isxaimiki nosos- ekseliksi efragmatos - diagnosi- typoi - entopisi sto ekγ- epiplokes -therapia

Question 1

What are the characteristics of stable angina?

Answer 1

Chest pain occurring with exertion and improving with rest, ST depressions often seen on ECG, usually secondary to atherosclerosis

Question 2

How does the etiology of Prinzmetal (variant) angina differ from other forms of angina?

Answer 2

It is 2° to coronary artery spasm at rest w/transient ST elevations on ECG, triggers are tobacco, cocaine, triptans (but often unknown)

Question 3

How do the symptoms of unstable angina differ from those of stable angina?

Answer 3

Chest pain →↑in frequency or intensity, or occurs on minimal/no exertion, a result of incomplete coronary artery occlusion due to thrombosis

Question 4

A 55-year-old man with angina takes a vasodilator. How may this actually aggravate his ischemia?

Answer 4

Blood is shunted within the coronaries to areas of higher perfusion, away from those of critical stenosis/ischemia (coronary steal syndrome)

Question 5

At what point is ischemic heart disease given the term myocardial infarction rather than unstable angina?

Answer 5

When acute thrombosis due to coronary artery atherosclerosis results in myocyte necrosis with cardiac biomarker elevation

Question 6

What are the five possible manifestations of ischemic heart disease?

Answer 6

Angina, coronary steal syndrome, myocardial infarction, sudden cardiac death, and chronic ischemic heart disease

Question 7

What usually causes sudden cardiac death? How soon after onset of symptoms do people die?

Answer 7

Lethal arrhythmias, such as ventricular fibrillation; within 1 hour

Question 8

What is chronic ischemic heart disease?

Answer 8

Progression to congestive heart failure over many years due to chronic ischemic damage from coronary atherosclerosis

Question 9

What electrocardiogram change are you likely to see with stable angina during an exercise stress test? With Prinzmetal angina?

Answer 9

ST depressions; ST elevations

Question 10

You suspect that your patient has unstable angina. What ECG changes may be seen with unstable angina? Would biomarkers help with diagnosis?

Answer 10

Possible ST depression and/or T-wave inversion; cardiac biomarkers are uninformative (but are useful for diagnosis of myocardial infarction

Question 11

What test would you perform to diagnose whether a myocardial infarction is transmural or subendocardial?

Answer 11

ECG (transmural infarcts may show ST elevations, subendocardial infarcts may show ST depressions)

Question 12

Your patient is a heavy smoker who complains of chest pain at rest. His ECG shows transient ST elevations. What could you treat him with?

Answer 12

Treat with calcium channel blockers, nitrates, and smoking cessation (he most likely has Prinzmetal angina)

Question 13

What do most myocardial infarctions arise from?

Answer 13

Acute thrombosis from ruptured coronary artery atherosclerotic plaques

Question 14

What diseases and conditions are associated with sudden cardiac death?

Answer 14

CAD (up to 70% of cases), hypertrophic/dilated cardiomyopathies, hereditary ion channelopathies (e.g., Brugada and long QT syndromes)

Question 15

A 60-year-old man has crushing chest pain that radiates to his left arm. Which coronary arteries may be occluded (most to least likely)?

Answer 15

Left anterior descending, right, circumflex

Question 16

A 65-year-old man comes to the ED, because he thinks he is having a heart attack. What symptoms may he have?

Answer 16

Diaphoresis, nausea, vomiting, severe retrosternal pain, left arm/jaw pain, dyspnea (shortness of breath), fatigue

Question 17

How long after a myocardial infarction does the infarcted myocardium show extensive coagulative necrosis?

Answer 17

1–3 days

Question 18

How long after an MI does the infarcted myocardium appear normal both grossly and on light microscopy? Can complications occur at this time?

Answer 18

In the first 4 hours; yes, as there is still risk for arrhythmias, heart failure, or cardiogenic shock

Question 19

How long after a myocardial infarction does the infarcted myocardium first show contraction bands? What are contraction bands?

Answer 19

4–24 hours after injury; contraction bands are due to free radical damage in reperfusion injury

Question 20

How long after a myocardial infarction does early coagulative necrosis begin? What changes are seen on light microscopy at this time?

Answer 20

After 4 hours; one sees edema, hemorrhages, neutrophils, and wavy fibers begin to appear

Question 21

A patient has a myocardial infarction and is stabilized. A day later, the cardiologist is still worried about the patient. Why?

Answer 21

Patients are still at risk for arrhythmias, heart failure, and cardiogenic shock for up to 1 day after the myocardial infarction occurs

Question 22

During what period of time after a myocardial infarction is there the greatest risk for ventricular pseudoaneurysm formation?

Answer 22

From 3–4 days after myocardial infarction

Question 23

Describe the appearance and coloring of the affected myocardium 2 months after a myocardial infarction.

Answer 23

The myocardium appears gray-white, demonstrating a completely contracted scar

Question 24

At the cellular level, what happens to the infarcted myocardium on the first day of a myocardial infarction?

Answer 24

Intracellular contents of necrotic cells are released into the blood and neutrophil migration starts

Question 25

As a result of macrophage-mediated structural degeneration, what are some possible dangerous sequelae of an MI 3–14 days after it occurs?

Answer 25

Free wall rupture, tamponade, papillary muscle rupture, mitral regurgitation, LV pseudoaneurysm, interventricular septal rupture

Question 26

A man with severe CAD suddenly drops dead. Cardiac biopsy is performed an hour later. Is a normal appearance on light microscopy surprising?

Answer 26

No, as there are often no abnormal light microscopy findings for up to 4 hours after an MI has occurred

Question 27

A 65-year-old man presents to the ED with 1 hour of crushing retrosternal pain radiating to his jaw. What is the diagnostic gold standard?

Answer 27

Electrocardiography is the gold standard diagnostic test for MI within 6 hours of onset of symptoms

Question 28

Describe the time period of cardiac troponin I elevation after acute myocardial infarction.

Answer 28

Troponin I rises 4 hours after a myocardial infarction and is elevated for 7 to 10 days (more specific than other protein markers)

Question 29

Which protein marker is the most specific during the early stages of myocardial infarction?

Answer 29

Troponin I

Question 30

In which tissue other than the myocardium is CK-MB found? What is it useful for diagnosing?

Answer 30

Skeletal muscle; useful for diagnosing reinfarction on top of acute myocardial infarction, as levels return to normal in 48 hours

Question 31

ST-segment elevations on ECG indicate what type of damage to the myocardium?An ST depression? Pathologic Q waves? Poor R wave progression?

Answer 31

Transmural infarct (STEMI); subendocardial infarct (NSTEMI); evolving or old transmural infarct; evolving or old transmural infarct

Question 32

Hyperacute (peaked) T waves, inverted T waves, or a new left bundle branch block on an ECG could all indicate what type of infarct?

Answer 32

Transmural infarct (evolving or old)

Question 33

Describe the time period of CK-MB elevation after acute myocardial infarction.

Answer 33

CK-MB rises 6–12 hours after a myocardial infarction and returns to normal after 48 hours (unless there is reinfarction)

Question 34

A 50-year-old man with myocardial infarction symptoms has ST depressions on electrocardiogram. How much of his ventricular wall is necrotic?

Answer 34

His ECG suggests a subendocardial infarct, where

Question 35

A 50-year-old man has a transmural myocardial infarction. What does his electrocardiogram show? How much of the cardiac wall is affected?

Answer 35

ST elevations and Q waves; the entire wall is affected

Question 36

A 43-year-old woman comes to the ED with chest pain. Electrocardiogram shows ST elevations in V5 and V6. What territory is occluded?

Answer 36

Left circumflex artery or left anterior descending artery, as the infarct is anterolateral

Question 37

A 43-year-old woman comes to the ED with chest pain. Electrocardiogram shows ST elevations in V3 and V4. What vessel is occluded?

Answer 37

Left anterior descending artery in the distal segments, causing an anteroapical infarction

Question 38

A 43-year-old woman comes to the ED with chest pain. Electrocardiogram shows ST elevations in leads I and aVL. Where is the infarct?

Answer 38

The left circumflex artery, causing a lateral wall infarction

Question 39

A patient with substernal chest pain is en route to the hospital. You are terrified that the patient may die. Why?

Answer 39

Cardiac arrhythmia is a major cause of death in MI patients before they reach the hospital—also common in the first few days after an MI

Question 40

What complication of myocardial infarction can result in cardiac tamponade?

Answer 40

Ventricular free wall rupture

Question 41

What is the cause of the friction rub that can be heard 1–3 days after a myocardial infarction?

Answer 41

Postinfarction fibrinous pericarditis

Question 42

What three complications can result from ventricular pseudoaneurysm formation after a myocardial infarction?

Answer 42

Mural thrombus embolization, arrhythmia, and decreased cardiac output (CO) (greatest risk is 3–14 days after myocardial infarction)

Question 43

What is Dressler syndrome?

Answer 43

An autoimmune syndrome resulting in fibrinous pericarditis several weeks after myocardial infarction

Question 44

An 83-year-old man with recent myocardial infarction has worsening dyspnea. He has bibasilar rales and jugular venous distention. Diagnosis?

Answer 44

Pulmonary edema due to left ventricular failure as a complication of recent myocardial infarction

Question 45

An 80-year-old man with sudden-onset chest pain and ST elevation on electrocardiogram has hypotension and tachycardia. Diagnosis?

Answer 45

Cardiogenic shock (high risk of mortality due to a large infarct)

Question 46

A ventricular septal defect can result from which post-MI complication? When is the period of greatest risk for this complication?

Answer 46

Interventricular septum rupture; like all other ruptures, greatest risk is 3–14 days post-MI

Question 47

Which post-MI complication is associated with fibrosis and causes a dyskinetic, outward bulge during contraction?

Answer 47

True ventricular aneurysm, which could arise 2 weeks to several months after MI

Question 48

What are the standard treatments for unstable angina and non-ST-segment–elevation myocardial infarction?

Answer 48

Anticoagulation (e.g., heparin), antiplatelet therapy (e.g., aspirin + clopidogrel), β-blockers, statins, ACE inhibitors

Question 49

You suspect that a patient has unstable angina. What medications could you provide for symptom control?

Answer 49

Nitroglycerin, morphine

Question 50

A patient was just diagnosed with a transmural myocardial infarction. What is the most important therapy for this patient?

Answer 50

Reperfusion therapy is the most important therapy for a STEMI, as percutaneous coronary interventions are preferred over fibrinolysis

Question 51

A woman with a STEMI is rushed to the cardiac catheterization lab. On returning to the floor, do you initiate therapies typical for NSTEMIs?

Answer 51

Yes, as such patients, in addition to reperfusion, benefit from these (anticoagulation, antiplatelets, β-blockers, ACE inhibitors, statins)