Lecture 2 (CAD)-Exam 1 Flashcards

Question

Prinzmetal/variant angina * An angina that occurs due to what? * Can occurs when? * Can be triggered by?

Answer 1

* An angina that occurs due to **spasms** (sudden, intense contractions) of the coronary arteries, **temporarily** reduces blood flow to the heart muscle (myocardium) * Can occur at rest and is often unpredictable * **Can be triggered by stress, exposure to cold, or certain medications**

Answer 2

* Main symptom is chest pain described as squeezing, pressure, or tightness * More common in younger adults * **Gold standard is coronary angiography** – will demonstrate coronary spasm – hallmark of PVA * Responds well to medications such as calcium channel blocker, nitroglycerin

Answer 3

Also known as angina pectoris – it is a symptom characterized by chest pain or discomfort that occurs when the myocardium does not receive enough oxygen-rich blood

Answer 4

* Myocardial ischemia secondary to exertion (Imbalance between myocardial oxygen demand and delivery) * Occurs in a predictable pattern and is relieved by rest or medication (nitroglycerin) * A temporary reduction in blood flow to the heart – fixed/stable stenosis *

Answer 5

* Chest Pain or angina pectoris (squeezing/pressure/substernal) that builds up rapidly in 30 seconds and typically disappears within 5 -15 minutes with rest * Aching, heaviness, pressure, squeezing or dull mid-sternal discomfort with radiation to the neck, jaw, left shoulder, or arm * “Anginal equivalent”: SOB, fatigue, nausea/reflux/indigestion, diaphoresis, dizziness, jaw pain, arm pain

Answer 6

* Arrythmias * Fever * HTN * Cocaine use * Aortic stenosis * Anemia (decrease hemoglobin) * CHF (HTN+vasular spasm)

Answer 7

sharp, seconds, pleuritic, positional, tender to palpation

Answer 8

* Unstable angina * NSTEMI/STEMI

Answer 9

* **New** onset angina * **Worsening** symptoms with activity and/or at rest * More unpredictable * Considered for urgent or emergent evaluation

Answer 10

* Mild to moderate ST-segment depression may be seen during episodes of chest pain. * Transient T-wave inversion may also be seen during or shortly after an episode of chest pain. * May have a normal EKG, especially if the episode of chest pain has resolved by the time the EKG is performed. Transient changes that disappear when pain free

Answer 11

* Absence of elevated cardiac enzymes * No evidence of cardiac myocyte necrosis

Answer 12

* Complete and prolonged occlusion of a coronary blood vessel * Defined based on ECG criteria * Half die before they reach the hospital * Most deaths occur within 1 hour of onset due to ventricular fibrillation

Answer 13

* usually results from severe coronary artery narrowing, transient occlusion, or microembolization of thrombus * Defined by an elevation of cardiac biomarkers in the absence of ST elevation * Evidence of myocyte ischemia

Answer 14

* Usually severe & intolerable; retrosternal, central (may radiate to left/right/both arm, neck, jaw) * Remember - atypical presentation in women, elderly and diabetics * Prolonged: 20 minutes to hours, does it stop with rest or not? * Quality: “**heavy**”, “crushing,” “constricting,” “compressing,” “oppressing”, **stabbing** * Can also be described as pressure, squeezing, **burning** * Chest pain is caused by ischemia, not infarction **(Supply and demand)**

Answer 15

* Nausea/vomiting: The inferior part of the heart is often supplied by the right coronary artery. An infarction in this area can lead to stimulation of the vagus nerve, which can cause nausea and vomiting. * Weakness * Dizziness, palpitations * Cold sweat, sense of impending doom * Diaphoresis (sweating) is a predictor of ACS (ST segment elevation)

Answer 16

* General distress and diaphoresis are often seen * Heart sounds are frequently normal, possible gallop and murmur can be heard. * Lung exam is normal, although at times crackles may be heard pointing toward associated congestive heart failure (CHF) * Bilateral leg edema may be present indicating CHF

Answer 17

Levine sign- closed fist over the chest

Answer 18

1. pancreatitis and gastritis. 2. aortic dissection 3. pulmonary emboli

Answer 19

ACS-Closed fist over chest

Answer 20

* More commonly occur within a few hours of awakening * Sympathetic nervous system increases heart rate variability and increase in heart rate * Adrenal glands release adrenaline/cortisol which can trigger rupture of plaques in the coronary arteries

Answer 21

* Emotional stress * Vigorous physical exercise * Medical illness * Surgery

Answer 22

* EKG – should be the initial diagnostic test * Coronary CT calcium score * Stress Test (exercise treadmill test, nuclear stress test, dobutamine or adenosine stress test, stress echo)

Answer 23

* Cardiac catheterization + all the outpt dx testing * Labs:Troponin, CKMB, BNP

Answer 24

* The initial diagnostic test which should be ordered is the EKG * ST elevation and Q waves are the 2 most characteristic features of AMI. Seen only in 50% of patients at presentation * STEMI will have ST elevation of 1mm or more in at least 2 contiguous leads * “injury pattern” occurs with transmural ischemia

Answer 25

* NSTEMI with have new ST depression occurs in ~ 1/3 of patients * T- wave changes are common, but non-specific – unless they are new and are deep T-wave inversions * Unstable angina and NSTEMI will have signs of ischemia (ST depression or new T wave inversion). * EKG Evolution: good idea to repeat the EKG frequently if ACS is suspected, as the initial EKG may be normal.

Answer 26

* Deep, wide, larger than 1 box * **Indicates prior MI** * Sign of irreversible myocardial damage from previous MI, indicates scar/dead myocardium

Answer 27

* Can detect amounts of coronary artery calcium as an indicator of atherosclerosis in the coronary arterial tree * appropriate prognostic value for the determination of coronary artery stenosis but not for discriminating between different severities of stenoses * Not used alone. Combined with other info such as risk factors for coronary artery disease. ## Footnote 88.6% sensitivity and 86.2% specificity

Answer 28

* **A higher coronary calcium-score suggest higher chance of significant narrowing of coronaries and higher risk of future heart attack** * With use of IV contrast, noninvasive coronary angiography is possible via CT scan

Answer 29

Agatston Score * **0** = no calcium is seen. Low chance of developing a heart attack in the future. * **100 to 300** = Moderate plaque deposits. Associated with a relatively high risk of a heart attack or other heart disease over the next three to five years. * A score **greater than 300** is a sign of very high to severe disease and heart attack risk.

Answer 30

* Most widely used test for both the diagnosis of Ischemic Heart Disease (IHD) and the estimation of the risk and prognosis. * Non-invasive, affordable screening test * 12-lead EKG before, during, and after exercise * Standardized incremental increase in external workload while symptoms, EKG and blood pressure are monitored. * May not detect low grade stenosis (<50%)

Answer 31

* **Positive if >2mm ST depression and/or hypotension** * Effected by baseline ECG changes * Negative test does not exclude CAD

Answer 32

* Wall motion – how the heart contracts, reduced or abnormal wall motion can indicate areas of ischemia * Can assess how the heart valves function during increased workload * Can indicate if CAD is suspected

Answer 33

Troponins are regulatory proteins found in skeletal and cardiac muscle and play a role in muscle contraction 3 types: * **Troponin C** is present in both cardiac and skeletal tissue * **Troponin T** is also found in both cardiac (more) and skeletal tissue * **Troponin I** is cardiac specific

Answer 34

* When damage or death of cardiac tissue occurs, cardiac troponin (cTn) is released into circulation by cardiac muscle cells * Traditional troponin begins to rise 4-6 hours after symptom onset, peaks by 18-24 hours, BUT remains in detectable levels for > 72-96 hours * High sensitivity troponin is detectable sooner

Answer 35

Natriuretic peptides (NP’s) are key proteins that improve and regulate circulation * They regulate blood pressure, inhibit cardiac hypertrophy and remodeling * **Is used as a biomarker for congestive heart failure** **BNP** is expressed predominantly by cardiomyocytes

Answer 36

* When there is ventricular distention/myocardial muscle stretching, it is released by those cardiac cells * Guides diagnoses and treatment of congestive heart failure

Answer 37

Creatinine kinase is an enzyme that catalyzes the reversible phosphorylation of creatinine by ATP * CKBB – found in central nervous system (brain) * CKMM- found in adult skeletal muscle * CKMB – found in myocardium (1-2% in skeletal too)

Answer 38

* Gold standard test - assessment of coronary artery anatomy by coronary angiography * Therapeutic or diagnostic * Variety of catheter-based interventions can be used to alleviate the obstruction to blood flow in the coronary arteries. (PCI, PTCA, balloon angioplasty) * Certain stenotic valvular and arterial lesions can be treated with catheter-delivered balloon expansion, deployment of stents, or stent mounted bioprosthetic valves

Answer 39

Interpretation is subjective, tools to evaluate degree of stenosis: IVUS, iFR * IVUS- intravascular US – specialized US probe that images the inside of the vessel * iFR – instantaneous wave free ration – pressure based index that provides a measure of pressure difference across a coronary artery stenosis

Answer 40

Coronary artery disease (CAD) is a narrowing of the coronary arteries with atherosclerotic plaque. This limits the supply of oxygen rich blood to the heart muscle * Lower yield: Heart disease is the leading cause of death among men and women in the United States. Coronary artery disease affects 16.5 million Americans. The American Heart Association (AHA) estimates that someone in the US has a heart attack about every 40 seconds. In addition, for patients with no risk factors for heart disease, the lifetime risk of having cardiovascular disease is 3.6% for men and less than 1% for women. Having 2 or more risk factors increase the lifetime risk of cardiovascular disease to 37.5% for men and 18.3% in women

Answer 41

Risk factors: male, advanced age, race, smoking, diabetes, family history, dyslipidemia, life style

Answer 42

MONA * Morphine * Oxygen * Nitroglycerin/nitrates * Aspirin 325mg First medical contact to device time * 90 min at PCI capable hospital * 120 min at non-capable PCI hospital

Answer 43

Goal is to reduce progression: * **Manage Dyslipidemia** – high intensity statin * **Antiplatelet** – ASA +/- others (see next slide!) * *Beta-blockers* - slow the heart, allow increased ventricular filling, and reduce oxygen demand (improves mortality) * **Calcium-channel blockers** reduce afterload and contractility and dilate coronary arteries * **Nitrates** (decreases pre-load, dilate coronary arteries)

Answer 44

Exercise stress test/stress echo to assess severity

Answer 45

* 325 mg x 1 given at time of ACS event * Given to all patients unless contraindicated * Inhibits platelet aggregation & development of coronary thrombosis * Maintenance dose 81mg daily

Answer 46

SE: Bleeding and thrombocytopenia * Abciximab (ReoPro) * Eptifibatide (Integrilin) * Tirofiban (Aggrastat)

Answer 47

Percutaneous coronary intervention (PCI)/Percutaneous Transluminal Coronary Angioplasty (PTCA) * Preferred to thrombolytics/fibrinolytics Coronary artery bypass grafting (CABG)

Answer 48

* Quick, non-invasive procedure, but does still have risks associated * Dual antiplatelet therapy for 12 months * Accessed through the femoral artery or radial artery (first choice) * PCI carries increased risk of redevelopment of angina requiring repeat angiography and revascularization, specifically in DM patients

Answer 49

* PCI is usually advised for patients with one or two vessel disease or high risk patients where surgery is not advisable * High risk PCI can be done with mechanical support via Impella, IABP * Decision best made by team approach: cardiologist + cardiac surgeon

Answer 50

* **Bleeding and Hematoma**: can occur at the catheter insertion site, which is often the femoral or radial artery. * **Vascular Injury**: Injury to the artery at the catheter insertion site can lead to complications such as dissection (tearing) or thrombosis (clotting). * **Stent Thrombosis**: Blood clots may form within a stent placed during PCI.

Answer 51

* Artery Dissection: The coronary artery can tear during the procedure, potentially leading to further narrowing or blockage. * Restenosis: Narrowing of the artery may recur in the months following PCI, requiring additional interventions. * Acute Closure: The treated artery may close suddenly during or after the procedure, leading to chest pain or heart attack.

Answer 52

* Myocardial Infarction: there is a risk of heart attack during the procedure due to factors such as artery dissection or acute closure. * Arrhythmias: can trigger abnormal heart rhythms, including ventricular tachycardia or fibrillation * Kidney Injury: The contrast dye can cause kidney injury, particularly in patients with pre-existing kidney disease. * Allergic Reactions: allergic reaction to the contrast dye or other materials used during the procedure.

Answer 53

* Radiation Exposure: Patients and healthcare providers are exposed to ionizing radiation during the procedure, which may carry long-term risks, especially with repeated exposure. * Death: Although rare, there is a risk of death associated with PCI, typically 1%, higher in complex cases or patients with significant comorbidities.

Answer 54

* More efficacious in patients with diabetes * More beneficial in patients with low EF * AKA BETTER OUTCOMES

Answer 55

* Age: Older age is associated with increased surgical risks, including higher rates of complications such as infection, bleeding, and mortality. * Diabetes: Increases the risk of wound healing complications and graft failure. * Chronic Kidney Disease: May increase the risk of postoperative renal complications. * Chronic Obstructive Pulmonary Disease (COPD): Can increase the risk of respiratory complications postoperatively.

Answer 56

* Peripheral Vascular Disease: May increase the risk of graft failure and other vascular complications. * Left Ventricular Dysfunction: Poor left ventricular function increases the risk of perioperative complications and mortality. * Emergency Surgery: CABG performed on an emergency basis (e.g., for acute coronary syndromes) has higher risks compared to elective surgery. * Obesity: Increases the risk of wound infections, sternal dehiscence, and other complications.

Answer 57

* Previous Cardiac Surgery: A history of prior cardiac surgery may increase the complexity of the procedure and the risk of complications. * Lifestyle Factors: Smoking and poor adherence to medical treatment may affect outcomes and increase surgical risks. * Bleeding and Blood Transfusions: Excessive bleeding during or after surgery may require blood transfusions or additional surgery to control bleeding.

Answer 58

Infection: * Wound Infection: Infection at the surgical site, particularly the chest incision. * Sternal Infection (Mediastinitis): Infection of the breastbone (sternum) and surrounding tissues, which can be serious. Arrhythmias: * Atrial Fibrillation: Common after CABG, can increase the risk of stroke and may require treatment. * Heart Block: May require temporary or permanent pacing.

Answer 59

Pulmonary Complications: * Atelectasis: Collapse of lung tissue. * Pneumonia: Inflammation of the lungs, often related to prolonged mechanical ventilation Renal Complications: * Acute Kidney Injury (AKI): May result from reduced perfusion during surgery.

Answer 60

Neurological Complications: * Stroke: Risk of stroke during or after surgery due to clots or reduced blood flow. * Cognitive Dysfunction: Postoperative cognitive decline, sometimes known as "postoperative cognitive dysfunction" (POCD). Graft Complications: Graft Occlusion- Blockage of the grafts, which can lead to recurrence of symptoms or heart attack. Gastrointestinal Complications: Gastrointestinal Ischemia- reduced blood flow to the gut, potentially causing damage.

Answer 61

* Used for larger vessels, less severe stenosis * Taken via endoscope

Answer 62

* Can be taken open or endoscopic * Used for severe stenosis vessels * Important to use dual-arterial conduit, especially in younger patient

Answer 63

* Gold standard conduit for LAD * Need to ensure the subclavian is patent, can see on the cardiac cath or additional testing

Answer 64

* Most widely used conduit in coronary artery bypass grafting surgery * Previously was completed as an open technique - a long skin incision, increased pain, decreased patient satisfaction * The great saphenous vein is the longest vein in the body, runs anteriorly to the medial malleolus at the foot and then runs in a direction posterior and medial to the knee to the groin and the saphofemoral junction

Answer 65

* SVG compared to radial grafts have less durability and increased tendency to degenerate * During the first year, SVG graft occlusion can occur in 10-15% cases and 50% of them have significant or complete occlusion by ten years

Answer 66

* Radial artery patency graft rate is more than 90% at both one year and 5 years * Redundancy exists as the brachial artery divides into the ulnar and radial artery, they meet in the hand in the palmer arch * Must check Allen’s test first to ensure the radial artery can be taken

Answer 67

* Ulnar dominance is the most common pattern of blood supply to the hand. Studies have shown that approximately 60-65% of people have ulnar dominance. * Radial Dominance: About 10% of people have radial dominance, where the radial artery is the primary blood supplier to the hand. * Balanced Dominance: The remaining 25-30% of individuals have balanced or co-dominance, where both the radial and ulnar arteries contribute equally to the blood supply of the hand

Answer 68

* Radial artery prone to spasm * Radial artery graft to left sided coronaries with severe stenosis >70% can be reasonable * Radial artery graft to the right sided coronaries with severe stenosis >90% can be reasonable

Answer 69

* The LIMA is the gold-standard conduit and associated with significant improvement in short and long term outcomes and survival of patients undergoing CABG * Around 90% of LIMA grafts remain free of significant stenosis at 10 years, many up to 20 years * Less prone to atherosclerotic disease * Class 1 indication for grafting of the left anterior descending artery (LAD) with LIMA