Ischemic Heart Disease & Vascular Disease

Question 1

What causes a MI?

Answer 1

Atherosclerosis = MC cause (caused by plaque rupture –> acute coronary artery thrombosis

Coronary artery vasospasm: cocaine, variant (prinzmetal) angina

Question 2

What are s/s of a MI?

Answer 2

Anginal pain: retrosternal pressure (>30mins), not relieved by rest/nitro

Levine’s sign: clenched fist on chest

Pain at rest indicates > 90% occlusion

Sympathetic stimulation: anxiety, diaphoresis, tachy/palpitations, N/V, dizziness

Question 3

What are s/s of a silent MI? Who are they MC in?

Answer 3

MC in women, elderly, obese, DM

Abd pain, jaw pain or dyspnea w/out CP

Question 4

What does a MI look like on PE?

Answer 4

Usually normal +/- S4

CP + bradycardia (may suggest inferior wall MI)

Question 5

How do you dx a MI?

Answer 5

ECG:

• NSTEMI or unstable angina
• STEMI: ST elevation ≥ 1mm in ≥ 2 anatomically contiguous leads +/- reciprocal changes in opposite leads.

Cardiac markers: 3 sets every 8 hrs (troponin most sensitive/specific)

Question 6

What ECG finding is considered equivalent to a STEMI?

Answer 6

LBBB

Question 7

What is the natural STEMI progression?

Answer 7

Peaked T waves –> ST elevations –> Q waves –> T wave inversion

Question 8

When does troponin return to baseline?

Answer 8

7-10 days

Question 9

How do you treat unstable angina or NSTEMI?

Answer 9

Anti-thrombotic:
- Antiplatelet tx: ASA, ADP inhibitors (Clopidogrel - good for those w/ ASA allergy), GP IIb/IIIa inhibitors

-Anticoag: unfractionated heparin, LMWH (enoxaparin), fondaparinux

Adjunctive:
- BBs (metoprolol), nitrates, morphine, CCBs

Question 10

How do you treat a STEMI?

Answer 10

1. Reperfusion (mainstay tx, within 12hrs of sx onset)
   - PCI: within 3h of sx onset, superior to thrombolytics
   - Thrombolytic (used if PCI is not an option): Alteplase (rTPA), streptokinase
2. Antithrombotic:
   - Chewable ASA (lowers mortality by 20%), heparin (unfractionated/LMWH), GP IIb/IIIa inhibitors
3. Adjunct:
   - BBs (decrease mortality), ACEI (slows progression of CHF), nitrates, morphine, statin

Question 11

What class of meds should NOT be used in MI is cocaine induced?

Answer 11

Beta blockers!!! –> unopposed alpha vasoconstriction

Question 12

What are the 4 classes of angina pectoris?

Answer 12

I: angina only w/ strenuous activity

II: angina w/ more prolonged or rigorous activity, slight limitation of physical activity

III: angina w/ usual daily activity, marked limitation

IV: angina @ rest. Often unable to carry out activity

Question 13

What are the s/s of angina pectoris?

Answer 13

Clinical history = utmost importance

1. Substernal poorly localized CP brought on by exertion, radiates to arm, teeth, lower jaw, usually short in duration (< 30 mins, typically 1-5 mins). Levine’s sign. Pain relieved w/ rest or nitro
2. Dyspnea, nausea, diaphoresis, numbness, fatigue
3. Epigastric or shoulder pain

Question 14

How do you dx ischemic heart disease? What is gold standard?

Answer 14

1. ECG: ST depression, T wave inversion, normal in 50%
2. Stress testing (most useful noninvasive tool):
   - Stress EGG
   - Myocardial perfusion imaging stress
   - Stress echo
   - MRI
3. Coronary angiography = definitive dx/GOLD

Question 15

What is definitive tx for angina?

Answer 15

1. PTCA (indicated if 1 or 2 vessel disease NOT involving left main coronary artery & in whom ventricular function is normal)
2. CABG (indicated if left main coronary artery disease, 3 vessel disease, EF < 40%)

Question 16

How can you medically treat angina?

Answer 16

Nitro
BBs
CCBs
ASA

Question 17

What is the classic outpatient regimen for angina?

Answer 17

Daily ASA, sublingual nitro prn, daily BB & statin

Question 18

What causes rheumatic fever? Who is it MC in?

Answer 18

GABHS (aka Strep pyogenes) - infection typically precedes onset of RF by 2-6 wks

MC in children 5-15yo

Question 19

What is the “major” Jones Criteria ?

Answer 19

"CANCER"
Carditis
Arthritis (2 or more joints)
Nodules
Chorea 
Erythema marginatum 
Rheumatic fever

Question 20

What is the “minor” Jones Criteria?

Answer 20

"CAFE P"
CRP increased 
Arthralgia
Fever
Elevated ESR 

Prolonged PR

Question 21

How do you treat rheumatic fever?

Answer 21

ASA +/- corticosteroids

PCN G = abx of choice (or erythromycin if PCN allergic)

Question 22

Describe peripheral venous disease

Answer 22

SF: greater/lesser saphenous veins

Deep: femoral, iliac, popliteal, posterior tibial & SF femoral

Perforating veins

Question 23

What is Virchow’s triad?

Answer 23

1. Intimal damage
2. Stasis
3. Hypercoagulability (Factor V Leiden mutation)

Question 24

What causes varicose veins?

Answer 24

Increased estrogen: OCPs, pregnancy

Prolonged standing, obesity

Question 25

What are s/s of varicose veins?

Answer 25

Dilated, tortuous veins

Dull ache, worsened w/ prolonged standing & relieved w/ elevation

Venous stasis ulcers

Question 26

How do you treat varicose veins?

Answer 26

Leg elevation, compression stockings

Sclerotherapy, radiofrequency or ablation, ambulatory phlebectomy