Manifestations and evaluation of Ischemic Heart Disease

Question 1

What is Ischemic Heart disease, and what’s the most common cause of it

Answer 1

• disease caused by ischemia to the heart

- usually caused by plaque build up in the coronaries: atherosclerosis

Question 2

State the different Ischemic heart diseases

Answer 2

• Asymptomatic
• Stable angina, unstable angina, prinzmetal angina
• CHF
• Sudden death
• ACS:
  .STEMI, Sudden death,
  .NSTE ACS (Unstable agina, NSTEMI)

Question 3

Ischemic Heart Disease: pathomechanism

Answer 3

• atherosclerosis-> blocking up to 70% at least for the coronary blood flow for symptoms to occur

Question 4

Ischemic Heart Disease: Signs and Symptoms

Answer 4

• angina
• Paraesthesia: abnormal dermal sensation (e.g., a tingling, pricking, chilling, burning, or numb sensation on the skin) with no apparent physical cause
• Dyspnea
• diaphoresis
• Response to sublingual nitrate
• ECG changes
• Arrhythmia

Question 5

Ischemic Heart Disease: Diagnosis/Evaluation

Answer 5

• Pres test probability (PTP): an online test which predicts probability of coronary artery disease in patients with chest pain, based on different factors like: age, gender, symptoms…
• Family/Medical history
• Physical exam
• ECG
• Exercise ECG
• Echo
• MRI/CT
• PCI: Percutaneous Coronary Intervention

Question 6

Cardiac syndrome X: def, T

Answer 6

• Angina due to decreased flow, but normal coronaries
• mostly seen in women
• T: beta blockers like metoprolol however beta blockers can make coronary spasms worse. Which is a distinct diagnosis from prinzmetal angina -> which will worse it with metoprolol

Question 7

Silent Ischemia/infarction, what is it, Cohn’s classification

Answer 7

• Silent ischemia: inadequate supply of blood to the heat, but doesn’t cause any symptoms like chest pain

Cohn’s classification:

• Class I: asymptomatic despite CAD
• Class II: silent ischemia in patients after documented MI
• Class III: silent ischemia with patients with chronic stable angina, unstable angina, prinzmetal angina. Most common type of silent ischemia

Question 8

Invasive coronary angiography (ICA) for diagnosis

Answer 8

Early:

• clinical profile suggesting a high event risk: LVEF < 50% + typical angina
• High Pre-test probability (PTP) > 85%
• Special professions, like pilots

Late: after stress/imaging testing

Question 9

SCAD: Spontaneous Coronary Artery Dissection: def

Answer 9

Spontaneous coronary artery dissection (SCAD) is a rare emergency condition that occurs when a tear forms in one of the blood vessels in the heart. This tear can slow or block blood flow to the heart which can cause damage to the heart muscle or affect the normal heart rhythm.
Affects mostly women

Question 10

SCAD: Treatment

Answer 10

• Lifestyle changes: stop smoking, BMI< 25 kg/m2, Exercise training > 3 times per week, LDL-C < 1.8 mmol/l, BP < 140/90 mmHg, HbA1C < 7%, avoid HRT
• Optimal Medical Therapy / revascularization

Question 11

Medical management of patients with stable coronary artery disease: Event prevention

Answer 11

• Lifestyle management
• control of risk factors
• Educate the patient
• Aspirin, Statins, Consider ACEi or ARBs

Question 12

Medical management of patients with stable coronary artery disease: Angina relief

Answer 12

1st line treatment:

• Short acting nitrates, +
• BB or CCB for the HR
• consider CCB-DHP if low heart rate or intolerance/contraindications
• consider BB + CCB-DHP if CCS Angina > 2

2nd line treatment:

• Ivabradine
• long acting nitrates
• nicorandil
• ranclazine
• trimetazidine

Question 13

Detection of high risk patients: risk stratification based on

Answer 13

• Clinical evaluation
• ventricular function
• response to stress testing
• coronary anatomy (syntax score)

Question 14

List the non-invasive diagnostic tests

Answer 14

• exercise perfusion scintigraphy
• Exercise echocardiography
• CT angiography, MRI