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Utah / kirklin > General Cardiac > Flashcards

General Cardiac Flashcards

1
Q

time scale for myocardial death

A

some with 20’ of ischemia – wide spread in 60’

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2
Q

Fissuring

A

Fissuring, or rupture, of atherosclerotic plaques is probably the genesis of the acute coronary syndromes termed unstable angina and acute MI. When this occurs, mural or occlusive coronary thrombi often coexist and contribute further to development of the unstable states.F25

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3
Q

plaques at highest risk of rupture

A

These plaques are characterized by relative softness, a high concentration of cholesterol and cholesterol esters, and a lipid pool that tends to be situated eccentrically.

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4
Q

a 33% loss in diameter –> ? loss in crossectional area

A

50%

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5
Q

a 50% loss in diameter –> ? looss in xs area

A

75%

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6
Q

a 67% narrowing of the coronary diatmeter –> % ? loss in xs area

A

90%

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7
Q

FFR what is it?

A

Pressure distal to obstruction/MAP FFR

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8
Q

Systolic cardiac function

A

contractility of the ventricle

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9
Q

Diastolic dysfunction

A

describes the compliance and extensibility and is related to the preload

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10
Q

CASS score , description of how its calculated?

A

Summation of 5 global wall regions from an RAO cine projection

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11
Q

CASS score & LVEF:

No LV dysfucition

A

EF 65%

CASS < 5

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12
Q

CASS score vs LVEF:

Mild LV dysfunction

A

LVEF 50-65%

CASS score 5-9

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13
Q

CASS socre vs LVEF:

Modrate dysfunction

A

LVEF: 35-50%

CASS: score 9-15

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14
Q

CASS score vs LVEF:

severe dysfunction

A

LVEF :15%

CASS: > 15

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15
Q

Aortic regurgitaion - what dimensions are used to grade

A

LV Enlargment

LVESD,

LVEDD

EF

Fractional shortening

Echo vena contracta

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16
Q

LV Diamterers in severe AI

A
  • LVESD > 50mm
  • LVEDD> 70mm
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17
Q

EF criteria for severe AI

A

EF< 50%

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18
Q

Echo vena contracta c/w severe AI

A

VC > 6-7mm

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19
Q

timi flow grades range

A

‘TIMI Grade Flow’ is a scoring system from 0-3 referring to levels of coronary blood flow assessed during percutaneous coronary angioplasty:

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20
Q

timi 0 flow

A

TIMI 0 flow: (no perfusion) refers to the absence of any antegrade flow beyond a coronary occlusion.

TIMI 1 flow: (penetration without perfusion) is faint antegrade coronary flow beyond the occlusion, with incomplete filling of the distal coronary bed.

TIMI 2 flow: (partial reperfusion) is delayed or sluggish antegrade flow with complete filling of the distal territory.

TIMI 3: is normal flow which fills the distal coronary bed completely

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21
Q

TIMI 1 flow

A

TIMI 1 flow: penetration without perfusion

faint antegrade coronary flow beyond the occlusion, with incomplete filling of the distal coronary bed.

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22
Q

TIMI 2 flow

A

TIMI 2 flow: partial reperfusion

delayed or sluggish antegrade flow with complete filling of the distal territory.

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23
Q

TIMI 3 flow

A

TIMI 3: is normal flow which fills the distal coronary bed completely

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24
Q

Sokolov-Lyon criteria

A

Sokolov-Lyon criteria

ECG criteria for LVH if sum is > 35 mm

S wave depth in V1

+

tallest R wave in V5 or V6

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25
Q

LV Strain pattern on ECG

A

ST segment depression and T wave inversion in the left-sided leads

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26
Q
A
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27
Q

Frequency of death in the US from CAD

(how many dealths per minute) ?

A

1 Death per minute

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28
Q

Prevlance of CAD in the US

A

5.5 - 7.5 million have symptomatic CAD

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29
Q

what are the categories of of risk factors for CAD?

A
  1. Category 1: Interventions Proven to lower risk.
  2. Categorty 2: interventions Likely to lower risk
  3. Category 3: if modified, Might lower risk
  4. Category 4: cannot be modified
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30
Q

Category 1 risk factors for CAD

A

Category 1 interventions proven to lower risk

  1. smoking
  2. LDL cholesterol
  3. High cholesterol diet
  4. Hypertension
  5. Left ventricular hypertrophy
  6. Thrombogenic factors
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31
Q

Category 2 risk factors for CAD

A

Category 2 interventions likely to lower risk

  1. Diabetes mellitus
  2. Physicial inactivity
  3. HDL cholesterol (low)
  4. Triglycerides
  5. Obesity
  6. Post menopausal state
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32
Q

Category 3 risk factors for CAD

A

Category 3 - if modified might lower risk

  1. Psychosocial factors
  2. Lippoprotiein (a)
  3. Homocysteine
  4. Oxidative stress
  5. Alcohol consumption
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33
Q

Category 4 risk factors for CAD

A

Category 4 - non-modifiable risk factors for CAD

  1. Age
  2. Gender
  3. Family History
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34
Q

CAS LV Regions

A
  1. septal
  2. anterolateral
  3. lateral
  4. posterolateral
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35
Q

Fundamental pathogenesis of CAD ?

A

Pathogenesis of CAD

  1. Proliferation of smooth muscle cells
  2. Connective tissue matrix proliferation
  3. Lipid accumulation
    • intracellular
    • extracellular
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36
Q

steps to coronary artery lesion

A
  1. Fatty streak
  2. Diffuse intimal thickening
  3. Fiberous plaque
  4. Advanced complex lesion
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37
Q

In atherosclerosis - what is a Fatty Streak

A

Fatty streak - first step in atherosclerosis

invasion of the intima

begins in teens to 20’s

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38
Q

In atherosclerosis - what is Diffuse intimal thickening

A

Diffuse intimal thickening - second step to atherosclerosis

  • increased smooth muscle cells
  • increased connective tissue deposition
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39
Q

In atherosclerosis - what is the Fiberous plaque?

A

Fiberous plaque - third step to atherosclerosis

  • proliferation of smoothe muscle cells
  • Fiberous cap is placed with a zone of necrotic tissue below
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40
Q

in atherosclerosis what is the advanced (complicated lesion)

A

Final stage of atherosclerosis

Features:

  • Calcification
  • Hemorrhage
  • Fissues and cracks in the intima
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41
Q

Rate of progress in atherosclerosis

A
  1. in 2 years 20% of stenosis will worsen in severity
  2. 50% of patients will devellop important new lesions
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42
Q

dye used in radionuceotide testing for CAD

A

thallium 201

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43
Q

sensitivity and specificity for radionuceotide testing for CAD

A
  1. sensitivity: 90%
  2. specificity: 75%
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44
Q

Persantine - what is it ?

A

Dipyridamole (Persantine)

  1. Chronic: inhibits blood clot formation chronically
  2. Acute: causes blood vessel dilation when given at high doses over a short time.

Mechanism: inhibits the phosphodiesterase enzymes that normally break down cAMP

It inhibits the cellular reuptake of adenosine into platelets, red blood cells, and endothelial cells leading to increased extracellular concentrations of adenosine.

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45
Q

Stress ECHO Findings diagnosis for CAD

A
  1. Initial augmentation of contractility followed by “dropout” (loss) - diagnostic of ischemic area
  2. Failure to agument suggest scar

Sensitivity and specificity 85%

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46
Q

Natural history of CAD with respect to extent of disease

5 year survival for any single system

A

5 year survival for any single coronary system: 90-95%

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47
Q

Natural history of CAD with respect to extent of disease

5 year survival for RCA disease alone

A

5 year survival for any RCA coronary disease : 96%

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48
Q

Natural history of CAD with respect to extent of disease

5 year survival for distal LAD disease alone

A

5 year survival for distal LAD coronary disease : 92%

49
Q

Natural history of CAD with respect to extent of disease

5 year survival for proximal LAD disease alone

A

5 year survival for proximal LAD coronary disease : 90%

50
Q

Natural history of CAD with respect to extent of disease

5 year survival for two system coronary artery disease

A

5 year survival for disease of two coronary system : 88%

51
Q

Natural history of CAD with respect to extent of disease

5 year survival for three system coronary artery disease

A

5 year survival for disease of 3 coronary system : 70%

52
Q

Natural history of CAD with respect to extent of disease

5 year survival for left main coronary artery disease

A

5 year survival for left main coronary artery disease : 40-60%

53
Q

Risks related to reprofusion of myocardium?

A

The process is complex because, in addition to these beneficial effects

spontaneous reperfusion can result in:

  1. hemorrhage
  2. edema
  3. ventricular electrical instability.
54
Q

Teleologic explanation for unstable angina / AMI

A
  • Fissuring (rupture) of plaque causes
  • luminal or occlusive emboli may further occlude the artery
  • Coronary stenosis < 50% are belived to play a role
  • Phenotype of these plaques:
    1. < 50% stenosis
    2. relatively soft
    3. increased cholesterol and cholesterol esters
    4. eccentric lipid pool
55
Q

% of patients with CAD have a significantly stenotic LM.

A

10-20% of patients with CAD have a significantly stenotic LM

56
Q

FFR indicator for surgery:

A

0.75 - 0.88%

57
Q

Natural history of coronary artery disease is dependent on:

A
  1. severity
  2. distribution
  3. Rate of progress on both
58
Q

Diastolic function in patients with CAD

A

Decreased diastolic function

present as:

  1. reduced filling rate
  2. increased time to peak filling rate
59
Q

Echocardiography:

What are the longitudinal segments of the heart?

A

BASE (to the papillary muscles)

MID VENTRICLE (to the distal third)

APEX (distal third)

60
Q

What is unstable angina ?

A

CHA Class IV Angina: mild activity. It may occur at rest but must be brief (<15 minutes) in duration.

If the angina is of longer duration, it is called UNSTABLE ANGINA .

Should be < 10 day prior to presentation

This implies inability to carry out even mild physical activity.

this signifies a prognostically significant change in the coronary circulation

61
Q

ARTS-II Trial - what does the anacronym stand for?

A

ARTS - II Trial: Arterial Revascularization Therapies Part II:

a non-randomized comparison of:

contemporary PCI vs. coronary artery bypass grafting (CABG)

in patients with multi-vessel coronary artery lesions

62
Q

ARTS-II Trial - Study Design

A

ARTS-II Trial Study Design

607 Patients treated with Sirolimus-eluting stent

  • compared with historical control
  • 3.7 stents per patient
  • Endpoints:
    • MACE
63
Q
A
64
Q

ARTS II Trial Results

A
  • No difference in ARTS II Stents and ARTS 1 CABG MACE at one yar
  • Improvement in Sirolimus stents over BMS but not CABG
65
Q

Seven factors Most predicticve of early mortality after CABG:

A

Seven factors Most predicticve of early mortality after CABG:

  1. Older age
  2. Female gender
  3. Previous CABG
  4. Urgency of operation
  5. Increasing LV dysfunction
  6. Left main disease
  7. Increasing extent of coronary artery disease

OFPUFLL

66
Q

SYNTAX Study population

A

SYNTAX Study population

Coronary disease including:

  • isolated left main
  • Left main + 1, 2, or 3 Vessel disease
  • TVD

With no prior surgery

No valvular disease

67
Q

General study design for Syntax trial

A

Syntax

  • Randomize 1500 patients in to two groups of 750 PCI and CABG
  • Determined to be amenable to both by MD comittee
  • Stent were TAXUS DES
68
Q

Syntax trial: one-year outcomes

Major differences between PCI and CABG

A

SYNTAX Trial at 1 Year: Major differences betwen groups

  • Revascularization: CABG: 5.9%; PCI: 13.7%
  • Stroke: CABG: 2.2%, PCI: 0.6%
69
Q

SYNTAX Trial at 1 Year: Outcomes with no difference between groroups

A

SYNTAX TRIAL at One Year: Outcomes with no difference at 1 year

  • MACCE (not stroke alone): PCI and CABG: each about 7.7%
  • MI at one year: CABG: 3.2%, Stent: 4.8%; P: NS
70
Q

Difference between Hibernating and Stunned myocardium

A
    • Hibernating myocardium: chronic ischemica, depressed contractility,
      • depresed contractility
      • Slowly improves after revascularization (weeks to months)
  • Stunned myocardium: post MI - ventricular dysfunction, but viable muscle
    • acute injury with quick recovery (days to weeks)
      *
71
Q

Major steps to coronary artery thrombosis:

A

Coronary artery thrombosis - Major Steps:

  1. Vasospasm
    • Due to the release of Thromboxane A2
  2. Plaque Repture
    • Secondary to ulceration and fissure formation
    • leads to ….
  3. Platelet Activation
    • Cycle of: Adhesion –> Aggregates –> TXA2
    • Decreased tissue plasminogen activator 2
72
Q

Vasospasm in Coronary artery thrombosis:

A

Coronary artery thrombosis - Vasospasm

First step is vasospasm

Due to the release of Thromboxane A2

73
Q

Coronary artery thrombosis -

Plaque Repture

A

Plaque Repture - second step to Coronary artery thrombosis:

Secondary to ulceration and fissure formation

leads to …. Platelet Activation

74
Q

EVIDENCE FOR CABG

Name the t__hree major tirials demonstrating evidence for CABG vs Rx

A

Three major tirials demonstrating evidence for CABG vs Rx

  1. VA
  2. European Coronary Surgery study group
  3. Coronary Artery Surgery Study
75
Q

EVIDENCE FOR CABG

Problems with the Three major tirials demonstrating evidence for CABG vs Rx

A
  • VA
  • European Coronary Surgery study group
  • Coronary Artery Surgery Study

*Issues* (these trials are mostly historical interest):

  • Arterial Grafts:
    • only used in the CASS study, and then in only 14% of patients
  • New Cardioprotection not used
  • Rx therapy not current
    • Beta blockers < 50% of all patients
    • statins, ACE inhibitors not standard
76
Q

EVIDENCE FOR CABG

overall findings from the Three major tirials demonstrating evidence for CABG vs Rx

A
  • VA
  • European Coronary Surgery study group
  • Coronary Artery Surgery Study

*Results* (these trials are mostly historical interest):

  • Median survival for LM and LAD disease were similar:
  • ~13 years for CABG, 6.6 years for Rx
77
Q

Indications for CABG in patients without symptoms.

A

in the asymptomatic patient the CABG is done to improve overall prognosis. Indications for surgery:

  1. LM > 50% stenosis (IA)
  2. Proximal LAD > 50% (IA)
  3. 2 or 3 vessel disease with dec LVEF (IB)
  4. Large area of ischemia (>10% of LV) (IB)
  5. 1 VD without proximal LAD disease and without > 10% EF (IIIA)
78
Q

Indications for CABG in the symptomatic patient (4) ?

A
  1. Any stenosisis > 50% with limiting angina or equivalent on OMM
  2. Dyspnea/CHF and a large area of ischemic LV (>10%)
  3. ISchemia supplied by a vessels with > 50% stenosis
  4. No limiting symptoms with omtx (IIIC)
79
Q

Indications for CABG vs PCI

1VD or 2VD - non proximal LAD

A

1VD or 2VD non proximal LAD

CABG: IIb C

PCI: IC

80
Q

Classification system for Reccomendations:

Class I

A

Class 1 Recomendation:

conditions for which the evidence and general agreement that a given procedure is useful and effective.

81
Q

Indications for CABG vs. PCI

1VD or 2 VD with prximal LAD

A

CABG: 1A

PCI: IIaB

82
Q

Classification system for recomendations

Class II

A

Class II Recomendations:

conditions about which there is conflicting evidence.

  • IIa: weight of the evidence/opinion is in favor of usefullness and efficacy
  • IIb: usefullness efficacy is less well establisched by evidence or oppion
83
Q

Classificaiton system for reccomendations

Class III

A

Class III Reccomendations:

conditions for whehich there is evidence and or general agreement that a given treatment may be less efficatious or even harmful.

84
Q

Level of Evidence

A

A

Level of Evidence A

Multiple RCT or meta-analysis

85
Q

Level of Evidence

B

A

Level of Evidence B:

Single RCT or non-randomized studies

86
Q

Level of Evidence:

C

A

Level of Evidence C:

  • Consensus
  • Small studies
  • retrospective studies
87
Q

Post infarction myocardial Necrosis -

time scale vs. percent necrosis - when is the most damage ?

A

Peak dammage is done at 24hrs (~80%)

after that the dammage plateaus

88
Q

CAD: What are the treatment options?

A
  1. Coronary Thrombolysis
  2. Angioplasy
  3. CABG
89
Q

Indications for thrombolysis post MI

A

Indicaitons for Thrombolysis post MI

  1. Impending or evolving MI
  2. within 3 hours of symptom onset
  3. Chest pain c/w angina
  4. ECG Changes
    1. ST elev >1mm in >2 limb leads
    2. ST elevation > 2mm > 2 precordial
  5. Absence of contraindications
90
Q

Contraindications to thrombolytics for MI

A
  1. Recent trauma
  2. within 6 weeks major surgery
  3. GIB (3months)
  4. Bleeding diasthasis
  5. Chronic liver disease
  6. allergy to thrombolytics
  7. stroke with residual
  8. TIA 6 months
  9. Cerebral hemorrhage
91
Q

Patient who is a setup for possible MCS after CABG

A

Early surgery after a transmural infarct has a higher risk and may need MCS

92
Q

Epidemiology of air in the CPB circuit

A

Incidence:

0.003-0.007%) but outcomes are poor despite heroic salvage efforts and mortality is near 50%.

93
Q

General steps for AIR entrained in the CPB cirucit.

A

General Steps for air in the cirucit

  1. most important step: is to immediately discontinuing cardiopulmonary bypass and clamp the arterial and venous lines to avoid pumping more air.
  2. Head in trendelenberg position
  3. Vent the aorta
  4. The patient’s upper body should be tilted steep Trendelenburg position and the
  5. RCP CVP is monitored as flow is initiated and increased to 1-2 liters/min.
  6. Hypothermia (20-22 degrees C)
  7. Resumption of Conventional cardiopulmonary bypass:
    1. is reinstituted with deep barbiturate anesthesia,
    2. hypothermia,
    3. elevated perfusion pressures
    4. Oxygen is used at 100% concentration to maximize blood content and to maximize the elimination gradient for nitrogen.
  8. Post Bypass
    1. Rewarming is done late and cautiously.
      1. Cerebral edema is anticipated and is treated with steroids, mannitol and barbiturates.
      2. High FiO2 is continued postoperatively for several hours.
      3. If available, hyperbaric oxygen therapy may be helpful for up to five hours after the incident.
94
Q

Contuct of RCP after air embolism in circuit .

A
  1. Retrograde cerebral perfusion:
    1. disconnecting the arterial line from the arterial cannula and connecting it to a redirected single cannula in the superior vena cava.
    2. CVP is monitored as flow is initiated and increased to 1-2 liters/min.
95
Q

RCP following air embolism in circuit

  • flow
  • temperature
A
  1. CVP is monitored as flow is initiated and increased to 1-2 liters/min.
  2. Hypothermia (20-22 degrees C) is used to lower the metabolic demands of the brain and to increase the solubility of gas in the blood.
96
Q

Most potent risk factor for in hospital mortality after a CABG

A

SHOCK

97
Q

Components of the STS Risk Model for CABG (10)?

A
  1. Multiple reoperations (OR: 4.19)
  2. Firss reop (OR 2.76)
  3. Shock (OR: 2.04)
  4. Surgery status (1.96)
  5. Renal failure / Dialyisis (1.88)
  6. Immunosupresion (1.75)
  7. IDDM (1.5)
  8. IABP (1.46)
  9. Chronic lung disease (1.4)
  10. Percutaneous angiopasty , 6 hrs (1.32)
98
Q

CABG Graft outcomes

LIMA at 1, 5, and 10 years

A

LIMA Patency

95-98% at one year

95% at 5 years

85-90% at 10 years

99
Q

CABG Conduit outcomes

LIMA at 1 year

A

LIMA patentcy at one year: 95-98%

100
Q

CABG Conduit outcomes

LIMA at 5 year

A

LIMA patentcy at 5 years: 94%

101
Q

CABG Conduit outcomes

LIMA at 10 year

A

LIMA patentcy at 10 years: 94%

102
Q

CABG Conduit Patency Rate

Radial Artery

A

Radial artery - is highly dependent on the distal runoff

Data shows:

90% patency at 1 year

85-90% patency at 5 years

103
Q

CABG Conduit Patency Rate

Saphenous vein at 1, 5, and 10 years

A

SVG patency rate at:

1 year: 85-90%

5 years: 75%

10 years : 50%

104
Q

CABG Conduit Patency Rate

Saphenous vein at 1 year

A

SVG patency rate at one year :

1 year: 85-90%

105
Q

CABG Conduit Patency Rate

Saphenous vein at 5 year

A

SVG patency rate at 5 year :

5 year: 75%

106
Q

CABG Conduit Patency Rate

Saphenous vein at 10 year

A

SVG patency rate at one year :

10 year: 50%

107
Q

CABG outcomes vs Graft used

SVG only

Relief of Angina at 10 and 15 years

A

SVG:

50% symptom free at 10 years

15% symptom free at 15 years

108
Q

CABG outcome vs Graft Used

IMA + SVG

Symptom free at 10 years

A

at 10 years 75% are angina free

109
Q

Benefits of IMA use

A
  1. Decreased incidence of reoperation
  2. Incrased time to reoperation
  3. IImproved event free survival
110
Q

In what situation is a radial artery best considered

A

when will be bypassing a stenosis >75-80% narrowing

111
Q

Post first time CABG survival

at 5, 10, 15 years

A

5 years: 90%

10 years: 80%

15 years: 60%

  • 90% 10 year survival with the use of a LIMA
112
Q

Post first time CABG survival

at 5 years

A

5 years: 90%

113
Q

Post first time CABG survival

at 10 years ?

A

10 years: 80%

  • 90% with the use of a LIMA
114
Q

Post first time CABG survival

at 15 years

A

15 years: 60%

115
Q

Quality of life post CABG

  • Quantification of satisfactory QOL?
  • Who is least likely to have an improved QOL ?
A

Quality of life post CABG

  • Quantification of satisfactory QOL?
    • most surviving patients report a satisfactory QOL at 5 years
  • Who is least likely to have an improved QOL?
    1. CHF
    2. Women
    3. Older patients
    4. Diabetics
116
Q

Most common complications following CABG

A
  1. Heart failure (65%)
  2. Neurologic event (7%)
  3. Hemorrhage (7%)
  4. Respiratory failure (7%)
  5. Dysrhythmia (6%)
  6. transmural MI (1-5%)
  7. Sternal wound infection (1-4%)
  8. Renal dysfunction
117
Q

Effect of CABG on ventricular arrhytmia

A

Cabg does not effect the frequency or severity of exercise or resting induced ventricular arrhythmia

118
Q

SYNTAX Trial at 1 Year:

Revascularization rate in CABG and PCI

A

SYNTAX Trial at 1 Year.

Revascularization:

  • CABG: 5.9%
  • PCI: 13.7%

Utah / kirklin (12 decks)

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