Ischemic Heart Disease 2

Question 1

Diagnostic hx of stable coronary artery disease

Answer 1

1) chest pain (angina pectoris) usu with exertion

2) dyspnea

Question 2

Physical exam in stable coronary artery disease

Answer 2

Normal OR

1) prior MI damage - CHF
2) atherosclerosis in vasc beds (carotid bruit)

Question 3

Tests to run for stable coronary artery disease

Answer 3

1) ECG (at rest and with exercise stress test)
2) echo
3) perfusion imaging,
4) ultrafast CT
5) coronary angiography

Question 4

Signs on ECG with coronary artery disease

Answer 4

1) Resting ECG
- ST depression
- T inversion
- Q waves from prior infarction

2) stress test
- dynamic ST seg changes

Question 5

Problems with ECG dx

Answer 5

1) resting ecg NOT SENSITIVE

2) stress test = sensitivity/specificity suboptimal

Question 6

stress ECG with ischemic response

Answer 6

horizontal/downslope ST depression with exercise = subendocardial ischemia

Question 7

how do you improve sensitivity and specificity of stress ECG

Answer 7

1) concurrent myocardial perfusion = radiopharm

2) wall motion (echo)

Question 8

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

Answer 8

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)

Question 9

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

Answer 9

stable angina

Question 10

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

Answer 10

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

Question 11

pros/cons of

CT or direct angiography

Answer 11

Pros =

1) dx coronary obstruction –> angina
2) angioplasty + bypass surgery

Cons =

1) no info about vessel wall
2) not good for predict future

Question 12

angiography ___ pathologic extent of CAD

Answer 12

underestimates

Question 13

angiography underestimates ____

Answer 13

pathologic extent and severity of CAD

tells us obstruction of lumen BUT not vessel wall

Question 14

how do you estimate severity of coronary lesion

Answer 14

use fractional flow

if ratio of distal coronary/aortic pressure < 0.75, SIGNIFICANT STENOSIS

Question 15

what is purpose of fractional flow

Answer 15

to estimate severity of coronary lesion

Question 16

how can you use CT chest?

Answer 16

noninvasive dx of coronary atherosclerosis (using coronary calcium builds up in chronic inflamm/coronary athero)

Question 17

how do you treat coronary artery disease

Answer 17

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

Question 18

effect of smoking cessation on CV risk

Answer 18

no random trials

but levels return to normal w/n 10 yrs of quit smoking

Question 19

classes of drugs for CAD

lipid modifying

Answer 19

statin

Question 20

classes of drugs for CAD

anti-platelet

Answer 20

aspirin

clopidogrel

Question 21

classes of drugs for CAD

anti-anginal

Answer 21

nitrates
beta blockers
Ca2+ ch blockers

Question 22

classes of drugs for CAD

LV dysfunction

Answer 22

ACE inhibitor or ARB

Question 23

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

Answer 23

resting ECG

coronary angiography

Question 24

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

Answer 24

resting ST depression

PVC

Question 25

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

Answer 25

1) hospitalization
2) IV nitro
3) beta blcoker
4) aspirin + anti-platelet
5) anticoag (hep)
6) early cath + coronary intervention

Question 26

early coronary angioplasty reduces risk of ____

Answer 26

recurrent ischemic events in unstable angina

Question 27

effect of angioplasty on vessel wall

Answer 27

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

Question 28

Problems with balloon angiography (2)

Answer 28

1) acute occlusion

2) restenosis

Question 29

how to treat acute occlusion during balloon angioplasty

Answer 29

stents + antiplatelets

Question 30

how to treat restenosis during balloon angioplasty

Answer 30

stents (elute antiprolif drugs)

Question 31

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

Answer 31

acute MI with ST elevation

Question 32

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

Answer 32

resting ECG

coronary angio

Question 33

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

Answer 33

1) immediate aspirin, nitro +/- beta blocker

2) reperfusion ASAP using coronary angioplasty if DON’T HAVE THROMBOLYTICS

Question 34

define coronary angioplasty

Answer 34

treating coronary obstructions percutaneously

Question 35

when to use CABG vs. coronary angioplasty

Answer 35

when you have multiple blockers

Question 36

main types of CABG grafts?

Answer 36

come from:
1) internal mammary artery- resistant to atherosclerosis

2) saphenous vein

Question 37

___ not as successful as coronary grafts

Answer 37

prosthetic materials

Question 38

angiography is a lumen test NOT VESSEL WALL

Answer 38

know