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Exam 1 Keystone > L8 - Ischemic Heart Disease > Flashcards

L8 - Ischemic Heart Disease Flashcards

1
Q

IHD may become clinically manifest as

A
    1. chest discomfort
      * 2. heart failure
      * 3. abnormal EKG or stress test
      * 4. arrhythmias, sometimes with resulting syncope or “sudden cardiac death”
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2
Q

What is the most common cause of death in the US?

A

Sudden cardiac death (due to arrhythmias)

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3
Q

Which is false?
A. >60% are “sudden” (Occur Within Minutes to Hours of Onset of Symptoms or Without Warning), of which 1/3 are instantaneous & >70% occur outside hospital
B. Most sudden cardiac deaths (SCD’s) are due to ventricular fibrillation
C. Most SCD’s are associated with underlying coronary atherosclerosis and in many, old remote myocardial infarction (M.I.).
D. In the majority of sudden cardiac death an acute M.I. is responsible for triggering the arrhythmia causing the SCD episode

A

D. is NOT responsible for triggering arrhythmia

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4
Q

IHD is an imbalance where myocardial ____ exceed myocardial _________

A
  1. oxygen demand

2. blood flow

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5
Q

4 major determinants of myocardial o2 demand

A

a. Intraventricular systolic pressure
b. Ventricular cavity radius (cavity radius times systolic pressure equals ventricular wall tension by the Laplace equation).
c. Heart rate
d. Contractility of the muscle

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6
Q

3 sudden cardiac death mechanisms and which ones are reversible?

A
  1. ventricular tachycardia - 10%
  2. ventricular fibrillation - 60%
  3. asystole EMD and bradycardia- 30%

First 2 are reversible

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7
Q

Angina pectoris is a consequence of myocardial ______ exceeding myocardial ________

A
  1. oxygen demand

2. oxygen supply

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8
Q
  1. coronary blood flow
  2. oxygen delivery (hematocrit, o2 saturation)

CBF (AV)O2

A

o2 supply

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9
Q
  1. blood pressure (afterload)
  2. Ventricular volume (preload)
  3. Heart rate
  4. contractility

MVO2

A

o2 demand

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10
Q

Formula that is related to the regulation of coronary blood flow to meet increased myocardial o2 demand

A 
F = P/F
F = coronary blood flow
P = perfusion pressure gradient
R = coronary resistance
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11
Q

How can you increase perfusion pressure gradient to increase coronary blood flow? (2)

A
  1. increased aortic diastolic pressure

2. decreased LV diastolic pressure

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12
Q

How can you decrease coronary resistance to increase coronary blood flow?

A
  1. Autoregulation (metabolic factors)
  2. Neural factors
  3. Pharmacologic agents
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13
Q

Etiology of ischemic heart disease

A
  1. • Aortic Outflow Tract Disease With Pathological Left Ventricular Hypertrophy e.g. Aortic Valve Stenosis or Insuffiency or Idiopathic Hypertrophic Cardiomyopathy
  2. • Primarily a Matter of Increased MVO2. Also Inadequate Capillary Proliferation To Keep Up with the Hypertrophy
  3. Vast Majority Due To:
    • Disease of Coronary Arteries
    • Atherosclerosis
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14
Q
  • Described as: Tightness, Ache, Squeezing, Pressure, Weight or Burning
  • Often Described with Palm or Clenched Fist Pressed Against the Sternum – Levine’s Sign
  • Most Commonly Substernal
  • May Radiate To or Be Only Felt in Shoulders &/or Arms, Neck, Mandible, or Interscapular Areas
A

STABLE Angina

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15
Q

What precipitates stable angina?

A

Events that increase MVO2 (o2 demand)

  • cold environment
  • heavy meal
  • early in day
  • superimposed isometrics
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16
Q

What is the duration of stable angina?

A
  • *NEVER a Few Seconds
  • *Occasionally One Minute, Usually 3 To 5 Minutes, Rarely 15 to 20 Minutes.
  • *Prompt Relief After Discontinuation of Precipitating Cause &/or Use of s.l. NTG.
  • Subinguinal nitroglycerine
  • *Longer Duration Indicates Unstable Angina
17
Q

Classification of chest pain:

  1. typical angina (definite)
  2. atypical angina (probable)
  3. Noncardiac chest pain
A

Typical:

(1) Substernal Chest Discomfort with a characteristic quality & duration that is
(2) Provoked by exertion or emotional stress and
(3) Relieved by rest or nitroglycerin.

18
Q

When do you do a graded treadmill test?

A

For stable typical or probably angina at time of:

  1. inita evaluation
  2. changing ischemic symptoms

NOT if presenting with acute coronary syndromes (acute MI, unstable angina)

19
Q

Advantage of treadmill test

A

Correlates patient activity and myocardial o2 demands with:

  • objective evidence of ischemia and
  • specific cardiac symptoms
20
Q

What is the classic presentation of stable angina on the EKG of the treadmill test?

A

ST segments start to sag down

21
Q

How else can you confirm diagnosis of angina aside from the treadmill test?

A
  1. Cardiac perfusion imaging studies

2. stress echo

22
Q

T/F Angina is a pathophysiologic or functional diagnosis

A

T

23
Q

What is the most definitive test of presence or absence of abnormality of the epicardial coronary arteries?

A

Coronary angiography

24
Q

What percentage of narrowing of the coronary artery is required to limit max coronary flow?

A

50%

25
Q

T/F: MI is reversible if you take away the stressor

A

False: this is true of angina. Cant take stress away in MI

26
Q

T/F: MI has the same symptoms as angina

A

True - cant make a diagnosis based on history

27
Q

Cardiac Ischemic Pain or Discomfort Similar to But More Prolonged and Usually More Severe Than Stable Exertional Angina Pectoris

Often associated with dyspnea, sweating and nausea
Can be silent

A

MI

28
Q

Physical exam of MI

A

• BP &/or HR May Be Normal, ⇑ or ⇓

Low grade fever

29
Q

diagnosis of MI

A
  • History By Itself Suggests Cardiac Ischemic Pain But Is Not Diagnostic of Infarction (Cardiac Necrosis).
  • Requires either:
    • Typical Evolution of EKG ST Elevations & Formation of New Q Waves
    • Or Rise & Fall of “Cardiac Biomarkers” i.e. Cardiac Troponin I or T

Peaks at about 6-8 hours after onset of infarction & remains abnormal for 1-2 weeks.

30
Q

Complications of MI (3)

A
  1. Arrhythmias
  2. CHF due to diastolic, systolic, or papillary mm dysfunction
  3. hypotension (cardiogenic shock)
31
Q 
Acute coronary syndrome:
- 	• With ST ⇑ & “+” Cardiac Biomarkers = 
	• Q wave MI
		○ *Most Form a Q on EKG = Q Wave MI 
	• Non-Q Wave MI
		○ *Few Do Not Form Q = Non-Q Wave MI
A

ST elevation MI

32
Q

Acute coronary syndrome:
• Without ST ⇑ But With “+” Cardiac Biomarkers
• Non-Q Wave MI
○ *Most Do Not Form Q on EKG = Non-Q Wave MI.
• Q Wave MI

*Few Do Form a Q on EKG = Q Wave MI
Unstable angina: Angina Without Stable, Purely Exertional Pattern
No ST ⇑
No “+” Cardiac Biomarkers

A

Non-ST elevation MI

33
Q

Which is false regarding unstable angina?
A. New onset exertional angina
B. Exertional angina of increasing frequency &/or decreasing level of exertion provoking it
C. Angina occurring with activity
D. Occurring during sleep (“Nocturnal Angina”)
E Prolonged angina > 20-30 minutes duration

A

C. Angina decubitus

34
Q

How do acute coronary syndromes occur?

A

Due to rupture of unstable atherosclerotic plaque

Exam 1 Keystone (9 decks)

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