ischemic heart disease

Question 1

What is an exercise stress test?

Answer 1

pt exercises with continuous HR and EKG monitoring until pt achieves 85% of predicted HR or until pt has angina or ischemia on EKG. Ischemia diagnosed if signso f reproducible angina or obvious signs of ischemia at low workloads

Question 2

What is a nuclear stress test?

Answer 2

Patient is injected wiht thallium-201 or technetium-99-sestamibi. SPECT performed to assess myocardial perfusion. Used when clinicial suspects ischemic heart disease but results of regular exercise stress test are equivocal

Question 3

What is pharmacologic stress testing?

Answer 3

administration of cardiac inotrope like dobutamine instead of exercise to increase myocardial demand. often performed in conjunction with SPECT or done for patients who can’t tolerate exercise

Question 4

PET myocardial imaging

Answer 4

injection of PET with 3d detection of hear to look for perfusion defects and tissue viability

Question 5

coronary angiography

Answer 5

gold standard for CAD but much more invasive

Question 6

What are the signs and symptoms of hypercholesterolemia?

Answer 6

usually a SILENT disease
very high triglycerides and LDL lead to xanthomas (lipids in tendons), xanthelasmas (lipids in eyelids), and cholesterol emboli in retina (seen on fundoscopic exam)

Question 7

When and how do you screen for cholesterol?

Answer 7

• blood for serum cholesterol should be collected from a fasting patient (12-14 hrs)
• screens in men over 35 and women over 45
• screen young if pt has other risk factors for CAD like tobacco, HTN, HDL

Question 8

What are the guidelines for treatment of hyperlipidemia?

Answer 8

1. atherosclerotic disease with clinic effects (ACS, MI, stable or unstable angina, stroke, TIA, PAD, coronary revascularization): give high intensity statin if age or equal to 7.5%, give mod or high statin

Question 9

What are the effects of statins and what are their important side effects?

Answer 9

-decrease LDL, increase HDL
inhibit HMG-CoA reductase (cholesterol precursor)
-can cause hepatotoxicity- check LFTs before strating
-can case myositis, esp. in combo with fibrates and niacin

Question 10

What are the cholesterol absorption inhibitors?

Answer 10

Drug name: ezetimibe

• decr LDL only
• relatively few side effects- rare incr in LFTs, rare myalgias diarrhea

Question 11

What are the fibric acids?

Answer 11

gemfibrozil, fenofibrate

• work in the blood- all stimulate LPL and activate PPAR-alpha to induce HDL synthesis
• main effect: decr. triglycerides
• also decr LDL and inc HDL
• side effects: myositis, incr LFTs, cholesterol gallstones

Question 12

What are the bile acid sequestrants?

Answer 12

cholestyramine, colestipol, colesevelam

• prevent intestinal reabsorption of bile acids
• pts don’t like these- bad taste, GI upset
• decr LDL

Question 13

Niacin

Answer 13

• best to incr HDL
• but, can cause facial flushing (decr. by ASA or long-term use)
• incr LFTs
• insulin resistance
• gout exacerbation

Question 14

Which patients are most likely to have asymptomatic myocardial ischemia?

Answer 14

diabetics- sensory neuropathy

Question 15

What other conditions can present like angina?

Answer 15

-GERD, esophageal spasm

Question 16

What is the significance of unstable angina?

Answer 16

• 1/3 pts of have an MI within 3 yrs

- often caused by plaque rupture, hemorrhage, or thrombosis

Question 17

What does the EKG show in unstable angina?

Answer 17

-ST depression, possible t wave changes

Question 18

What are the first treatments for angina?

Answer 18

• IV morphine, supplemental O2, nitroglycerin, ASA, beta blockers, statins (particularly before percutaneous coronary intervention), administer K and mag (want K>4 and mag >2)
• Antiplatelet and anticoagulation:
• -if no PCI planned, give clopidogrel or ticagrelor; give low molecular weight heparin
• -if PCI planned, give glycoprotein IIb/IIIA inhibitor like abciximab, tirofiban, or eptifibatide; give unfractionated heparin

Question 19

When is percutaneous transluminal coronary angioplasty indicated for patients with unstable angina?

Answer 19

• cases that don’t respond to meds
• catheter inserted through femoral or brachial artery
• balloon inflated to dilate stenotic vessel
• catheters also used for athrectomy or stent placement

Question 20

When is CABG indicated for pts with unstable angina? Where are graft tissues taken from?

Answer 20

• if left main stenosis >50%, three vessel disease, or hx of CAD and DM
• usually uses saphenous vein and internal mammary artery