Ischemic Heart Disease

Question 1

What are the two main causes of ischemic heart disease?

Answer 1

Atherosclerotic and non-atherosclerotic

Question 2

What are atherosclerotic causes of coronary heart disease?

Answer 2

Angina pectoris and acute coronary syndrome

Question 3

What are the two branches of acute coronary syndrome?

Answer 3

STEMI (st-elevation MI) and NSTEMI (non-st elevated MI)

Question 4

Explain ischemia:

Answer 4

Decreased blood supply to the myocardium or increased demand for blood

Question 5

Explain infarction:

Answer 5

Death or necrosis of tissue with results from prolonged ischemia or total occlusion of blood flow to the tissue

Question 6

What are the most common causes of ischemia?

Answer 6

Coronary arterial disease (plaque in the vessel which impedes blood flow), and increased metabolic demand:

1. Hypertrophic cardiomyopathy
2. Aortic stenosis

Question 7

Describe stable angina:

Answer 7

Predictable, regular chest pain that is manageable

Question 8

Describe unstable angina:

Answer 8

Non-predictable, intense, medication helps minimally

Question 9

What are two other types of angina?

Answer 9

Variant angina and microvascular angina

Question 10

What is variant angina also known as?

Answer 10

Prinzmetals Angina (caused by coronary artery spasm, occurs in between 1-6 am, unrelated to exercise)

Question 11

What is microvascular angina due to?

Answer 11

Microvascular dysfunction

Question 12

What is CABG?

Answer 12

Coronary Artery Bypass Graft

Question 13

What happens in CABG?

Answer 13

GSV or internal mammary artery harvested, one end proximal and other distal to blockage

Question 14

When is CABG performed?

Answer 14

When angioplasty (balloon and stent) cannot be done:

1. When blockage is unreachable percutaneously
2. Too many blockages to stent (>3-4)

Question 15

What is the treatment for ischemia/angina/chest pain?

Answer 15

Nitroglycerine (nitrates) are given (pills/spray/aspirin) to lower cause vasodilation (reduces arterial resistance and causes veinous congestion reducing preload).

Question 16

What is used to prevent thrombi?

Answer 16

1. Antiplatelet drugs: ASA/Aspirin, plavix

2. Anticoagulants: Warfarin/coumadin, pradax

Question 17

What are the downsides to CABG? (3)

Answer 17

• Higher mortality rates than angioplasty
• Longer recovery time
• Cant be done on weak patients

Question 18

What do beta blockers do?

Answer 18

Lower HR, BP, and afterload (lowers O2 demand)

Question 19

What do calcium channel blockers do?

Answer 19

Lower muscle contraction lowering after load

Question 20

What is the gold standard for IHD diagnosis?

Answer 20

Coronary angiogram

Question 21

What is the treatment for MI?

Answer 21

MONA (done within 5 mins):

Morphine
Oxygen
Nitrates (NOT if low BP or viagra)
ASA/Aspirin
1. Heparin
2. Thrombolysis
3. Reperfusion (CABG/PCI)

Question 22

What is TPA?

Answer 22

Tissue plasminogen activator - most effective MI clot busting medications

Question 23

What are the types of TPA?

Answer 23

1. Streptokinase

2. Urokinase (from human and pig urine)

Question 24

What do TPA (streptokinase and urokinase) do?

Answer 24

Cut the chains of plasminogen which prevents them from forming strands or fibrinogen that cause blood clots.

Question 25

What is STEMI? (4)

Answer 25

- Transmural (occurring through whole thickness of the myocardium endo to epi) - Anterior MI (anterior leads) - ST segment is elevated - Big Q wave

Question 26

How will the ST segment appear with STEMI MI?

Answer 26

Elevated

Question 27

What is NSTEMI? (4)

Answer 27

- Small zone of ischemia/cell death - Subendocardial MI only - ST segment is depressed - no Q wave

Question 28

NSTEMI is what kind of MI only?

Answer 28

Subendocardial MI only

Question 29

How will the ST segment appear with NSTEMI MI?

Answer 29

Depressed

Question 30

What does a big Q wave indicate?

Answer 30

A big heart attack (untreated ST elevation) lead to necrosis

Question 31

ECG change to peaked T waves indicates what?

Answer 31

Acute MI

Question 32

Symmetric flat or reversed T waves indicates what?

Answer 32

Chronic ischemia

Question 33

The left main coronary artery branches to what?

Answer 33

LAD, Cx, and RCA

Question 34

LAD supplies what walls?

Answer 34

Anterior and septal walls

Question 35

Cx gives rise to what in a left dominant system?

Answer 35

PDA

Question 36

RCA usually supplies what?

Answer 36

SA and AV nodes

Question 37

RCA gives rise to what in a right dominant system?

Answer 37

PDA

Question 38

Abnormal septal motion may be seen with what?

Answer 38

LBBB, WPW (Wolf-Parkinson white syndrome), or paced rhythms

Question 39

Define sygmoid septum:

Answer 39

Basal septal focal hypertrophy

Question 40

Describe the hemodynamic properties of a sygmoid septum:

Answer 40

Subaortic stenosis, LVOT acceleration

Question 41

Describe the wall motion of a sygmoid septum:

Answer 41

Hypokinetic

Question 42

IHD/CAD could result in what kind of dysfunction?

Answer 42

Papillary muscle dysfunction

Question 43

Thrombus formation in the LV is more common with MI's located where?

Answer 43

Anterior

Question 44

What are the applications for LV contract enhancement?

Answer 44

1. Detect intracardiac shunts 2. Enhance Doppler signals 3. LV opacification 4. Myocardial perfusion

Question 45

Describe a VSD or wall rupture post MI

Answer 45

- MI damages the wall - Wall thins and becomes necrotic - Wall weakens - Wall ruptures - Shunt occurs

Question 46

What is Dressler's syndrome?

Answer 46

Acute pericarditis post infarct

Question 47

What are the 3 main features of Dressler's syndrome?

Answer 47

1. Fever 2. Pleuritic pain 3. Pericardial effusion 4. Tamponade: rare

Question 48

How quickly does the survival rate of MI drop with no pulse?

Answer 48

10% every min | Need CPR and defibrillation (AED)

Question 49

What does the elevation/depression of the ST segment indicate?

Answer 49

Elevation above TP segment = infarct Depression lower than TP segment = ischemia

Question 50

List 2 enzymes released during myocardium injury?

Answer 50

1. CKMB | 2. Troponin C

Question 51

What direction would the MR jet aim if there was a large inferior MI. And why?

Answer 51

Anterior Due to posteromedial papillary muscle dysfunction