Ischemic Heart Disease II

Question 1

True or False:

Coronary Artery Disease (CAD) and Ischemic Heart Disease (IHD) are the exact same thing.

Answer 1

True

Question 2

How do you diagnose CAD?

Answer 2

ECG At Rest: ST depression and T wave inversion. (Q-waves for prior MI)

ECG with Stress: Dynamic ST changes such as horizontal or downsloping ST segment (reflects subendocardial ischemia)

ECHO or Perfusion studies improve sensitivity

Question 3

Does this patient shown in the Perfusion Study have CAD?

Answer 3

Yes. Note the incomplete circulation

Question 4

Is there evidence of ST dynamic changes?

Answer 4

Yes sir.

Notice the horizontal ST in V4-V6

Question 5

How do you treat a stable CAD?

Answer 5

Stable CAD: Focus on modifying risk factors (diet, smoking, excercise etc). Treat symptoms with meds.

Angina (use nitrates, beta-blockers).

Control BP

Lower Lipid Profile (statin)

Aspirin for antiplatelet.

Question 6

How do you treat unstable CAD?

Answer 6

Same as stable CAD

+

Hospitalization and EARLY catheterization and ACE inhibitors for LV fxn.

Question 7

How do we know if a lesion in an artery is severe enough to cause symptoms?

Answer 7

Use Fractional Flow Reserve:

1. Put 2 Caths in coronary artery (one above and below lesion)
2. Dilate vessel with adenosine
3. Determine Maximal flow and extrapolate pressure
4. If ratio of above:below is .75 then angioplasty is indicated

Question 8

True or false:

Within 10 years of quitting smoking, risk of coronary events return to levels of “never smoked”

Answer 8

True, although it is based on observational data, not large randomized trials.

Question 9

The following is an ECG from a resting individual. Would the patient likely have stable or unstable CAD? Why

Answer 9

Unstable:

Notice the ST depressions in V4-V6.

Question 10

What problems do we worry about when performing a balloon angioplasty? What are the solutions?

Answer 10

Problem: Accute Occlusion

• Solution: Stents and antiplatelet drugs

Problem: Restenosis

• Solution: Stents that elute antiproliferative drugs

Question 11

A 59 year old man with long-standing diabetes, difficultly controling HTN, mild hypercholesterolemia andno prior history of CAD, comes to your clinic. He complains of abrupt onset of crushing substernal chest pain, diaphoresis, dyspnea, nausea and vomitin. Upon examination you note the patient clutching his chest, diaphoretic (sweating), elevated neck veins, and rales.

You order an ECG and a cornoary angiogram. The ECG shows ST elevation and the angiogram shows a blockage in a coronary artery. What do you do next?

Answer 11

Immediate: aspirin, nitroglycerin, ± beta blocker

ASAP: Reperfusion therapy (aka place a stent)

The patient is having an acute MI (STEMI)

Question 12

When might bypass surgery be better than percutaneous intervention (such as stent placement)?

Answer 12

If multiple blockages are present and/or if stent placement has failed previously.

Question 13

What are popular vessels for grafts in bypass surgery?

Answer 13

Internall mammary Artery or saphenous vein.