Ischemic Heart Disease

Question 1

Risk Factors for Cornary Artery Disease

Answer 1

• obestiy
• smoking
• HTN
• hyperlipidemia
• DM
• family history
• diet (fatty)
• sedintary lifestyle
• men & post-menopausal women

Question 2

Acute Coronary Syndrome
- 3 types & how they’re differentated

Answer 2

Unstable Angina
NSTEMI
STEMI

differentated by amount of tissue death
-unstable angina: no necrosis – just partial (90%) occulusion of the artery
-NSTEMI: partial necrosis of the myocardium (not full thickness)
-STEMI: necrosis full thickness death of the myocytes resulting in infarction

Question 3

Stable Angina
- patho & etiology
- signs & symptoms
- diagnostic results
- treatment

Answer 3

Angina: chest pain
patho: reduced blood flow to the heart (but not a partial or full blockage resulting in necrosis yet) but ischemia due to mismatch in blood O2 demand and flow

symptoms of stable: predictable pattern of chest pain (usually provoked with exertion) and gets better with rest

• chest pain: symptoms are unable to differentiate from MI so need to take seriously has this ever happened before

Diagnosis: no changes in EKG or biomarkers

Treamtn: Nitroglycerin & rest will relieve the pain

Question 4

Unstable Angina
- patho & what differentiates it from stable
- symptoms
- diagnostic tests
- treatment

Answer 4

unstable = changing chest pain
1. angina which is not relieved with rest
2. cahnges in the angina from before
3. angina which is new-onset (happens earlier in exercise

patho: due to atherosclerotic disease (most commonly a plaque) which breaks and creates stenosis of teh artery but not occlusion yet (still blood flow– just reduced)

symptoms: similar to an MI
- substernal chest pain, sweating, inc. HR, radiating pain, elevated BP
- symptoms are NOT releaved with rest or with nitroglycerin – thats how we know its unstable not stable angina

Diagnosics:
- EKG: may have ST depression or inverted T waves
- cardiac enzymes: will be NEGATIVE –> how we rule out an MI because there is no cardiac cell death

Treatment
- Asprin
- oxygen (if hypoxic)
- beat-blocker (to slow HR and decrease O2 demand)
- nitroglycerin (decrease O2 demand of heart vessels)
- anti-platlet (clopidagrel) therapy & anti-coag (heprain, enoxiparin)

Question 5

STEMI
- patho
- symptoms
- diagnosis
- treatment

Answer 5

ST elevated myocardial infarction

patho: infacrtion of the FULL thickness of the heart wall due to blockage & complete occlusion of teh cornary arteries (various locations)

symptoms
- chest pain: retrosternal, radiating to jaw, left arm & back
- atypical in women, DM & elderly pts.
- tightness, squeezing and pressure in the chest “levines sign”
- chest pain NOT releived by nitro or rest
- dyspnea, nausea, vomiting, dixxiness and syncope all possible
- hypotensive =more severe (normally HTN)

Diagnosis
- EKG: ST-elevation in the affected leads
- cardiac enzymes: POSITIVE for troponin (99th percentile), CK-MB, myoglobin (quickest to rise)

Treatment
- get to teh cath lab – for a PCI and cprnary angiogram
- Oxygen: if hypoxic
- asprin: for pain
- nitroglycerin: to reduce O2 demand of heart
- beta-blockers: to decrease HR and O2 demand
- anti-platlet& coag. therapy (heparin, fibrinolytics, long term tx.)

Question 6

NSTEMI
- patho
- symptoms
- diagnosis
- treatment

Answer 6

non-ST elevation myocardial infarction

patho: ruptured plaque from atherosclerosis in the vessels leading to partial ischemia of the mycardium but not full thickness
- either partial occulsion of a large vessel or full occlusion of a small vessel

symptoms
- chest pain: substernal, crushing, left arm and jaw pain
- chest pain not releaved with rest or nitro
- sweating, hyper or hypotensive

Diagnostics
- EKG: no ST elevation but can show ST depression and inverted T waves
- cardiac biomarkers: will be postive

Treatment
- may need trip to cath lab (less urgent that STEMI but still needed)
- oxygen (hypoxic)
- asprin
- beta blocker (reduce HR and O2 demand
- nitroglycerin (decrease O2 demand)
- anti-platlet therapy & anti-coag.

Question 7

where will you see on EKG…
- inferior wall MI
- anterio-lateral MI
- anterio-septal MI
- Lateral wall MI

Answer 7

inferior wall MI: ** II, III, avf**
anterio-lateral MI: V1, V2, V3, V4 (anterior) & I, avL, V5, V6 (lateral)
anterio-septal: V1,V2 (septal, anterior)
lateral MI: I,avL,V5,V6

Question 8

when are fibrinolytics given
contraindications

Answer 8

• given to extend time when trasnferring pt. to the cath. lab

contraindications
- previous hemorrhage stroke
- CVA in last year
- intracranial neoplasm
- internal bleeding
- aortic dissection

Question 9

GPIIb/IIIa antagonists
- what do they do
- contraindications

Answer 9

• inhibit platelet aggregation

contraindications
- active bleeding
- recetn surgery/trauma
- uncontrolled HTN
- stroke
- intracrainal issues
- low platelets

Question 10

long term treatment medications for those who have had ACS

Answer 10

• nitro
• beta blocker
• CCB
• platlet &anti-coag. inhibitor (asprin + clopidogrel/ ticagrelor/prasegrel + anti-coag.)
• statins to reduce cholesterol
• DM: on metformin or glipizide

Question 11

spontaneous cornary artery dissection
- patho
- who affected
- what vessel

Answer 11

• dissection of the cornary arteries with poor pathology as to why
• affects women of childbearing years
• pregnancy — MI afterwards
• LAD is most commonly affected vessel