**Ischemic Heart Disease

Question 1

Stable angina c/f

Answer 1

1. Coronary artery NOT completely blocked
2. Chest pain worse on exertion
3. Lasts <10mins

Question 2

Coronary Artery disease includes (3)

Answer 2

1. Stable angina
2. Acute coronary syndromes
   -Unstable angina
   -Non - ST elevated Myocardial infarction
   
   • ST elevated Myocardial infarction
3. Variants of angina

Question 3

Mc r/f of CAD

Answer 3

HTN

Question 4

Most sever/worst r/f of CAD

Answer 4

DM

Question 5

Most important r/f of CAD

Answer 5

LDL cholesterol

Question 6

Most imp r/f to eliminate to see immediate benefit in CAD

Answer 6

Smoking (↓50% risk in 1yr, ↓90% in 2yrs)

Question 7

Menstruating women virtually never have myocardial infarctions. Why?

Answer 7

Protective effect of menstruation and
Estrogen

Question 8

Tako Tsubo cardiomyopathy

Answer 8

Post overwhelming emotional stress
Ballooning of apical LV, Lv dyskinesis
*Coronary angio normal
ST elevated

Question 9

Pt with left sided chest pain,

ECG shows elevated ST seg. Next step Cardiac markers? Diagnosis?

Answer 9

ST segment elevated -
Diagnosis: STEMI

Question 10

Pt with left sided chest pain,

ECG normal/no ST elevation. Next step Cardiac markers? Diagnosis?

Answer 10

Cardiac troponin
Positive - NSTEMI
Negative - Unstable angina

Question 11

Thrombolytic therapy is beneficial in?

Answer 11

STEMI - complete blockade

Harmful in Unstable angina and NSTEMI

Question 12

Exercise tolerance test/Stress test (ETT)

Answer 12

Done for stable angina
Chest pain h/o on exertion
ECG normal
Cannot pin point etiology

Pt should be able to run on threadmill

Question 13

Chest pain h/o on exertion
Cannot pin point etiology
ECG BASELINE ABNORMALITIES,
what tests are indicated?

Answer 13

Baseline abn ECG d/t LBBB, LVH
While exercising below inv can be done
1. Nuclear isotope uptake: thallium or sestamibi
Myocardial perfusion scan
↓Uptake - artery block
2. ECHO - ↓wall motion (low blood supply)

When results are abn, do
●CT - Coronary angio
●Best - invasive coronary angiogram
<50% insignificant
>70% block - STENT in the same procedure

Question 14

Chest pain h/o on exertion
Cannot pin point etiology
ECG normal
But pt cannot execise, what can induce exercise like symptoms?

Answer 14

Dipyridamole/Adenosine with nuclear scan
Dobutamine with ECHO

Question 15

Criteria for Stent and CABG in CAD

Answer 15

Stent:
2 vessels are blocked

CABG/Bypass Sx:
2 vessels blocked with DM
3 vessels blocked
Left main artery blocked (50% stenosis)

Question 16

Holter monitor

Answer 16

Ambulatory, continuous ECG monitor
RHYTHM EVALUATION - AF, flutter, ectopy such as premature beats, ventricular tachycardia.

Cannot detect ischemia/ST seg

Question 17

STEMI Mx

Answer 17

●MONA therapy - initial
1. ASPIRIN (30mg loading dose)
2. Morphine - chest pain
3. NTG if chest pain not reduced with morphine (nitroglycerine)
4. O2 if sat <90%

●SEND IMMEDIATELY TO CATHETER LAB - with in 90mins
Percutaneous coronary intervention (PCI) performing ..
CT-CA stent/CABG

●In absence of catheter lab, THROMBOLYTICS (tPA tissue plasminogen activator) - within 6hrs
Streptokinase not used in aus

(Clopidogrel, prasugrel, or ticagrelor if aspirin C/I)

Question 18

STEMI symptoms onset <12 hrs and >12hrs mx

Answer 18

<12 hrs - Aspirin, PCI&raquo_space; thrombolytics
> 12 hrs - same mx, urgency wont change outcome

Question 19

NSTEMI Mx

Answer 19

No ST seg elevation, ST DEPRESSION seen in few cases
Troponin positive

First - Aspirin …
Troponin

Next - Heparin (URGENT) to avoid clotting (does not break clots)
No ST elevation - thrombolysis not req

Angiogram with in 48hrs - >70% block - stent

Question 20

Mcc of death after PCI for CAD

Answer 20

Ventricular fibrillation

Question 21

Complications of CAD

Answer 21

1. Postinfarction angina after PCI - do bypass Sx
2. Pump dysfunction
   ●Contractile dysfunction - LV, RV, Both ventricles, true aneurysm
   ●Mechanical- mitral regurgitation, pseudoaneurysm
   ●Electromechanical dissociation
3. Dressler syndrome: MI f/b Pericarditis like pain
   Mx- Aspirin, NSAIDs

Question 22

Prinzmetal angina

Answer 22

Caused d/t spasm of coronary artery
Happens at rest
ST elevation only during episodes - difficult to diagnose
ETT, CT-CA will be normal

●Diagnosis:
Ergonovine - causes coronary artery spasm - ST elevation

●Rx:
NTG/CCB

Question 23

ECG in NSTEMI

Answer 23

1. ST depression -
   downsloping/horizontal in 2 contiguous leads significant (upsloping not significant)
2. T wave flattening or inversion