Ischemic Heart Disease (Coronary artery disease) Flashcards
1
Q
What is ischemic heart disease?
A
Narrowing or obstruction of the coronary arteries Sufficient to prevent adequate blood and oxygen supply to the myocardium (ischemia)
not getting enough blood
2
Q
What may IHD lead to?
A
May progress to the point the myocardium is damaged (infarction)
3
Q
What are two types of IHD etiology?
A
- Atherosclerotic
- Non-Athersclerotic
4
Q
What is the most common IHD etiology?
A
Atherosclerotic
5
Q
What are examples of non- Atherosclerosis causes of IHD? 3
A
- Embolus into coronary artery
- Trauma
- Coronary artery dissection
6
Q
What does this image represent?
A
Plaque progression from a fatty streak on the intima to a superficial erosion of the endocardial layer
7
Q
In terms of atherosclerotic plaque progression, when the thrombus forms, what does it occlude? and where does it usually occur?
A
- The lumen of the artery
- Distal to an arterial branching
8
Q
What are some major risk factors for IHD? 5
A
- Age
- Smoking
- Diabetes mellitus
- Dyslipidemia
- Hypertension
9
Q
What are some predisposing risk factors for IHD? 4
A
- Abdominal obesity
- Family history
- Obesity
- Physical inactivity
10
Q
What is ischemia?
A
Decreased blood supply to the myocardium
11
Q
What is an infarction?
A
Death or necrosis of tissue which results from prolonged ischemia
12
Q
Can ischemia occur due to increased demand for blood?
A
Yes
13
Q
Is ischemia reversible?
A
Yes
14
Q
What is a total occlusion of blood flow to the tissue?
A
Infarction
15
Q
Between ischemia and infarction which one is reversible?
A
Ischemia is reversible
16
Q
What the most common causes of ischemia? 2
A
- Coronary artery disease
- Increased metabolic demand
17
Q
What is coronary artery disease (CAD)?
A
Plaque in the vessel which impedes blood flow
18
Q
How would someone have ischemia due to increased metabolic demand? 2
A
- Hypertrophy cardiomyopathy (more muscle)
- Aortic stenosis (more work or high afterload)
19
Q
Everything downstream of the obstruction dies unless there is what?
A
Collateral circulation from another vessel
20
Q
In terms of infarction, cell death starts to happen when? (Time frame)
A
Within 1 hour and is complete by 4
21
Q
What are signs/ symptoms of ischemia/ Myocardial infarctions? 2, 8
A
- Angina Pectoris (chest pain)
- SOB
- Syncope
- Fatigue
- Can be silent (Asymptomatic)
- Sweating
- Nausea and vomiting
- Anxiety
22
Q
What might a CXR show in terms of ischemic heart disease? 3
A
May show
- Pulmonary edema
- Cardiomegaly
- May appear normal
23
Q
Where would we auscultate for ischemic heart disease?
A
S4, possible S3
24
Q
What might we hear when we auscultate for ischemic heart disease?
A
Mitral regurgitation murmur (systolic murmur at apex)
25
How many patients have Mitral regurgitation after acute Mitral infarction?
Up to 60%
26
What is angina pectoris caused by?
Reduced O2 delivery to a section of the myocardium
27
What is angina pectoris felt as?
Heaviness, burning or aching pain in the chest +/- left arm
28
In terms of angina pectoris women have what kind of symptoms?
Generalized symptoms
29
What might angina pectoris possibly be caused by? (Besides O2 delivery)
Coronary spasm
30
What is stable angina a result of?
Stable plaque
31
What can stable angina be described as in terms of pain?
Predictable, regular chest pain
32
What the solution for stable angina?
Rest or nitroglycerine
33
How does unstable angina pain compare to stable angina? And how predictable is it?
More intense/ painful and not predictable
34
What is the solution for unstable angina?
May require immediate intervention
35
What does Myocardial infarctions lead to?
MI >> Arrhythmias (VT, VF) >> Asystole
36
When someone experiences MI what is immediately needed?
CPR and Defibrillation
37
In terms of Cardiac arrest survival rates drops by how much every minute without a pulse?
10%
38
During Myocardial infarction, once the pulse is back, what do we do?
Thrombolytics and PCI or emergency bypass
39
What are two types of Myocardial infarctions?
1. NSTEMI
2. STEMI
40
What is NSTEMI?
Zone of ischemia with small zone of cell death
41
In terms if NSTEMI it usually affects which area?
Subendocardial
42
What does the ST segment look in terms of NSTEMI?
Depressed
43
What is STEMI in terms of Myocardial infarction?
Transmural, which means through the whole thickness of the myocardium
*from Endo to epi*
44
What does the ST segment look like in terms of STEMI?
Elevated
45
What does these images represent from top down?
1. Normal
2. ST depression
3. Infarct
46
What does ST depression indicate?
Ischemia
47
What does ST elevation represent?
Infarction
48
During MI where does arrhythmias originate?
In the ventricle
49
In terms of MI, what kind of heart blocks will we see?
AV block
50
If we see a new LBBB on an ECG what might this mean?
MI
51
In terms of MI what does Q waves indicate on the ECG?
Old MI (necrotic tissue)
52
In terms of MI, what does peaked T waves indicate?
Acute MI
53
In terms of MI, what does reversed T waves indicate on a ECG?
Chronic ischemia
54
What are some treatment options for ischemic heart disease? 6
1. Smoking adjustment
2. Diet
3. Exercise
4. Stress management
5. Weight loss
6. BP reduction
55
What are some medications that can help assist with ischemic heart disease treatment? 4
1. Pain relief meds
2. Anticoagulation
3. Beta blockers
4. Calcium channel blockers
56
What kind of pain relief meds does someone take for ischemic heart disease medication?
Nitroglycerine
57
What kind of anticoagulation medication does someone take for ischemic heart medicine? 2
1. Plavix
2. Warfarin/ coumadin
58
What are somethings we can look at to help diagnose ischemic heart disease? 6
1. ECG
2. Stress test
3. Echo
4. MIBI (Nuclear) stress test
5. Cardiac CT or MRI
6. Acute phase of MI requires blood work with enzymes
59
What is the gold standard for diagnosis for IHD?
Coronary angiogram
60
What is a stress test?
Exercise or pharmacological
61
How can we detect ischemic heart disease with Cardiac CT or MRI?
Perfusion defects
62
How can we diagnose Ischemic heart disease with the Acute phase of MI blood work and enzymes?
Certain blood and enzymes are released with myocardium injury occurs such as
1. Creatine kinase myocardial band
2. Troponin C (C- cardiac)
63
What are four MI differential diagnosis tools? (Signs we see)
1. Aortic dissection
2. Tension pneumothorax
3. Pericardial disease
4. Pleural effusion
64
What is the goal of Myocardial infarction management?
To restore normal coronary blood flow and save the myocardium
65
What are somethings we can do for MI management? 3
1. Cath lab - Angioplasty
2. Surgical
3. Lifestyle changes
66
What are some surgical paths for MI management?
1. **Coronary artery bypass graft (CABG)**
2. Other
67
What does this image demonstrate?
Coronary angiography
68
What does this image demonstrate?
Coronary artery bypass graft
69
What is the role of echo in terms of ischemic heart disease? 2
1. Assess for Wall motion and thickening
2. Assess for regional wall thinning of affected wall segments
70
What is regional wall thinning of affected wall segments caused by?
Scarring and fibrosis over time
71
What does regional wall thinning of affected wall segments look like sonographically?
Increased echogenicity
72
Wall thickness with acute MI will look how?
Normal
73
What is sigmoid septum?
Basal septal focal hypertrophy
74
In terms of sigmoid septum, myocardial disarray may be related to what?
Reduced perfusion in that segment which caused it to thicken
75
What is the prognosis for sigmoid septum?
Increased risk for adverse cardiac events
76
What demographic is sigmoid septum more prominent in? 2
1. Diabetics
2. Elderly
77
What are some post MI complications? 7
1. Secondary MR
2. Thrombus formation
3. Aneurysms
4. Dressler's syndrome and post MI pericarditis
5. Acquired VSD
6. CHF
7. Ventricular arrhythmia
78
What is papillary muscle dysfunction?
Ischemia of papillary muscle segment
79
What does papillary muscle dysfunction cause?
Improper contraction of the segment and the pap muscle
80
What does papillary muscle dysfunction affect? and what does it lead too?
MV function leading to eccentric regurgitation
81
In terms of Papillary muscle dysfunction, ruptures are more common with what?
Inferior MI
82
Papillary muscle dysfunction may also occur where?
In right heart and TV
83
LV thrombus is what? Where is it usually located?
Echodense mass usually in apex
84
How does LV thrombus present? 2
1. Protruding vs mural
2. Mobile vs. Sessile
85
What kind of view visualization is required for LV thrombus?
2 view visualization
86
How are aneurysms grouped?
Either true or pseudo aneurysms
87
How common are Aneurysms?
Rare
88
What may line aneurysm?
Thrombus
89
Thrombus that lines aneurysm may cause what?
Systemic emboli
90
In terms of aneurysms, patients may present with what?
Continuing angina
91
What does these images represent?
True aneurysm vs Pseudo aneurysm
92
What does a pseudo aneurysm look like? 3
1. Narrow neck
2. Wall rupture
3. Filled with thrombus
93
What does a true Aneurysm look like? 5
1. Thin walls (<5mm)
2. 80% at apex
3. Wide neck
4. All 3 wall layers present
5. May leak into pericardium
94
95
When does Acute pericarditis POST MI occur?
1-4 days post MI
96
How many people are affected by acute pericarditis post MI?
25% of patients
97
What are 3 main features of acute pericarditis?
1. Fever
2. Pleuritic pain
3. Pericardial effusion
98
In terms of acute pericarditis post MI, how often do we see Tamponade?
Rare
99
How does the pericardium look like during acute pericarditis post MI?
Pericardium may look bright over ABD wall motion area
100
What is pericarditis post MI related to?
Related to autoimmune response to necrosis
101
What is Dressler’s syndrome?
Delayed pericarditis
102
When does Dressler’s syndrome occur?
1-8 weeks post MI
103
How many people are affected by Dressler’s syndrome?
1-3% of patients (rare)
104
What is Dressler’s syndrome related to?
Autoimmune response to necrosis
105
What are some of the signs and symptoms of Dressler’s syndrome?
Same as pericarditis
106
What is VSD or Wall rupture due to in terms of MI?
Rupture of interventricular septum
107
What does VSD or Wall rupture due to MI sound like?2
1. Loud systolic murmur, left sternal border
2. Thrill
108
How does VSD or wall rupture due to MI move in the heart?
1. High velocity flow across septum
2. Flow into pericardium for wall rupture
109
What is the pathophysiology of VSD/ Wall rupture: post MI? 3
1. MI damages the wall
2. Shunt occurs
3. Can leak into pericardium
110
What are some non IHD chest pain causes? 2
1. Myocarditis
2. Takotsubo cardiomyopathy (TTC)
111
What is myocarditis?
Inflammation of the myocardium resulting in myocardial damage
112
What is the pathophysiology of myocarditis? 4
1. Myocardial infiltration produces toxin
2. Autoimmune response
3. Myocardial degeneration/ necrosis
4. May cause heart failure
113
What are some signs and symptoms of myocarditis? 1, 6
1. **Infection symptoms**
2. Chest pain
3. SOB
4. Fatigue
5. Arrthymia
6. Asymptomatic
114
What are some echo findings for myocarditis? 3,5
1. **Dilated or hypertrophied ventricles**
2. **LV dysnfunction**
3. **RWMA**
4. Possible valvular issues
5. Possible diastolic dysfunction
115
What are the criteria for TTC? 6
116
What is Takotsubo cardiomyopathy (TTC)?
Acute, transient or reversible LV dysfunction in the absence of obstructive CAD
117
What is TTC named after?
Japanese octopus trap
118
What does TTC mimic?
ACS
119
What is TTC triggered by?
Stress
120
Which demographic of people are affected by TTC?
Post menopausal women
121
How does TTC appear?
Transient, normal on F/U
122
What are four tips for IHD scans?
1. Make sure you are on axis to see the RWMA
2. Sweep
3. Focus set
4. Step out of the box (sometimes a new window is needed, or maybe a colour map)
