14

COURAGE trial outcome

Answer 14

no difference in all cause mortality and nonfatal MIs between pts with stable angina treated w/ maximal medical therapy alone vs medical therapy with PCI and bare metal stenting

Question 15

Percutaneous coronary intervention (PCI)

Answer 15

consists of both coronary angioplasty with a balloon and stenting

Should be considered in pt’s with one, two, or three vessel disease

• Even with 3 vessel dz, mortality and freedom from MI have been shown to be equivalent between PTCA with stenting and CABG
• only drawback: higher frequency of revascularization procedures in pts who receive a stent

Best if used for proximal lesions

Restenosis significant problem (up to 40 percent w/in first 6 mo)
-no evidence of restenosis at 6 mo = usually doesn’t occur

Question 16

Coronary artery bypass grafting

Answer 16

Main indications:

• 3 vessel disease with more than 70% stenosis in each vessel
• Left main coronary dz with more than 50% stenosis
• Left ventricular dysfunction

Question 17

Acute coronary syndrome

Answer 17

Clinical manifestations of atherosclerotic plaque rupture and coronary occlusion

Generally refers to: USA, NSTEMI, or STEMI

Question 18

Why can a stress test be negative for an MI?

Answer 18

Stress tests only detect flow-limiting high-grade lesions

Mechanism of MI is acute plaque rupture onto a moderate lesion

Question 19

How do you distinguish a USA and NSTEMI?

Answer 19

Often considered together because it is very difficult to distinguish the two based on patient presentation

If cardiac enzymes elevated, then NSTEMI

Question 20

Enoxaparin vs heparin in USA and NSTEMI

Answer 20

Risk of death, MI, recurrent angina lower in enoxaparin group at 14 days, 30 days, 1 yr.

Need for revascularization lower in enoxaparin group

ESSENCE trial

Question 21

Thrombolytic therapy indications

Answer 21

not beneficial in USA

Indicated in STEMI when no access to urgent catheterization for PCI

Question 22

Statins in post MI pts

Answer 22

reduced risk of death by 24%
Reduced risk of stroke by 31%
reduction in need for CABG or coronary angioplasty by 27%

Question 23

Substernal chest pain persisting for longer than 30 minutes and diaphoresis

Answer 23

Strongly suggests acute MI

Question 24

Right ventricular infarct presentation

Answer 24

Inferior ECG changes
hypotension
Elevated jugular venous pressure
hepatomegaly
CLEAR LUNGS

PRELOAD DEPENDENT
Do NOT administer nitrates or diuretics as will cause CV collapse

Question 25

ECG findings for anterior infarct

Answer 25

ST segment elevation V1-V4 (acute/active)

Q waves in leads V1-V4 (late change)

Question 26

ECG findings for posterior infarct

Answer 26

Large R wave in V1 and V2
ST segment depression in V1 and V2
Upright and prominent T waves in V1 and V2

Question 27

ECG findings for lateral infarct

Answer 27

Q waves in lead I and aVL (late change)

Question 28

ECG findings for inferior infarct

Answer 28

Q waves in leads II, III, aVF (late change)

Question 29

Serial cardiac enzymes

Answer 29

once on admission, q8 hrs until 3 drawn

higher the peak and longer enzyme levels remain elevated, more severe the myocardial injury and worse the prognosis

Question 30

Drugs shown to reduce mortality in MI

Answer 30

aspirin
b-blockers
ACEI