Ischemic Heart Disease

Question 1

Def of ischemic HD and 5 basis of perfusion imablance

Answer 1

Effects on cardiac fxn and structure due to insuff O2 delivery via coronary arteires

Athero - most common
Spasm - with or without atherosclerosis
Systemic hypotension
Aortic valve dz - syphilitic ostial stenosis

Kawasaki - rare, coronary arteritis with thomboroiss and aneurysms in children/teens with circulating antiendothelial ABs ….IVIG

Question 2

Coronary anatomy

Answer 2

RCA goes around back to supply post LV

Circumflex is lateral

LADA is anterior

Question 3

Risk factors for CAD and effects

Answer 3

HTN, cigs, hyperlip, DM

Affects mostly the proximal portion of epicardial branches

NArrowing commonly involves 2 or more branches

Narrowing >75% affects distal flow

Collaterals expand to compensate

Question 4

Angina pectoris

Answer 4

Typical AP of paroxysmal chest pain worse with exertion and relieved by rest…inc demand in setting of fixed suplply

Ischemic injury is reversilbe and accompanied by ECG changes…deteriorates ot unstable AP

Atypical angina - pain at rest and spont reduction in supply in absnece of inc demand..probabyl due to transient coronary artery stenosis from a spasm

Question 5

MI

Answer 5

Zone of irreversible injury…commonly setting of severe atheroscelrotic narrowing of 2 or more branches

Coagulative necrosis

Hemorrhage into vulnerable plaque, erosion of vulnerable laque with luminal thrombosis, coronary spasm…udden atherothrombosis

Question 6

CHF
Sudden death
Arrhythmias

Answer 6

Extensive muscle loss and scarring

Initil presentation in about 30% of cases

V tach
Vfib
Afib

Question 7

Lab findings in MI

Answer 7

ECG changes - Q waves…loss of R waves ST segment elevation, ventricular arrhythmias, heart block

ST elevation/non-STEMI
Q wave or non Q wav

CK-MB, troponin or CRP

Leukocytosis and ESR

Myocardial perfusion scans…maps areas of loss of blood flow

ECHo - zone of akeiniesia, dyskinesia of LV or IV septum

Question 8

Transmural vs. nontransmural

Answer 8

Trnasmural MI - Larger/full thickness…Q wave and ST elevation due to complete loss

Non - small and subendocardial myocardial zonal necrosis….non Q wave, non STEMI, shorter and incomplete loss of coronary artery

Question 9

How does non-STEMI become STEMI

Answer 9

Non-Q wave to Q wave

From Subendocardial to myocardial necrosis to full thickness myocardian lnecoriss

Question 10

Gross morphologic changes

Answer 10

18-24 - pallor
24-72 - pallor iwth hyperemia
3-7 days - hyperemic border iwth central yellowing
10-21 days - max yellow and soft iwth vasc margins
7 weeks - white fibrosis

Question 11

Microscopic changes

Answer 11

1-3 - wave myocard fibers
2-3 - staining defect
4-12 - coag necrosis with bands
18-24 - continuning coag
24-72 - loss of nuclei and striations with neutrophilic infiltrate
3-7 days - macrophge and mononuclear infiltration being
10-21 days - fibrovascular response wth grnaulation
7 weeks - fibrosis

Question 12

Comps of MI

Answer 12

Hospital mortality

CHF, a fib, thrombus in atrial appendages

Question 13

CHF

Answer 13

Pulm congesiton and edema

Elevated RA and venous pressure

Hepatosplenomegaly

Peripheral edema

Pleural effusion, ascites, pericardial effusion

DOE/PND, wt gain, DVT, PE

Question 14

Dressler’s syndrome

Answer 14

2 weeks

Fibrinous pericarditis

Chest pain, fever, and friction rub

Question 15

CABG

Answer 15

Spahenous vein bypass graft…connect aorta to distal coronary arteries

Question 16

VBG

Answer 16

Worry about neointima developing atheroscelrosis and stenosis

Question 17

Stent placement or PTA

Answer 17

Site of isolated coronary artery is distended with inflatbale catheter…retrograde throug hthe femoral artery

Stent comps are intimal reocclusion or late thrombosis…could also get thrombotic occlusion

Question 18

Homo FH

Answer 18

LDLR dual gene mutation is greatest known risk of fatal atheroscelrosis of any cause