Ischemic Heart Disease 2 Flashcards
Diagnostic hx of stable coronary artery disease
1) chest pain (angina pectoris) usu with exertion
2) dyspnea
Physical exam in stable coronary artery disease
Normal OR
1) prior MI damage - CHF
2) atherosclerosis in vasc beds (carotid bruit)
Tests to run for stable coronary artery disease
1) ECG (at rest and with exercise stress test)
2) echo
3) perfusion imaging,
4) ultrafast CT
5) coronary angiography
Signs on ECG with coronary artery disease
1) Resting ECG
- ST depression
- T inversion
- Q waves from prior infarction
2) stress test
- dynamic ST seg changes
Problems with ECG dx
1) resting ecg NOT SENSITIVE
2) stress test = sensitivity/specificity suboptimal
stress ECG with ischemic response
horizontal/downslope ST depression with exercise = subendocardial ischemia
how do you improve sensitivity and specificity of stress ECG
1) concurrent myocardial perfusion = radiopharm
2) wall motion (echo)
tests to run
1) 80 y/o woman
2) HTN, elev LDL, low HDL
3) chest tightness + SOB w/ exertion
4) BP 155/95, S4, carotid artery bruit
1) resting ecg (ST depression)
2) stress ecg with perfusion
3) reversible ischemia by perfusion imaging (can look for areas of heart with low blood flow)
what does she have
1) 80 y/o woman
2) HTN, elev LDL, low HDL
3) chest tightness + SOB w/ exertion
4) BP 155/95, S4, carotid artery bruit
stable angina
how to treat
1) 80 y/o woman
2) HTN, elev LDL, low HDL
3) chest tightness + SOB w/ exertion
4) BP 155/95, S4, carotid artery bruit
1) anti-anginal agents (nitrates + beta blocker)
2) control of BP with anti-Hypertensive
3) statin = lipid lower
4) aspirin = anti-platelet
5) may need further coronary angio if sx worsen
pros/cons of
CT or direct angiography
Pros =
1) dx coronary obstruction –> angina
2) angioplasty + bypass surgery
Cons =
1) no info about vessel wall
2) not good for predict future
angiography ___ pathologic extent of CAD
underestimates
angiography underestimates ____
pathologic extent and severity of CAD
tells us obstruction of lumen BUT not vessel wall
how do you estimate severity of coronary lesion
use fractional flow
if ratio of distal coronary/aortic pressure < 0.75, SIGNIFICANT STENOSIS
what is purpose of fractional flow
to estimate severity of coronary lesion
how can you use CT chest?
noninvasive dx of coronary atherosclerosis (using coronary calcium builds up in chronic inflamm/coronary athero)
how do you treat coronary artery disease
1) risk modification for prevention and treating disease
(diet, exercise, stop smoking)
2) drugs for angina, BP, lipids, platelets
3) revascularization with angioplasty or artery bypass surgery
effect of smoking cessation on CV risk
no random trials
but levels return to normal w/n 10 yrs of quit smoking
classes of drugs for CAD
lipid modifying
statin
classes of drugs for CAD
anti-platelet
aspirin
clopidogrel
classes of drugs for CAD
anti-anginal
nitrates
beta blockers
Ca2+ ch blockers
classes of drugs for CAD
LV dysfunction
ACE inhibitor or ARB
what tests?
1) 63 y/o m
2) 2 weeks of chest discomfort w/ min activity + SOB
3) 2 days of intermittent chest pain relieved by nitro in ER
3) hx of HTN, smoker, elev cholest
4) BP 160/93, premature beat, crackles, S4
resting ECG
coronary angiography
signs on resting ECG
1) 63 y/o m
2) 2 weeks of chest discomfort @ rest + SOB
3) 2 days of intermittent chest pain relieved by nitro in ER
3) hx of HTN, smoker, elev cholest
4) BP 160/93, premature beat, crackles, S4
resting ST depression
PVC
acute treatment for unstable angina
1) 63 y/o m
2) 2 weeks of chest discomfort @ rest + SOB
3) 2 days of intermittent chest pain relieved by nitro in ER
3) hx of HTN, smoker, elev cholest
4) BP 160/93, premature beat, crackles, S4
1) hospitalization
2) IV nitro
3) beta blcoker
4) aspirin + anti-platelet
5) anticoag (hep)
6) early cath + coronary intervention
early coronary angioplasty reduces risk of ____
recurrent ischemic events in unstable angina
effect of angioplasty on vessel wall
1) plaque pushed outward in direction of tunica adventitia to restore lumen
2) pt on anti-coag and anti-platelet
to prevent rupture of plaque
Problems with balloon angiography (2)
1) acute occlusion
2) restenosis
how to treat acute occlusion during balloon angioplasty
stents + antiplatelets
how to treat restenosis during balloon angioplasty
stents (elute antiprolif drugs)
what does this guy have?
1) 59 y/o m
2) hx of diabetes, HTN, mild hypercholest, no hx of CAD
3) sudden onset substernal chest pain, diaphoresis, SOB, N/V
4) sweaty, neck veins, rales
acute MI with ST elevation
what tests to run
1) 59 y/o m
2) hx of diabetes, HTN, mild hypercholest, no hx of CAD
3) sudden onset substernal chest pain, diaphoresis, SOB, N/V
4) sweaty, neck veins, rales
resting ECG
coronary angio
treatment?
1) 59 y/o m
2) hx of diabetes, HTN, mild hypercholest, no hx of CAD
3) sudden onset substernal chest pain, diaphoresis, SOB, N/V
4) sweaty, neck veins, rales
1) immediate aspirin, nitro +/- beta blocker
2) reperfusion ASAP using coronary angioplasty if DON’T HAVE THROMBOLYTICS
define coronary angioplasty
treating coronary obstructions percutaneously
when to use CABG vs. coronary angioplasty
when you have multiple blockers
main types of CABG grafts?
come from:
1) internal mammary artery- resistant to atherosclerosis
2) saphenous vein
___ not as successful as coronary grafts
prosthetic materials
angiography is a lumen test NOT VESSEL WALL
know
