Ischemic Heart Disease (Exam IV)

Question 1

What chemical mediators are released from ischemia that activate cardiac nociceptors?

Answer 1

Adenosine and Bradykinin

Question 2

What is the path for cardiac pain signals to reach the spinal cord?

Answer 2

Cardiac nociceptors → Afferent Neurons → T1 - T5 SNS ganglia and somatic nerve fibers.
- produce thalamic and cortical stimulation that results in chest pain of angina pectoris.

Question 3

What is the CNS response to cardiac ischemia?

Answer 3

• ↓ AV conduction and thus ↓HR
• ↓ Contractility

Question 4

Differentiate stable vs unstable angina.

Answer 4

• Stable - No change in chest pain severity or frequency in 2-mo period.
• Unstable - Increasing frequency and severity of chest pain.

Question 5

Are cardiac biomarkers (troponin) present with unstable angina?

Answer 5

NO. If they were, that would be an MI.

Question 6

What EKG abnormality is associated with old MI’s and/or current ischemia?

Answer 6

T-wave inversion

Question 7

What is nuclear stress testing utilized for?

Answer 7

Coronary Perfusion assessment

Question 8

What determines the significance of CAD during a nuclear stress test?

Answer 8

Size of the perfusion abnormality

Arrows point to arrows of lesser perfusion.

Question 9

What test can differentiate a new vs and old perfusion abnormality?

Answer 9

Nuclear Stress Testing

Question 10

What nuclear stress test tracers are used with exercise?

Answer 10

Thallium

Question 11

What nuclear stress test drugs are used without exercise?

Answer 11

Atropine
Dobutamine
Pacing

To dilate (adenosine, dipyridamole)

Question 12

When are adenosine and dipyridamole used with nuclear stress testing? Why?

Answer 12

Use to produce cardiac stress. These drugs dilate normal coronary arteries but evoke minimal or no change in diameter of artherosclerotic coronary arteries

Question 13

What test would be useful for imaging wall motion abnormalities or valvular function?

Answer 13

Echocardiography

Question 14

What is Prinzmetal Angina?

Answer 14

Coronary Spasm

Question 15

What is the mechanism of action for aspirin?

Answer 15

COX-1 Inhibition → TXA2 inhibition → Plt aggregation inhibition.

Question 16

How can aspirin be reversed?

Answer 16

Trick question. It can’t be, platelets are damaged until they die and are replaced.

Question 17

What is the mechanism of action of abciximab, eptifibatide, and tirofiban?

Answer 17

Platelet glycoprotein IIb/IIIa receptor antagonists

Inhibit platelet activation, adhesion, and aggregation.

Question 18

What drugs (discussed in lecture) are P2Y₁₂ inhibitors?

Bonus points! Name the glycoprotein IIb/IIIa receptor antagonist?

Answer 18

-Clopidogrel, Prasugrel, ticagrelor

-Abciximab, eptifibatide, tirofiban

Question 19

What common drug class will antagonize P2Y₁₂ inhibitors?

Answer 19

PPIs

Question 20

How does Prasugrel compare to Clopidogrel?

Answer 20

More predictable pharmacokinetics but greater bleeding risk.

Question 21

How do P2Y₁₂ inhibitors work?

Answer 21

Inhibit ADP receptor P2Y₁₂ and thus inhibit platelet aggregation.

Question 22

What drug classes are synergistic with nitrates?

Answer 22

• β-blockers
• CCBs

Question 23

When are nitrates contraindicated?

Answer 23

• Aortic Stenosis
• Hypertrophic Cardiomyopathy

Question 24

What drug class is the only one proven to prolong life in CAD patients?

Answer 24

β-blockers

Question 25

What properties do β-blockers have?

Answer 25

- Anti-ischemia - Anti-HTN - Anti-dysrhythmic

Question 26

Which β blockers are cardioselective?

Answer 26

- Atenolol - Metoprolol - Acebutolol - Bisoprolol

Question 27

Which β blockers are non-selective?

Answer 27

- Propanolol - Nadolol

Question 28

What risk is associated with non-selective β blockers in asthma patients?

Answer 28

↑ risk of bronchospasm in reactive airway disease patients.

Question 29

What drug class is uniquely effective is decreasing the severity/frequency of coronary vasospasm?

Answer 29

CCBs

Question 30

Angiotensin II will increase what four things?

Answer 30

- Myocardial hypertrophy - Interstitial myocardial fibrosis - Coronary vasoconstriction - Inflammatory responses

Question 31

Is troponin or CK-MB more specific for myocardial injury?

Answer 31

Troponin

Question 32

How soon with troponin start to increase after myocardial injury?

Answer 32

3 hours

Question 33

What diagnostic studies might indicate a myocardial infarction?

Answer 33

- EKG: abnormality (ex. LBBB) - US: Regional wall motion abnormalities

Question 34

What are indications for PCI treatment of an MI?

Answer 34

- Contraindicated tPa therapy - Severe HF and/or pulm edema - S/S for 2-3 hours - Mature clot (Failure of medical therapy, >50% L main or >70% epicardio coronary arteries, impaired EF < 40%)

Question 35

What risks are associated with PCI (percutaneous coronary intervention) ?

Answer 35

- Endothelial destruction - Bleeding - Thrombosis

Question 36

What is Dual Antiplatelet Therapy (DAPT) ?

Answer 36

- ASA w/ P2Y₁₂

Question 37

How long would one want to wait for elective surgery post angioplasty **with no stenting**?

Answer 37

2 - 4 weeks * 2 weeks

Question 38

How long would one want to wait for elective surgery post angioplasty **with bare-metal stent placement**?

Answer 38

At least 30 days (12 weeks preferable) * 6 weeks

Question 39

How long would one want to wait for elective surgery post angioplasty **with drug-eluting stent placement**?

Answer 39

At least 6 months (12 months if post ACS) * 1 year

Question 40

How long would one want to wait for elective surgery post-CABG?

Answer 40

At least 6 weeks (12 weeks preferable)

Question 41

Is glycopyrrolate or atropine preferred for treatment of bradycardia?

Answer 41

Glycopyrrolate

Question 42

Are β blockers or ACE-inhibitors continued peri-operatively?

Answer 42

β-blockers

Question 43

Are β blockers or ACE-inhibitors discontinued 24 hours prior to surgery?

Answer 43

ACE inhibitors

Question 44

What components are worth 1 point on the Revised Cardiac Risk Index (RCRI) ?

Answer 44

Question 45

What % risk of major cardiac events would be conferred by a RCRI score of 0 ?

Answer 45

0.4%

Question 46

What % risk of major cardiac events would be conferred by a RCRI score of 1 ?

Answer 46

1.0%

Question 47

What % risk of major cardiac events would be conferred by a RCRI score of 2 ?

Answer 47

2.4%

Question 48

What % risk of major cardiac events would be conferred by a RCRI score of ≥3 ?

Answer 48

5.4%

Question 49

What does 1 MET equal?

Answer 49

3.5mLO₂/kg/min

Question 50

What drug is the preferred treatment for tachycardia?

Answer 50

Esmolol

Question 51

What anticholinergic is the better option for treatment of bradycardia in CAD patients?

Answer 51

**Glycopyrrolate** > Atropine

Question 52

What coronary artery would you expect to be effected from abnormalities noted on II, III, and aVF?

Answer 52

RCA

Question 53

What coronary artery would you expect to be effected from abnormalities noted on I and aVL?

Answer 53

Circumflex artery

Question 54

What coronary artery would you expect to be effected from abnormalities noted on V3 - V5?

Answer 54

LAD