Ischemic Heart Disease I

Question 1

Percent of population that has had an MI

Answer 1

3-4%

Question 2

MCC of an MI

Answer 2

Atherosclerosis

Question 3

Pathogenesis of IHD

Answer 3

Supply that does not meet demand - Can be a blockage, or hypotension, or even anemia or bleeding out

Question 4

IHD continuum

Answer 4

Prinzmetal angina
Stable angina
Unstable angina
Myocardial Infarction: NSTEMI or STEMI

Question 5

Acute coronary syndrome

Answer 5

When there is plaque rupture and thrombus formation

STEMI, NSTEMI, or Unstable Angina all count

Question 6

How much blood is getting through in ACS

Answer 6

USA - No occlusion
NSTEMI - Partial occlusion
STEMI - Complete occlusion

Question 7

Presentation of stable angina

Answer 7

Typical patter with predictability
1-15 minutes persistence
Pain with activity

Question 8

Presentation of Unstable angina

Answer 8

Unexpected - a change from the patients usual pattern
Pain DOES NOT go away with rest or nitroglycerin
MI is imminent

Question 9

Continuum of myocyte cell death

Answer 9

Ischemia - As soon as there is a loss of blood flow - hurts but fine
Injury - Some cells will return to normal some won’t
Infarct - Tissue is fully dead and akinetic

Question 10

Acute infarct

Answer 10

Has happened within 3-5 days

Question 11

NSTEMI cause and presentation

Answer 11

Subendocardial wall of the LV, Septum or Papillary muscle is infarcted
ST depression or T wave inversion or nothing(won’t do that on a test)!!!!
Non Q wave

Question 12

STEMI cause and presentation

Answer 12

Transmural MI
ST elevation and Q waves
Label based on area we are seeing it in
ECG tombstoning

Question 13

Type I MI

Answer 13

Primary coronary event due to rupture of a plaque

Question 14

Type II MI

Answer 14

Secondary to ischemia d/t oxygen demand and decresed supply - Spasm, embolism, anemia, arrhythmias
Atherosclerosis is NOT THE CAUSE

Question 15

Type III MI

Answer 15

Sudden cardiac death

Question 16

Type IV MI

Answer 16

Have had an angioplasty or sent

Question 17

Type V MI

Answer 17

Associated with CABG

Question 18

Myocardial stunning

Answer 18

Heart stops working to save itself - restarts on reperfusion

Question 19

Hibernating myocardium

Answer 19

Tissue is alive but needs to be reperfused - MUGA scan

Question 20

3 Most common patients with silent ischemia

Answer 20

Diabetics, elderly, women

Question 21

2 branches of the right coronary artery

Answer 21

Marginal and Posterior Descending

Question 22

2 branches of left coronary artery

Answer 22

Circumflex and Anterior descending

Question 23

Supply to inferior portion of the heart (LV)

Answer 23

Right coronary artery

Question 24

Supply to the SA and AV node

Answer 24

Right coronary artery

Question 25

Supply to lateral heart

Answer 25

Left circumflex artery

Question 26

Supply to anterior heart (LV)

Answer 26

Left anterior descending artery (widowmaker)

Question 27

Supply to posterior heart

Answer 27

Right coronary artery - Posterior descending artery (Tall R wave in leads V1-V3)

Question 28

To questions for initial evaluation of a patient with chest discomfort

Answer 28

How likely is ACS? What is the risk of adverse events?

Question 29

One more time, what qualifies as ACS again?

Answer 29

Unstable angina NSTEMI STEMI

Question 30

Angina

Answer 30

Squeezing, gnawing pain in the chest

Question 31

ACS typical presentation

Answer 31

Rarely "pain" Substernal Radiation to left shoulder, scapula, jaw SUDDEN! (Past 1-2 days) Lasts 2-5 minutes - typically with exertion

Question 32

Aggravating/Alleviating factors for ACS

Answer 32

NTG and rest make it better Activity, meals, stress, sex, morning, supine position make it worse

Question 33

Associate s/s of ACS

Answer 33

Impending doom Fatigue Nausea

Question 34

Abnormal presentation of ACS in women

Answer 34

Pressure, fatigue, weakness Pay attention to risk factors

Question 35

Physical exam for ACS

Answer 35

May have high/low BP Fast/slow HR SICK APPEARING - Gray and Diaphoretic Altered consciousness

Question 36

1 substance that can induce chest pain

Answer 36

Cocaine - vasospasms

Question 37

Criteria of TIMI score

Answer 37

65+ Age 3+ CAD risk FACTORS Prior CAD Aspirin in past 7 days Severe angina ST deviation over 0.5 mm Elevated cardiac markers - CK-MB or troponin

Question 38

TIMI score interpretation

Answer 38

0-2 Low risk 3-4 Intermediate risk 5+ High risk

Question 39

HEART score

Answer 39

History ECG Age Risk factors Troponin

Question 40

History measurement for HEART score

Answer 40

2 - Highly suspicious 1 - Moderately suspicious 0 - Slightly suspicious

Question 41

ECG measurement for HEART score

Answer 41

2 - Significant ST depression 1 - Nonspecific repolarization disturbance 0 - Normal ECG

Question 42

Age measurement for HEART score

Answer 42

2 - 65+ 1 - 45-65 0 - 45 or less

Question 43

Risk factors for heart score

Answer 43

2 - Three risk factors 1 - One or Two risk factors 0 - No risk factors

Question 44

Troponin measurement for HEART score

Answer 44

2 - 3+ times the normal limit 1-3 times the normal limit Normal

Question 45

Interpretation and Intervention for HEarT scores

Answer 45

0-3 - Discharge (2.5% likelihood) 4-6 - Admit for observation (22.3% likelihood) 7-10 - Admit with early invasive strategies (72.7% likelihood)

Question 46

Normal troponin level

Answer 46

0.04 ng/mL (0.12 is three times normal)