ISCHEMIC HEART DISEASE Flashcards
The major determinants of myocardial oxygen demand (MVO2)
heart rate, myocardial contractility, and myocardial wall tension (stress).
the major site of atherosclerotic disease
Epicardial coronary arteries
The condition in which patients with IHD also can present with cardiomegaly and heart failure secondary to ischemic damage of the LV myocardium that may have caused no symptoms before the development of heart failure
ischemic cardiomyopathy
Which of the following is true regarding CSAP?
A. Crescendo-decrescendo in nature typically lasts 2–5 min, and can radiate to either shoulder and to both arms
B. Rarely localized below the umbilicus or above the mandible
C. Typical patient with angina is a man >50 years or a woman >60 years of age who complains of episodes of chest discomfort
D. Chest pain is described as heaviness, pressure, squeezing, smothering, or choking and only rarely as frank pain.
All are true
- Aortic stenosis, aortic regurgitation, pulmonary hypertension, and hypertrophic cardiomyopathy must be excluded, since these disorders may cause angina in the absence of coronary atherosclerosis.
- ischemia can cause transient LV failure with the appearance of a third and/or fourth heart sound, a dyskinetic cardiac apex, mitral regurgitation, and even pulmonary edema.
It is an independent risk factor for IHD and may be useful in therapeutic decision-making about the initiation of hypolipidemic treatment
High sensitivity CRP
*An elevated level of high-sensitivity C-reactive protein (CRP) (specifically, between 1 and 3 mg/L)
* Major benefit of high-sensitivity CRP is in reclassifying the risk of IHD in patients in the “intermediate” risk
TRUE OR FALSE: Presence of LVH is a significant indication of increased risk of adverse outcomes from IHD
True
The most widely used test for both the diagnosis of IHD and the estimation of risk and prognosis
STRESS TESTING
* involves recording of the 12-lead ECG before, during, and after exercise, usually on a treadmill
Indications in discontinuing treadmill stress test
- Evidence of chest discomfort
- Severe shortness of breath
- Dizziness
- Severe fatigue
- ST-segment depression >0.2 mV (2 mm)
- A fall in systolic blood pressure >10 mmHg
- Development of a ventricular tachyarrhythmia
ischemic ST-segment response in stress testing is generally defined as
flat or downsloping depression of the ST segment >0.1 mV below baseline (i.e., the PR segment) and lasting longer than 0.08 secs
Contraindications to exercise stress testing include
- Rest angina within 48 hours
- Unstable rhythm
- Severe aortic stenosis
- Acute myocarditis
- Uncontrolled heart failure
- Severe pulmonary hypertension
- Active infective endocarditis
What is the ISCHEMIA trial?
The ISCHEMIA trial informs decision-making about referral for coronary arteriography (with intent to perform revascularization) in patients with stable IHD and an ejection fraction >35% even in the presence of moderate-severe ischemia on noninvasive functional testing
What are the principal prognostic indicators in patients known to have IHD
- Age
- Functional state of the left ventricle
- Location(s) and severity of coronary artery narrowing
- Severity or activity of myocardial ischemia
specific sinus node inhibiting agent that may be helpful for preventing cardiovascular events in patients with IHD who have a resting heart rate ≥70 beats/ min (alone or in combination with a beta blocker) and LV systolic dysfunction.
Ivabradine
TRUE OR FALSE:
Aspirin should be administered indefinitely and a P2Y12 antagonist daily (dual antiplatelet therapy [DAPT]) for at least 1 year after implantation of a drug-eluting stent
TRUE
Which of the following best describes the typical presentation of stable angina pectoris?
A) Sharp, fleeting chest pain lasting seconds
B) Crescendo-decrescendo substernal discomfort lasting 2–5 minutes
C) Localized left submammary dull ache lasting hours
D) Chest pain that worsens with deep breathing and movement
Answer: B) Crescendo-decrescendo substernal discomfort lasting 2–5 minutes
Rationale: Stable angina is characterized by transient myocardial ischemia that presents as a heaviness, pressure, or squeezing sensation. It typically follows a crescendo-decrescendo pattern, lasts 2–5 minutes, and is triggered by exertion or emotional stress. Sharp, fleeting pain or prolonged aches are not characteristic of ischemic chest pain
Which of the following findings strongly suggests that a patient’s chest pain is NOT due to myocardial ischemia?
A) Chest discomfort relieved by sublingual nitroglycerin
B) Chest pain localized below the umbilicus or above the mandible
C) Pain occurring predictably with exertion
D) Radiation of pain to both arms
Answer: B) Chest pain localized below the umbilicus or above the mandible
Rationale: Myocardial ischemic pain is typically substernal and can radiate to the shoulders, arms, jaw, or epigastrium. Pain localized below the umbilicus or above the mandible is uncommon for ischemia and suggests a non-cardiac cause.
Which of the following laboratory findings is an independent risk factor for ischemic heart disease (IHD) and may aid in therapeutic decision-making?
A) Elevated high-sensitivity C-reactive protein (hs-CRP)
B) Decreased hematocrit
C) Low thyroid-stimulating hormone (TSH)
D) Elevated serum creatinine
Answer: A) Elevated high-sensitivity C-reactive protein (hs-CRP)
Rationale: An hs-CRP level between 1 and 3 mg/L is an independent risk factor for IHD and may help in reclassifying the risk in intermediate-risk patients.
What is the primary purpose of an exercise stress test in patients with suspected ischemic heart disease (IHD)?
A) To determine the patient’s cholesterol levels
B) To assess limitations in exercise performance and detect myocardial ischemia
C) To directly visualize coronary artery stenosis
D) To measure left ventricular ejection fraction
Answer: B) To assess limitations in exercise performance and detect myocardial ischemia
Rationale: The exercise stress test evaluates a patient’s exercise tolerance, detects ischemic ECG changes, and correlates them with chest discomfort. It does not measure cholesterol levels, directly visualize coronary stenosis (which requires coronary angiography), or assess left ventricular ejection fraction (which is done via echocardiography or MRI).
The most widely used test for both the
diagnosis of IHD and the estimation of risk and prognosis involves recording of the 12-lead ECG before, during, and after exercise, usually
on a treadmill
Which of the following ECG findings is considered diagnostic for myocardial ischemia during an exercise stress test?
A) Upsloping ST-segment depression
B) Flat or downsloping ST-segment depression >0.1 mV lasting longer than 0.08 s
C) T-wave inversion without ST-segment changes
D) Premature ventricular contractions
Answer: B) Flat or downsloping ST-segment depression >0.1 mV lasting longer than 0.08 s
Rationale: Flat or downsloping ST-segment depression is a hallmark of myocardial ischemia. Upsloping ST-segment depression, isolated T-wave inversions, and premature ventricular contractions are not considered diagnostic of ischemia.
Which of the following is a contraindication to performing an exercise stress test?
A) History of stable angina
B) Mild hypertension
C) Unstable rhythm and rest angina within 48 hours
D) Hyperlipidemia
Answer: C) Unstable rhythm and rest angina within 48 hours
Rationale: Contraindications to stress testing include recent rest angina (within 48 hours), unstable arrhythmias, severe aortic stenosis, acute myocarditis, uncontrolled heart failure, severe pulmonary hypertension, and active infective endocarditis. Stable angina, mild hypertension, and hyperlipidemia are not contraindications.
Which of the following increases the likelihood of a false-positive stress test result?
A) Severe three-vessel coronary disease
B) Obstructive disease limited to the circumflex artery
C) Resting ST-segment and T-wave abnormalities
D) Achieving target heart rate during the test
Answer: C) Resting ST-segment and T-wave abnormalities
Rationale: False-positive results are more common in patients with resting ST-segment and T-wave abnormalities, intraventricular conduction disturbances, left ventricular hypertrophy, or those taking cardioactive drugs (e.g., digitalis). Obstructive disease limited to the circumflex artery can lead to false-negative results.
What is considered an adverse prognostic sign during an exercise stress test?
A) Progressive increase in blood pressure with exercise
B) ST-segment depression persisting for more than 5 minutes after exercise
C) Achievement of 85% of maximal predicted heart rate
D) Mild fatigue at peak exercise
Answer: B) ST-segment depression persisting for more than 5 minutes after exercise
Rationale: Persistent ST-segment depression (>5 minutes post-exercise) suggests severe IHD and a high risk of adverse cardiac events. A normal response includes a progressive rise in heart rate and blood pressure, while achieving 85% of the maximal heart rate is the target for test completion.
Which of the following cardiac imaging techniques is used when the resting ECG is abnormal, such as in left bundle branch block or a paced ventricular rhythm?
A) Standard exercise stress test
B) Stress myocardial radionuclide perfusion imaging
C) Resting echocardiography
D) Coronary artery calcium scoring
Answer: B) Stress myocardial radionuclide perfusion imaging
Rationale: In cases where the resting ECG is abnormal, an exercise test alone may not be sufficient. Stress myocardial radionuclide perfusion imaging using thallium-201 or 99m-technetium sestamibi improves diagnostic accuracy by assessing myocardial perfusion and detecting ischemia
What is the primary purpose of pharmacologic stress testing with adenosine?
A) To directly measure left ventricular ejection fraction
B) To create a coronary “steal” phenomenon by increasing flow in nondiseased coronary segments
C) To stimulate ischemia by increasing myocardial oxygen demand (MVO2)
D) To evaluate myocardial fibrosis
Answer: B) To create a coronary “steal” phenomenon by increasing flow in nondiseased coronary segments
Rationale: Adenosine induces vasodilation, leading to a “coronary steal” effect where blood flow increases in healthy coronary arteries while diseased segments receive reduced perfusion. This helps identify ischemic areas via imaging.
According to the ISCHEMIA trial, early referral for an invasive strategy in patients with stable IHD and an ejection fraction >35% was associated with which of the following outcomes?
A) Reduction in myocardial infarction and death
B) Increased risk of cardiovascular mortality
C) No reduction in myocardial infarction or death but better angina relief
D) Worse angina symptoms compared to a conservative strategy
Answer:
✅ C) No reduction in myocardial infarction or death but better angina relief
Rationale: The ISCHEMIA trial showed that early referral for coronary arteriography and revascularization did not reduce the risk of myocardial infarction (MI) or death but was more effective than a conservative medical approach in relieving angina symptoms.
In patients who are unable to exercise due to peripheral vascular disease or deconditioning, what pharmacologic agent can be used as an alternative to stress testing?
A) Beta-blockers
B) Furosemide
C) Dobutamine
D) Metformin
Answer: C) Dobutamine
Rationale: Dobutamine is used in pharmacologic stress testing to increase myocardial oxygen demand (MVO2) by stimulating the heart rate and contractility, mimicking the effects of exercise.
Coronary arteriography is indicated in which of the following patients?
A) Patients with chronic stable angina who remain symptomatic despite medical therapy
B) Patients with unclear symptoms requiring confirmation or exclusion of IHD
C) Patients with angina and evidence of ischemia on noninvasive testing with ventricular dysfunction
D) All of the above
Answer:
✅ D) All of the above
Rationale: Coronary arteriography is indicated for (1) severely symptomatic angina patients despite medical therapy, (2) those with diagnostic uncertainty, and (3) those with ischemia on noninvasive testing combined with ventricular dysfunction.
In which scenario is coronary arteriography considered necessary after a myocardial infarction?
A) Patients with recurrent angina after MI
B) Patients with heart failure following MI
C) Patients with ischemic changes on stress testing post-MI
D) All of the above
Answer:
✅ D) All of the above
Rationale: Post-MI patients at high risk, including those with recurrent angina, heart failure, or ischemic signs on stress testing, should undergo coronary arteriography to assess the severity of CAD and guide further management.
Which of the following is NOT considered a major prognostic indicator in patients with known IHD?
A) Age
B) Severity of myocardial ischemia
C) Blood oxygen saturation
D) Functional state of the left ventricle
Answer: C) Blood oxygen saturation
Rationale: The principal prognostic factors in IHD include age, LV function, severity/location of coronary narrowing, and myocardial ischemia. Blood oxygen saturation is not a primary factor in assessing long-term IHD prognosis.
Which of the following findings indicates a high risk for adverse coronary events?
A) Completion of stage III of the Bruce protocol with a normal perfusion scan
B) ST-segment depression ≥0.2 mV at any stage of an exercise test
C) Normal left ventricular (LV) ejection fraction on echocardiography
D) No symptoms of angina despite mild coronary artery disease
✅ Answer: B) ST-segment depression ≥0.2 mV at any stage of an exercise test
Rationale: High-risk stress test findings include:
ST-segment depression ≥0.2 mV at any stage
ST depression persisting >5 minutes post-exercise
Drop in systolic BP >10 mmHg during exercise
Exercise-induced ventricular tachyarrhythmias
A and C indicate a low-risk profile, and D does not necessarily indicate an increased risk.
Which of the following factors is associated with an increased risk of coronary events?
A) Increased carotid intimal thickness on ultrasound
B) Elevated C-reactive protein (CRP) levels
C) Extensive coronary calcification on EBCT
D) All of the above
✅ Answer: D) All of the above
Rationale: CRP, coronary calcification, and carotid intimal thickening are all markers of systemic atherosclerosis and increase the risk of coronary events.
What is the primary mechanism by which β-blockers reduce myocardial oxygen demand?
A) Increase in myocardial contractility
B) Reduction in heart rate, blood pressure, and contractility
C) Direct coronary vasodilation
D) Increase in stroke volume
✅ Answer: B) Reduction in heart rate, blood pressure, and contractility
Rationale: β-blockers inhibit adrenergic activation, reducing heart rate, myocardial contractility, and arterial pressure, leading to decreased oxygen demand. They do not directly dilate coronary arteries (C).
Why should β-blockers not be discontinued abruptly in patients with ischemic heart disease?
A) They cause rebound hypertension and intensify ischemia
B) They cause sudden hypotension
C) They can lead to severe bradycardia
D) They increase the risk of hyperglycemia
✅ Answer: A) They cause rebound hypertension and intensify ischemia
Rationale: Sudden withdrawal of β-blockers can lead to adrenergic rebound, increasing heart rate and blood pressure, which may worsen ischemia and trigger myocardial infarction.
Which of the following β-blockers is cardioselective (β1-selective) and preferred in patients with mild bronchial obstruction?
A) Propranolol
B) Labetalol
C) Atenolol
D) Carvedilol
✅ Answer: C) Atenolol
Rationale: Cardioselective β1-blockers (e.g., metoprolol, atenolol) selectively block β1 receptors in the heart with less effect on β2 receptors in the lungs, making them preferable in mild bronchial obstruction.
What is the primary mechanism of action of calcium channel blockers (CCBs) in angina treatment?
A) Increase in myocardial contractility
B) Coronary vasodilation and reduction in myocardial oxygen demand
C) Direct activation of β-receptors
D) Inhibition of sodium channels in cardiac tissue
✅ Answer: B) Coronary vasodilation and reduction in myocardial oxygen demand
Rationale: CCBs dilate coronary arteries, reduce afterload, and decrease myocardial oxygen demand.
Which class of calcium channel blockers is most effective in treating Prinzmetal’s (variant) angina?
A) Dihydropyridines (e.g., amlodipine, nifedipine)
B) Nondihydropyridines (e.g., verapamil, diltiazem)
C) Both are equally effective
D) Neither, as CCBs are not used for variant angina
✅ Answer: A) Dihydropyridines (e.g., amlodipine, nifedipine)
Rationale: Dihydropyridines are potent vasodilators and are particularly effective in reducing coronary artery spasm, which is the hallmark of Prinzmetal’s angina.
Which of the following is a key indication for using a calcium channel blocker in patients with angina?
A) History of a recent myocardial infarction
B) Inadequate response to a combination of beta blockers and nitrates
C) Symptomatic improvement after beta blocker monotherapy
D) Advanced coronary artery disease with severe left ventricular dysfunction
✅ Answer: B) Inadequate response to a combination of beta blockers and nitrates
Rationale: CCBs are often used when patients fail to respond adequately to beta blockers and nitrates. They are also useful in specific conditions such as Prinzmetal’s angina and symptomatic peripheral arterial disease.
What is the primary mechanism of action of aspirin in preventing coronary events?
A) Inhibition of platelet P2Y12 ADP receptor
B) Inhibition of cyclooxygenase (COX) and thromboxane A2 production
C) Inhibition of the platelet glycoprotein IIb/IIIa receptor
D) Enhancement of nitric oxide production
✅ Answer: B) Inhibition of cyclooxygenase (COX) and thromboxane A2 production
Rationale: Aspirin irreversibly inhibits platelet cyclooxygenase (COX), which leads to a reduction in thromboxane A2 production, thereby inhibiting platelet aggregation and activation.
Which of the following is true regarding the use of clopidogrel in patients with ischemic heart disease (IHD)?
A) Clopidogrel is the first-line therapy for stable chronic IHD
B) Clopidogrel is often used as a substitute for aspirin in patients with aspirin-induced gastrointestinal side effects
C) Clopidogrel should be combined with aspirin in all patients with chronic stable IHD
D) Clopidogrel has no benefit in patients undergoing implantation of a coronary stent
✅ Answer: B) Clopidogrel is often used as a substitute for aspirin in patients with aspirin-induced gastrointestinal side effects
Rationale: Clopidogrel can be used as an alternative to aspirin for patients who experience side effects from aspirin, such as gastrointestinal issues. Combination therapy with aspirin and clopidogrel is recommended in acute coronary syndrome and stent placement, but it is not routinely recommended for chronic stable IHD (C).
Ranolazine is used to manage which of the following conditions in patients with IHD?
A) Acute myocardial infarction
B) Chronic angina despite standard therapy
C) Heart failure with preserved ejection fraction
D) Hypertension without associated angina
✅ Answer: B) Chronic angina despite standard therapy
Rationale: Ranolazine is used to manage chronic angina in patients who continue to experience symptoms despite treatment with nitrates, beta blockers, or calcium channel blockers. It works by inhibiting the late inward sodium current (INa), preventing sodium and calcium overload in ischemic myocytes.
What is the main mechanism of action of sodium-glucose cotransporter-2 (SGLT2) inhibitors in patients with IHD?
A) Inhibition of sodium and calcium overload in myocytes
B) Decreased intraglomerular hypertension and hyperfiltration
C) Reduction of myocardial oxygen demand
D) Direct vasodilation of coronary arteries
✅ Answer: B) Decreased intraglomerular hypertension and hyperfiltration
Rationale: SGLT2 inhibitors promote beneficial effects in IHD by decreasing intraglomerular hypertension and hyperfiltration, which improves cardiovascular and renal outcomes. They also reduce plasma volume and blood pressure, contributing to positive effects in patients with IHD.
Which of the following drugs is contraindicated in patients taking ranolazine due to potential interactions that may lead to QTc prolongation?
A) Aspirin
B) Ibuprofen
C) Ketoconazole
D) Metoprolol
✅ Answer: C) Ketoconazole
Rationale: Ranolazine should not be used with drugs that inhibit the CYP3A metabolic system, such as ketoconazole, diltiazem, verapamil, and other drugs that can cause QTc prolongation
Ivabradine is indicated for patients with IHD who have which of the following characteristics?
A) A resting heart rate <60 beats/min
B) Sinus node dysfunction and atrial fibrillation
C) A resting heart rate ≥70 beats/min and LV systolic dysfunction
D) Uncontrolled hypertension and hyperlipidemia
✅ Answer: C) A resting heart rate ≥70 beats/min and LV systolic dysfunction
Rationale: Ivabradine is used in patients with IHD and left ventricular systolic dysfunction who have a resting heart rate ≥70 beats/min. It is used alone or in combination with a beta blocker to prevent cardiovascular events.
Which of the following patients is most likely to benefit from coronary artery bypass grafting (CABG) rather than PCI?
A) Patients with single- or two-vessel disease and normal left ventricular (LV) function
B) Patients with multiple-vessel disease and impaired LV function
C) Patients with localized stenosis of the left anterior descending coronary artery
D) Patients with diabetes mellitus and mild symptoms
✅ Answer: B) Patients with multiple-vessel disease and impaired LV function
Rationale: CABG is preferred for patients with multiple-vessel disease and impaired LV function due to its greater benefit in long-term outcomes in these high-risk groups.
After implantation of a drug-eluting stent (DES), what is the recommended duration for dual antiplatelet therapy (DAPT)?
A) 1 month
B) 3–6 months
C) 6–12 months
D) At least 1 year
✅ Answer: D) At least 1 year
Rationale: After implantation of a drug-eluting stent (DES), dual antiplatelet therapy (DAPT), which includes aspirin and a P2Y12 antagonist, should be administered for at least 1 year to reduce the risk of stent thrombosis and restenosis.
Which of the following is typically used as a bypass conduit in CABG when an artery cannot be used?
A) Internal mammary artery
B) Radial artery
C) Saphenous vein
D) Jugular vein
✅ Answer: C) Saphenous vein
Rationale: When arteries like the internal mammary artery or radial artery cannot be used in CABG, a segment of the saphenous vein is typically used as a venous bypass conduit between the aorta and the coronary artery distal to the obstructive lesion.
What is the recommended treatment strategy for patients with single- or two-vessel disease and normal left ventricular (LV) function?
A) CABG
B) PCI
C) Medical therapy only
D) Coronary angioplasty with stent insertion
✅ Answer: B) PCI
Rationale: Patients with single- or two-vessel disease and normal LV function are typically advised to undergo PCI rather than CABG, as it is effective in improving outcomes and relieving symptoms.
Which patient group should coronary artery bypass grafting (CABG) be considered for as the initial method of revascularization?
A) A patient with single-vessel disease and normal LV function.
B) A patient with three-vessel disease and diabetes mellitus, and impaired LV function (ejection fraction <50%).
C) A patient with left main coronary artery disease that is suitable for PCI.
D) A patient with two-vessel disease and normal LV function, with no significant symptoms.
Correct Answer: B) A patient with three-vessel disease and diabetes mellitus, and impaired LV function (ejection fraction <50%).
Rationale: CABG is preferred for patients with three-vessel disease or two-vessel disease involving the proximal left anterior descending artery, particularly when they have impaired LV function or diabetes mellitus. These patients have a higher risk, and CABG offers better long-term outcomes.
