LECT intro to ischemic heart disease, angina, MI (Unrein)

Question 1

what is ischemic heart disease physiology

and what are some major etiologies?

Answer 1

Ischemic heart disease physiology
Coronary blood demand exceeds coronary blood flow
Decreased supply vs. Increased demand
Myocardial metabolism is aerobic!

Etiologies (supply versus demand)
Atherosclerosis
Hyperthyroidism
Anemia
Emotional stress- heart break 
Variant angina
Prinzmetal’s - vasospasm in etiology, associated with other vasospastic phenomena

Question 2

what are the ischemic equivalents/associated symptoms?

Answer 2

Shortness of breath
Diaphoresis
Nausea and/or vomiting- b/c visceral phenomenon 
Dizziness- hypoperfusion
Weakness

Question 3

what are the risk factors for IHD

Answer 3

Increasing age
Male

Smoking***

• -Dose-response relationship
• -2-3 fold increase risk of dying form cardiovascular disease
• -Rapid risk reduction in 2 years after quitting

Hypertension-

Diabetes – microvascular changes

High cholesterol/Dyslipidemia – the most powerful modifiable risk factor

Family history
Premature heart disease in a first-degree relative
Male <55

Cocaine use - causes coronary artery vasospasm and increased metabolic demand/rate of heart

Methamphetamine use
Physical inactivity

Question 4

in terms of the framingham risk scale, what is low risk, intermediate risk and high risk …

Answer 4

Low risk 20% 10-year Framingham risk
Aggressive risk modification

The risk assessment tool below uses information from the Framingham Heart Study to predict a person’s chance of having a heart attack in the next 10 years. This tool is designed for adults aged 20 and older who do not have heart disease or diabetes.

based on age, sex, total cholesterol (should be less than 200), HDL (should be >40), smoker history and systolic BP

Question 5

what is metabolic syndrome

Answer 5

Clustering of risk factors with a two fold increase in CAD risk

Insulin Resistance
Hyperglycemia
Hypertension
Elevated Triglycerides
Low HDL cholesterol
Obesity
Nearly doubles the risk of cardiovascular disease

Question 6

what are the most important risk factors to reduce to prevent IHD

Answer 6

lower cholesterol***

stop smoking

decrease pscyhosocial stressors

HTN

Abdominal obesity

Question 7

what are the diagnostic tests for ischemic events…

Answer 7

EKG

Serum bio-makers
CPK – MM, MB, BB
Troponin
LDH (1-5)

Exercise stress test

Pharmacological stress test

Imaging augmentation
Angiography

CT determined coronary artery calcium score
Maybe useful for patient with an intermediate risk for CAD

Question 8

exercise stress test

Answer 8

have the patient hooked up to cardiac monitoring device

get them up to max heart rate which is 220-age

bruce protocol

Question 9

pharmacological stress test… what agents are used?

Answer 9

dobutamine (catecholamine)–> increase cardiac stress and oxygen demand

adenosine/dipyridamole
-vasodilation, work through coronary steal–> the one artery that has the narrowing will have the blood taken away from it and you can pick up ischemic event with this

Question 10

Angiography

Answer 10

gold standard for defining coronary occlusion

Question 11

WHAT 3 criteria are needed to define typical chest pain….

Answer 11

1) Central substernal pain/discomfort – usually retrosternal
May radiate to the shoulder, arms, jaw or back
Visceral – usually poorly located; associated with nausea, vomiting, diaphoresis and/or shortness of breath

2) Exertional – Brought on or increased with activity/emotional stress
25% maybe silent ischemia
25% atypical
Woman, diabetics, elderly

3) Relieved by nitrates or rest

Question 12

what if you only have 2 of the 3 criteria that defines typical chest pain

Answer 12

then it is atypical chest pain

Question 13

chest pain evaluation chart

Answer 13

look at it!

30-39
have 3= intermediate
have 2 and male = intermediate

40-49 male with 3 = high, male with 2 or 0 = intermediate
female with 3 = intermediate

50-59
male high with 3
female with 3 or 2 = intermediate

60-69
male with 3 high
female with 3 high

Question 14

low probablility work up?

Answer 14

no further work up

Question 15

intermediate probability with eKG normal?

Abnormal EKG?

Answer 15

normal EKG–> stress test

EKG abnormal–> stress test with possible imaging augmentaiton, treatment based upon findings

high probability
-medical therapy followed by a stress test or coronary angiography

Question 16

how do you define unstable angina?

Answer 16

getting worse
comes on at rest
new onset

Question 17

what are the criteria in a TIMI score?

scores and interventions?

Answer 17

Age ≥ 65
≥ 3 traditional cardiac risk factors
Documented CAD with a ≥ 50% stenosis
ST segment abnormalities
≥ 2 two anginal episode in the last 24h hours
Used aspirin in the last week
Elevated cardiac enzymes

Risk score
0-2 low risk – medical therapy and stress test to evaluate therapy, if stress test abnormal - angiography
3-4 intermediate risk – medical therapy and early angiography
5-7 high risk – medical therapy and early angiography

Question 18

how would you differentiate acute aortic dissection from acute coronary syndrome

Answer 18

aortic dissection–> in the back and often described as a tearing sensation- may extend into the right coronary artery and present as actual inferior wall MI w

widened mediastinum

Question 19

how do you differentiate pericarditis from acute coronary syndrome

Answer 19

recent viral illness
pleuritic chest pain
pulses paradoxus

Question 20

PE differentiated from acute coronary syndrome?

Answer 20

new onset of A-fib

inactivity

malignancy/hypercoaguable state

pleuritic chest pain

Question 21

if a patient has ST elevation MI what is the best treatment….

Answer 21

Cath lab!!! door to balloon time <90 minutes

Thrombolytic therapy (2nd choice)

Question 22

what are the absolute contraindications for thrombolytic therapy

Answer 22

Intracranial Hemorrhage
Ischemic CVA in the last 3 months
Facial trauma in the last 3 months
Bleeding diathesis

Question 23

what are the relative contraindications for thrombolytic therapy

Answer 23

Thrombolytic therapy does not has a clear benefit weighed against the risks beyond 12 hours
Chronic, severe, poorly-controlled hypertension
Severe uncontrolled hypertension on presentation
Ischemic CVA > 3 months, known intracranial pathology
Dementia
Internal bleeding within the last 4 weeks
Noncompressible vascular site
Pregnancy
Peptic Ulcer disease
Current anticoagulant use

Question 24

what are early complications with MI

Answer 24

thromboytics -

• bleeding
• reperfusion arrhythmias

IWMI

• bradycardia and AV block- AV nodal perfusion by the RCA
• right ventricular infarction,
• hypotension for volume depletion

AWMI

• pump failure
• cardiogenic shock

Question 25

late (after 24-48 hrs) complications in MI

Answer 25

Cardiogenic shock

VSD- new systolic murmur and thrill on LSB

papillary muscle rupture and MR
-new systolic murmur , pulmonary edema, thrill,

Free wall rupture
first infarction, anterior infarct, females, elderly
typically fatal

left ventricular thrombosis– stroke post MI
-blood stasis, endocardial injury and possible inflammation lead to hypercoagulable state

Question 26

what are the indications for angiography

Answer 26

EF < 40%
Clinically significant ischemia on non-invasive testing
Arrhythmias during acute hospital stay
Recurrent chest pain during the hospital stay
Significant heart failure during the stay

Question 27

post acute coronary syndrome mortality *** interventions?? what are they

Answer 27

b-blocker

aspirin

ACE inhibitor

HMG-CoA reductase inhibitors

management of hyperglycemia (below 180)

Question 28

does coronary revasculatrization have effect on mortality?

Answer 28

Percutaneous intervention (PCI) shown not to have improvement overall in survival or recurrent acute events, except those with silent ischemia by noninvasive stress testing. It is primarily reserved for those with positive stress tests, failure of medical therapy or poor surgical risk

Question 29

when is coronary artery bypass grafting indicated/

Answer 29

in patients with Left main disease

left main equivalent (high grade stenosis >70% proximal LAD and circ)

three vessel disease

two vessels involving proximal LAD and EF <50%

Question 30

what is unique about females presenting with IHD

Answer 30

average age of diagnosis is 10 years later than males

more vasospastic presentation and less obstructive coronary disease

more atypical presentations - SOB, palpitations, dizziness, syncope

Question 31

what is unique about diabetics with IHD?

Answer 31

2-8 times more likely to suffer and die from cardiovascular diseases

can often present without chest pain!! - they just present with atypical presentation- don’t feel well

Patients typically have more advanced and higher grade disease and less collateralization at presentation

Risk reduction:
Glycemic control***
Blood pressure control

Diagnosis
Often difficult due to autonomic neuropathy
Fatigue, dyspnea, nausea and vomiting may predominate the presentation
Silent ischemia
Exercise stress testing has similar diagnostic value
Some care with angiography, but not an absolute contraindication – contrast nephropathy

Question 32

what is unique with the elderly in their presentaiton with IHD

Answer 32

Often present without chest pain
Shortness of breath
Exacerbation of existing and new presentation of CHF
Confusion/delirium

Change from baseline? broad DDx, check for ischemic events

can give you accurate history