General Cardiac Flashcards
1
Q
time scale for myocardial death
A
some with 20’ of ischemia – wide spread in 60’
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
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.
4
Q
a 33% loss in diameter –> ? loss in crossectional area
A
50%
5
Q
a 50% loss in diameter –> ? looss in xs area
A
75%
6
Q
a 67% narrowing of the coronary diatmeter –> % ? loss in xs area
A
90%
7
Q
FFR what is it?
A
Pressure distal to obstruction/MAP FFR
8
Q
Systolic cardiac function
A
contractility of the ventricle
9
Q
Diastolic dysfunction
A
describes the compliance and extensibility and is related to the preload
10
Q
CASS score , description of how its calculated?
A
Summation of 5 global wall regions from an RAO cine projection
11
Q
CASS score & LVEF:
No LV dysfucition
A
EF 65%
CASS < 5
12
Q
CASS score vs LVEF:
Mild LV dysfunction
A
LVEF 50-65%
CASS score 5-9
13
Q
CASS socre vs LVEF:
Modrate dysfunction
A
LVEF: 35-50%
CASS: score 9-15
14
Q
CASS score vs LVEF:
severe dysfunction
A
LVEF :15%
CASS: > 15
15
Q
Aortic regurgitaion - what dimensions are used to grade
A
LV Enlargment
LVESD,
LVEDD
EF
Fractional shortening
Echo vena contracta
16
Q
LV Diamterers in severe AI
A
- LVESD > 50mm
- LVEDD> 70mm
17
Q
EF criteria for severe AI
A
EF< 50%
18
Q
Echo vena contracta c/w severe AI
A
VC > 6-7mm
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:
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
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.
22
Q
TIMI 2 flow
A
TIMI 2 flow: partial reperfusion
delayed or sluggish antegrade flow with complete filling of the distal territory.
23
Q
TIMI 3 flow
A
TIMI 3: is normal flow which fills the distal coronary bed completely
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
25
LV Strain pattern on ECG
ST segment depression and T wave inversion in the left-sided leads
26
27
Frequency of death in the US from CAD
(*how many dealths per minute*) ?
1 Death per minute
28
Prevlance of CAD in the US
5.5 - 7.5 million have *symptomatic* **CAD**
29
what are the _categories of of risk factors_ for **CAD**?
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
30
**Category 1** risk factors for **CAD**
**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
31
**Category 2** risk factors for _CAD_
**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
32
**Category 3** risk factors for _CAD_
Category 3 - if modified _might_ lower risk
1. Psychosocial factors
2. Lippoprotiein (a)
3. Homocysteine
4. Oxidative stress
5. Alcohol consumption
33
Category 4 risk factors for CAD
Category 4 - non-modifiable risk factors for CAD
## Footnote
1. Age
2. Gender
3. Family History
34
CAS LV Regions
1. septal
2. anterolateral
3. lateral
4. posterolateral
35
Fundamental pathogenesis of CAD ?
Pathogenesis of CAD
1. Proliferation of smooth muscle cells
2. Connective tissue matrix proliferation
3. Lipid accumulation
* intracellular
* extracellular
36
steps to coronary artery lesion
1. Fatty streak
2. Diffuse intimal thickening
3. Fiberous plaque
4. Advanced complex lesion
37
In atherosclerosis - what is a Fatty Streak
Fatty streak - first step in atherosclerosis
invasion of the intima
begins in teens to 20's
38
In atherosclerosis - what is Diffuse intimal thickening
Diffuse intimal thickening - second step to atherosclerosis
* increased smooth muscle cells
* increased connective tissue deposition
39
In atherosclerosis - what is the Fiberous plaque?
**Fiberous plaque** - third step to atherosclerosis
* proliferation of smoothe muscle cells
* Fiberous cap is placed with a zone of necrotic tissue below
40
in atherosclerosis what is the advanced (complicated lesion)
Final stage of atherosclerosis
Features:
* Calcification
* Hemorrhage
* Fissues and cracks in the intima
41
Rate of progress in atherosclerosis
1. in 2 years 20% of stenosis will worsen in severity
2. 50% of patients will devellop important new lesions
42
dye used in **radionuceotide testing** for _CAD_
thallium 201
43
*sensitivity* and *specificity* for _radionuceotide testing_ for **CAD**
1. *sensitivity*: 90%
2. *specificity*: 75%
44
**Persantine** - what is it ?
**_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.
45
Stress ECHO Findings diagnosis for CAD
1. Initial augmentation of contractility followed by "dropout" (loss) - diagnostic of ischemic area
2. Failure to agument suggest scar
Sensitivity and specificity 85%
46
_Natural history of CAD with respect to extent of disease_
5 year survival for any single system
_5 year survival_ for any **single** coronary system: 90-95%
47
_Natural history of CAD with respect to extent of disease_
5 year survival for RCA disease alone
_5 year survival_ for any **RCA** coronary disease : 96%
48
_Natural history of CAD with respect to extent of disease_
5 year survival for distal LAD disease alone
_5 year survival_ for **distal LAD** coronary disease : 92%
49
_Natural history of CAD with respect to extent of disease_
5 year survival for *proximal* LAD disease alone
_5 year survival_ for **proximal LAD** coronary disease : 90%
50
_Natural history of CAD with respect to extent of disease_
5 year survival for *two system coronary artery* *disease*
_5 year survival_ for disease of **two coronary system** : 88%
51
_Natural history of CAD with respect to extent of disease_
5 year survival for *three system coronary artery* *disease*
_5 year survival_ for disease of **3 coronary system** : 70%
52
_Natural history of CAD with respect to extent of disease_
5 year survival for *left main coronary artery* *disease*
_5 year survival_ for **left main** **coronary artery disease** : 40-60%
53
Risks related to reprofusion of myocardium?
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
Teleologic explanation for **unstable angina / AMI**
* **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
*%* of patients with **CAD** have a _significantly stenotic LM_.
_10-20% of patients_ with **CAD** have a *significantly stenotic **LM***
56
FFR indicator for surgery:
0.75 - 0.88%
57
Natural history of coronary artery disease is dependent on:
1. severity
2. distribution
3. Rate of progress on both
58
Diastolic function in patients with CAD
Decreased diastolic function
present as:
1. reduced filling rate
2. increased time to peak filling rate
59
**Echocardiography**:
What are the _longitudinal segments of the heart_?
BASE (to the papillary muscles)
MID VENTRICLE (to the distal third)
APEX (distal third)
60
What is unstable angina ?
**_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
**ARTS-II Trial** - what does the anacronym stand for?
**ARTS - II Trial:** **A**rterial **R**evascularization **T**herapies Part II:
*a non-randomized comparison of:*
_contemporary PCI_ vs. _coronary artery bypass grafting (CABG)_
in patients with *multi-vessel coronary artery lesions*
62
**ARTS-II Trial** - Study Design
**_ARTS-II Trial Study Design_**
607 Patients treated with Sirolimus-eluting stent
* compared with historical control
* 3.7 stents per patient
* Endpoints:
* MACE
63
64
ARTS II Trial Results
* No difference in ARTS II Stents and ARTS 1 CABG MACE at one yar
* Improvement in Sirolimus stents over BMS but not CABG
65
_Seven factors_ Most predicticve of *_early mortality_* after **CABG**:
_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
SYNTAX Study population
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
General study design for Syntax trial
**_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
**_Syntax_** trial: one-year outcomes
*Major differences* between _PCI_ and _CABG_
**_SYNTAX Trial at 1 Year_**: Major differences betwen groups
* _Revascularization_: CABG: 5.9%; PCI: 13.7%
* _Stroke_: CABG: 2.2%, PCI: 0.6%
69
**_SYNTAX Trial at 1 Year_**: *Outcomes* with _no difference_ between groroups
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
_Difference_ between **Hibernating** and **Stunned** myocardium
* * **_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
Major _steps_ to **coronary artery thrombosis**:
**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
**Vasospasm** in _Coronary artery thrombosis_:
**Coronary artery thrombosis** - **_Vasospasm_**
First step is *vasospasm*
Due to the release of Thromboxane A2
73
**Coronary artery thrombosis** -
_Plaque Repture_
**Plaque Repture** - second step to Coronary artery thrombosis:
Secondary to ulceration and fissure formation
leads to .... *Platelet Activation*
74
EVIDENCE FOR CABG
## Footnote
Name the _t__hree_ major tirials demonstrating evidence for **CABG vs Rx**
_Three_ major tirials demonstrating evidence for **CABG vs Rx**
1. VA
2. European Coronary Surgery study group
3. Coronary Artery Surgery Study
75
**EVIDENCE FOR CABG**
## Footnote
Problems with the _Three_ major tirials demonstrating evidence for **CABG vs Rx**
* 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
**EVIDENCE FOR CABG**
## Footnote
overall findings from the _Three_ major tirials demonstrating evidence for **CABG vs Rx**
* 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
_Indications_ for **CABG** in patients *without symptoms.*
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
_Indications_ for **CABG** in the **symptomatic patient (4) ?**
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
**Indications for CABG vs PCI**
1VD or 2VD - non proximal LAD
1VD or 2VD non proximal LAD
CABG: IIb C
PCI: IC
80
_Classification system for Reccomendations:_
## Footnote
**Class I**
_Class 1 Recomendation:_
conditions for which the evidence and general agreement that a given procedure is useful and effective.
81
_Indications for CABG vs. PCI_
1VD or 2 VD with prximal LAD
CABG: 1A
PCI: IIaB
82
_Classification system for recomendations_
## Footnote
**Class II**
_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
_Classificaiton system for reccomendations_
## Footnote
**Class III**
_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
_Level of Evidence_
## Footnote
**A**
**Level of Evidence A**
Multiple RCT or meta-analysis
85
_Level of Evidence_
## Footnote
**B**
_Level of Evidence B:_
Single RCT or non-randomized studies
86
_Level of Evidence:_
## Footnote
**C**
_Level of Evidence C:_
* Consensus
* Small studies
* retrospective studies
87
Post infarction **myocardial Necrosis** -
time scale vs. percent necrosis - _when is the most damage_ ?
Peak dammage is done at 24hrs (~80%)
after that the dammage plateaus
88
**CAD:** What are the treatment options?
1. Coronary Thrombolysis
2. Angioplasy
3. CABG
89
Indications for _thrombolysis_ post MI
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
_Contraindications_ to **thrombolytics** for MI
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
Patient who is a setup for possible MCS after CABG
Early surgery after a transmural infarct has a higher risk and may need MCS
92
Epidemiology of air in the CPB circuit
Incidence:
## Footnote
0.003-0.007%) but outcomes are poor despite heroic salvage efforts and mortality is near 50%.
93
*General steps* for **AIR entrained** in the **CPB cirucit**.
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
_Contuct of RCP_ after **air embolism** in circuit .
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
RCP following air embolism in circuit
- flow
- temperature
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
Most potent risk factor for in hospital mortality after a CABG
SHOCK
97
Components of the **STS Risk Model** for **CABG** (10)?
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
**CABG** Graft outcomes
LIMA at 1, 5, and 10 years
**LIMA Patency**
95-98% at one year
95% at 5 years
85-90% at 10 years
99
**CABG** Conduit outcomes
LIMA at 1 year
LIMA patentcy at one year: 95-98%
100
**CABG** Conduit outcomes
LIMA at 5 year
LIMA patentcy at 5 years: 94%
101
**CABG** Conduit outcomes
LIMA at 10 year
LIMA patentcy at 10 years: 94%
102
**CABG** Conduit Patency Rate
## Footnote
**Radial Artery**
Radial artery - is highly dependent on the distal runoff
Data shows:
90% patency at 1 year
85-90% patency at 5 years
103
**CABG** Conduit Patency Rate
**Saphenous vein** at 1, 5, and 10 years
SVG patency rate at:
1 year: 85-90%
5 years: 75%
10 years : 50%
104
**CABG** Conduit Patency Rate
**Saphenous vein** at 1 year
SVG patency rate at one year :
1 year: 85-90%
105
**CABG** Conduit Patency Rate
**Saphenous vein** at 5 year
SVG patency rate at 5 year :
5 year: 75%
106
**CABG** Conduit Patency Rate
**Saphenous vein** at 10 year
SVG patency rate at one year :
10 year: 50%
107
**CABG** outcomes vs **Graft used**
**SVG only**
_Relief of Angina at 10 and 15 years_
SVG:
50% symptom free at 10 years
15% symptom free at 15 years
108
CABG outcome vs Graft Used
IMA + SVG
Symptom free at 10 years
at 10 years 75% are angina free
109
_Benefits_ of **IMA** use
1. Decreased incidence of reoperation
2. Incrased time to reoperation
3. IImproved event free survival
110
In what situation is a radial artery best considered
when will be bypassing a stenosis \>75-80% narrowing
111
Post *first time* **CABG** _survival_
at 5, 10, 15 years
5 years: 90%
10 years: 80%
15 years: 60%
* 90% 10 year survival with the use of a LIMA
112
Post *first time* **CABG** _survival_
at 5 years
5 years: 90%
113
Post *first time* **CABG** _survival_
at 10 years ?
10 years: 80%
* 90% with the use of a LIMA
114
Post *first time* **CABG** _survival_
at 15 years
15 years: 60%
115
**_Quality of life post CABG_**
* Quantification of satisfactory QOL?
* Who is least likely to have an improved QOL ?
**_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
*Most common* _complications_ following **CABG**
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
Effect of CABG on ventricular arrhytmia
Cabg does not effect the frequency or severity of exercise or resting induced ventricular arrhythmia
118
**SYNTAX** Trial at 1 Year:
*Revascularization* rate in **CABG** and **PCI**
_**SYNTAX** Trial at 1 Year._
Revascularization:
* CABG: 5.9%
* PCI: 13.7%
