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Internal Medicine > JH IM Board Review - Coronary Artery Disease I > Flashcards

JH IM Board Review - Coronary Artery Disease I Flashcards

1
Q

Insufficient coronary blood flow occurs when:

2

A
  1. A plaque leads to arterial stenosis.
  2. Endothelial dysfunction prevents adequate vasodilation during exercise.
    ==> Can occur in the absence of severe luminal narrowing.
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2
Q

RFs for CAD - Strong:

9

A
  1. Older age.
  2. Male.
  3. Postmeno females.
  4. Up LDL, down HDL.
  5. Smoking.
  6. HTN.
  7. DM.
  8. Obesity/sedentary lifestyle.
  9. FHx of early CAD.
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3
Q

RFs for CAD - MODERATE:

5

A
  1. UP TGs.
  2. Small dense LDL.
  3. Up homocysteine.
  4. Stress or depression.
  5. Inflammatory markers (CRP, fibrinogen).
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4
Q

RFs for CAD - MILD:

2

A
  1. Lp(a).

2. C.pneumoniae.

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5
Q

A low HDL is an … for CAD.

A

Independent RF.

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6
Q

Importance of small dense LDL:

A

It has the lowest affinity for the LDL receptor and is therefore cleared to the least degree from plasma by the liver.

==> It may be the most atherogenic type of LDL.

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7
Q

Homocysteinuria:

A

Rare homozygous genetic disorder impairing homocysteine metabolism ==> SEVERE PREMATURE ATHEROSCLEROSIS.

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8
Q

…-…% of the population are heterozygous for homocysteinuria, which may account for up to …% of cases of premature atherosclerosis.

A

1-2%.

30%.

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9
Q

Homocysteinuria - Tx of elevated homocysteine levels with folate, B6, B12, does …

A

NOT reduce the risk of AMI or death.

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10
Q

Elevated Lp(a) means …

A

Increased number of LDL particles that contain the large glycoprotein apoprotein (a), which has a higher density than LDL.

==> MORE ATHEROGENIC.

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11
Q

Elevated Lp(a) is a/w …

A

CAD.

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12
Q

Niacin, estrogen, fenofibrate, and bezafibrate all reduce Lp(a).

However, …

A

NONE of these tx have been shown to reduce CVD events.

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13
Q

Elevated CRP and fibrinogen are a/w MIs and CAD.

BUT, …

A

It is unclear if they cause CAD or are simply markers of an associated inflammatory process.

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14
Q

C.pneumoniae has been isolated from atheromas and may contribute to plaque inflammation.

However, …

A

Pts hospitalized with an ACS had no reduction in CVD events when treated with long-term GATIFLOXACIN.

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15
Q

Which factors does the FRS use to assess cumulative risk?

A
  1. Age.
  2. Smoking.
  3. SBP.
  4. Tx for HTN.
  5. Total CH.
  6. HDL.
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16
Q

FRS cumulative risk score stratifies pts as:

A
  1. Low risk <10% CHD at 10y.
  2. Intermediate risk 10-20% at 10y.
  3. High risk >20% at 10y.
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17
Q

The most recent guidelines use which score?

A

The Pooled Cohort Equations (PCEs).

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18
Q

Approx. …% of pts with chronic stable angina have a normal resting ECG.

A

50%.

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19
Q

The presence of CAD can never definitively ruled in or out through stress testing alone, because …

A

Stress testing can yield both false(-) and false(+) results.

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20
Q

The se of an exercise treadmill test is approx …% and the sp is approx …%.

A

70%.

80%.

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21
Q

Stress testing can help …

A

Risk-stratifying the pts.

==> To determine the risk for future CVD events and death.

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22
Q

Need to know pretest probability for having CAD.

The clinician should be able to determine from Hx and PEx alone whether a pt has low, medium, or high pretest probability of CAD:

2 examples:

A

25yo woman with atypical sx and no RFs for CAD ==> Very low pretest probability.

75yo man with exertional angina and a history of HTN, DM, high CH, and smoking ==> High pretest probability.

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23
Q

Pretest probability helps stress test …

A

Result interpretation.

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24
Q

Stress tests add … for pts with either high or low pretest probabilities for CAD.

A

LITTLE DIAGNOSTIC INFO.

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25
Q

Stress tests are most useful for diagnosing CAD in pts with …

A

INTERMEDIATE pretest probability.

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26
Q

Stress test results should be categorized as:

4

A
  1. Inadequate.
  2. Negative.
  3. Positive low risk.
  4. Positive high risk.
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27
Q

Features of a high risk stress test:

A
  1. Exercise-induced hypotension.
  2. Angina or ischemic ECG changes at a low workload (<6min or <4 METS on Bruce protocol).
  3. ST-depression >2mm.
  4. ST-depression >6mm into recovery period.
  5. Any ST-elevation.
  6. V-arrhythmias.
  7. Imaging reveals reversible defects in multiple territories or LV cavity dilation.
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28
Q

Pts with positive stress tests w/o high-risk features are often treated …

A

Medically.

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29
Q

Pts with positive tests and high-risk features are more likely to have high-risk coronary anatomy (LAD disease, 3-vessel disease).

The best approach usually requires …

A

Cardiac catheterization and revascularization.

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30
Q

Types of stress tests - 2 options for stress:

A
  1. Exercise.

2. Pharmacologic.

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31
Q

Types of stress tests - 2 options for imaging:

A
  1. Nuclear isotope.

2. Echo.

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32
Q

Pharmacologic stress test uses which agents?

A
  1. Dobutamine.
  2. Adenosine agonists = adenosine, dipyridamole, regadenoson.

==> dilation is greater in normal arteries resulting in STEAL phenomenon from diseased vascular beds.

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33
Q

Nuclear isotopes used in stress tests (2):

A
  1. Thallium-201.

2. Technetium-99m (sestamibi).

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34
Q

Thallium 201 is a …

A

Potassium analogue taken up by myocardial cells.

==> Hypoperfused initially shows decreased uptake.

==> Tracer redistributes over several hours.

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35
Q

Thallium 201 is helpful in distinguishing …

A

Ischemia from infarcted myocardium.

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36
Q

Technetium-99m (sestamibi) is …

A

Also taken up by myocardial cells BUT BINDS IRREVERSIBLY.

==> No late washout makes it IDEAL for imaging MI and USA.

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37
Q

Tc-99m has … energy.

Better agent for …

A

Higher proton energy.

==> Better agent for imaging obese pts.

38
Q

To decide which stress test is best for a given pt, ask 2 questions:

A
  1. Can the pt exercise?

2. Does the resting ECG have ST-segments abnormalities?

39
Q

Can the pt exercise?

A

Yes ==> Treadmill.

No ==> Drug-induced stress.

40
Q

Does the resting ECG have ST-segment abnormalities?

A

If there are baseline ST-segment abnormalities (eg LVH with strain, paced rhythm, LBBB, ST depression, accessory pathways)

==> Then, the ECG alone may not permit an accurate diagnosis of ischemia, and an IMAGING modality will be required.

41
Q

Stress test is very safe:

A

1-2 deaths per 10,000 tests.

42
Q

Stress test should be avoided in:

7

A
  1. Pts with active USA.
  2. Severe AS.
  3. Possible AD.
  4. Severe HTN.
  5. Tachy/bradyarrhythmias.
  6. HCM.
  7. Other forms of outflow obstruction.
43
Q

Pharmacologic testing with adenosine agonists should be avoided in pts w/:

(2)

A
  1. Severe COPD.

2. Active wheezing.

44
Q

Calcium score screening CT is a …

A

Noninvasive and quantitative assessment of coronary artery calcification.

45
Q

Higher coronary artery calcium scores are a/w …

A

Increased risk for MI and death.

46
Q

Calcium score screening CT should be obtained only in …

A

Asx pts.

47
Q

A coronary artery calcium score of 0 is a/w …

A

Excellent survival, w/ all-cause, 10y mortality risk <1% or <0.1% per y.

48
Q

Coronary calcification can also be measured by …

A

CCTA (coronary CT angio).

49
Q

CCTA allows for …

A

Direct coronary artery visualization of a beating heart with little motion artifact.

50
Q

Most accurate noninvasive modality in ruling out CAD with a very high negative predictive value (>95%)?

A

CCTA.

51
Q

CCTA is less accurate in differentiating degrees of coronary artery stenosis >…%.

The PPV varies between …-… .

A

50%.

60-90%.

52
Q

Coronary angio is considered the … for diagnosing CAD.

A

Gold standard.

53
Q

Refer for cardiac catheterization if:

3

A
  1. Need to confirm or exclude CAD.
  2. Medical tx fails to relieve anginal sx.
  3. Hx and noninvasive testing suggest high-risk coronary anatomy.
54
Q

Treatment of chronic CAD:

A
  1. Address modifiable RFs.
  2. Correct illnesses that precipitate or exacerbate angina (eg infection, anemia, thyroid disease).
  3. Consider medications to relieve angina (beta-blockers, nitrates etc).
  4. Consider medications that decrease morbidity and mortality.
  5. Revascularization of chronic CAD (PCI, CABG).
55
Q

Beta blockers DO NOT reduce mortality in pts with …

A

Chronic stable angina w/o MI or HF.

56
Q

Beta blockers reduce BOTH morbidity and mortality in pts with …

A

Recent MI or HF with CAD.

57
Q

Which CCBs should NOT be used in pts with ACS?

A

Short-acting dihydropyridines.

==> They increase mortality.

***Long-acting agents are safe and effective in treating pts with chronic stable angina.

58
Q

Ranolazine - MoA:

A

Inhibits the late inward Na current.

==> Indirectly reducing the Na-dependent calcium current during ischemic conditions.

==> Leading to improvement in ventricular diastolic tension and O2 consumption.

59
Q

Medications that decrease morbidity and mortality:

A
  1. Aspirin.
  2. Lipid-lowering agents.
  3. ACEIs.
60
Q

Aspirin reduces risk of …

A

MI and death.

61
Q

All pts with CAD should be on aspirin unless …

A

There is a clear contraindication.

62
Q

The major indication for revascularization in CHRONIC CAD is for …

A

Relief of angina sx in pts on optimal medical management.

63
Q

Percutaneous coronary intervention (PCI) has 2 components:

A
  1. Percutaneous transluminal coronary angioplasty (PTCA), in which a balloon is used to split the atheromatous plaque and stretch the artery.
  2. Stent deployment, which provides a metal scaffold to help maintain artery patency.
64
Q

2 types of stents:

A
  1. Bare metal stents (BMSs).

2. Drug-eluting stents (DESs).

65
Q

Deciding between BMS and DES:

2

A
  1. No survival differences. DES reduces risk of repeat target-vessel revascularization and reinfarctions.
  2. BMS should be used in pts who cannot tolerate long-term dual-antiplatelet tx.
66
Q

The 4 thienopyridines:

A
  1. Clopidogrel.
  2. Prasugrel.
  3. Ticagrelor.
  4. Ticlopidine.
67
Q

Complications of PCI - Restenosis - Mechanism?

A

Incompletely understood but likely involves NEOINTIMAL THICKENING caused by smooth muscle cell proliferation.

68
Q

Restenosis - The dilated segment can shrink because of …

A

Elastic recoil.

69
Q

Restenosis - Incidence peaks between … after PCI but has significantly decreased with DES use.

A

3-6mo.

70
Q

Other complications of PCI:

A

1-2% risk of emergent bypass.

2-4% risk of MI (ie thrombosis).

1% risk of death.

71
Q

PCI risk of complications increases with lesions that are …

A

Long, tubular, eccentric, and calcified.

72
Q

In pts with stable CAD, PCI is quite effective in reducing angina, but it does NOT …

A

Reduce the risk of death or MI.

73
Q

CABG is … for relieving anginal sx.

A

EXCELLENT.

74
Q

CABG benefits compared with PCI:

A

Decreased repeated revascularization procedures.

75
Q

CABG - Complications:

A
  1. Sternal wound infection.
  2. MI.
  3. Stroke.
  4. Post-op arrhythmias.
  5. Death.
76
Q

Characteristics of pts with stable CAD who have lower mortality rates after CABG:

A
  1. Left main disease.
  2. 3-vessel CAD and decreased LV function **. (Weaker rec.)
  3. 3-vessel CAD and ischemia at low workload.
  4. 2-vessel or 3-vessel disease with proximal LAD involvement.
  5. Pts with DM: Higher 5y survival with CABG than with PCI.
77
Q

Following CABG, use statin therapy, which can help …

A

Decrease graft vessel disease (even in pts with only mild LDL elevation).

78
Q

How does multivessel PCI compare with CABG in pts with left main or 3-vessel CAD?

A
  1. At 1y ==> Major adverse cardiac events rates are higher in the PCI group, largely caused by an increased rate of repeat revascularization.
  2. At 1y ==> Rates of death and MI are the same in both groups, but STROKE is more likely to occur with CABG.
79
Q

Consider calculating the SYNTAX score to determine if CABG or PCI is preferable.

SYNTAX is an …

A

Angiographic scoring system that uses various angio parameters to assess multivessel CAD complexity.

80
Q

Pts with LOW SYNTAX scores have … differences in outcomes when treated with either multivessel PCI or CABG.

A

No.

81
Q

Pts with a HIGH SYNTAX score derive greater benefit from …

A

CABG, which is a/w less major cardiac events (cardiac death and MI).

82
Q

Smoking cessation decreases CHD event risk by …% within 3y.

A

60%.

83
Q

BP control — A …-…mmHg reduction results in a …% reduction in cardiovascular events.

A

5-6mmHg.

16%.

84
Q

Reduction in serum cholesterol by …% reduces cardiovascular events by …% and cardiovascular death by …%

A

10%

18%

10%

85
Q

DM increases risk of heart disease by …-… in men and …-… in women.

A

2x-4x

3x-7x.

86
Q

Though data are limited, maintaining ideal body weight and staying physically active may reduce risk of MI by …%.

A

50%.

87
Q

Aspirin as primary prevention — In men, pooled data suggest a …% reduction in first MI.

A

33%.

88
Q

In women, aspirin as primary prevention reduces the risk of … in those >65y but has NO effect on …

A

Stroke.

MI or death from CVD.

89
Q

Statins reduce the risk of first MI, even in pts with …

A

Moderately elevated cholesterol.

90
Q

Hormone tx increases the risk of CVD in the …

A

First 2 years of use.

91
Q

Moderate alcohol intake (one drink per day) decreases risk of MI by …-…%.

A

30-50%.

Internal Medicine (106 decks)

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