PMT, Johnston - CAD: Angina-Stable/Unstable

Question 1

What is the major underlying cause of CAD (and the cause of 90% of MI and most HF)

Answer 1

Atherosclerosis

Question 2

What is angina pectoris?

Answer 2

Chest discomfort, the most frequent expression of myocardial ischemia.

Question 3

What is Chronic Stable Angina?

Answer 3

A consequence of imbalance between oxygen supply-demand.

Question 4

Examples of supply angina

Answer 4

Decreased oxygen delivery to tissue leading to ischemia&raquo_space; coronary vasoconstriction, platelets releasing 5HT and TXA2.

Question 5

Examples of demand angina

Answer 5

Increase myocardial ocygen requirement and workload can lead to ischemia&raquo_space; exercise, stress, emotion, fever, LVH due to AS, Anemia (low O2 carrying capacity).

Question 6

The three disturbances/effects of ischemia.

Answer 6

1) Mechanical consequences
2) Biochemical consequences
3) Electrical consequences

Question 7

Examples of MECHANICAL consequences caused by ischemia (3).

Answer 7

1) HF (LVF and/or RVF)
2) Angina, if ischemia is prolonged or develop coronary occlusion, may lead to myocardial necrosis.
3) Segmental akinesis, bulging (dyskinesis)

Question 8

Examples of BIOCHEMICAL consequences caused by ischemia (3).

Answer 8

1) FA can’t be oxidized
2) Increased lactate production
3) Reduced pH with metabolic acidosis

Question 9

Higher lactate is associated with what?

Answer 9

Higher mortality

Question 10

Examples of ELECTRICAL consequences caused by ischemia (5).

Answer 10

1) T wave inversion
2) Transient displacement of ST segment
3) ST Depression - subendocardial (only inner infarcted)
4) ST Elevation - subepicardial (all infarcted)
5) Electrical instability - VT, Vfib

Question 11

What will angina look like on ECG?

Answer 11

50% of the time the ECG will look normal.

Question 12

See T wave inversion, think what?

Answer 12

Diffuse ischemia.

Question 13

Dx?
Heaviness in retrosternal region. Pain radiates to base of neck and into jaw. Radiates to L shoulder and arm. Crescendo/decrescendo for 20 minutes.

Answer 13

Angina

MI

Question 14

PE in angina:
S3 gallop means what?
Systolic murmur over apex with radiation into left axilla means what?

Answer 14

S3 indicates LV dysfunction leading to HF

Murmur is likely mitral regurgitation due to impaired blood supply to papillary muscles.

Question 15

Anginal systolic murmur in what locations is due to lesion of what vessel?

Answer 15

Inferior and inferior-posterior due to RCA impairment.

Question 16

What are non-chest pain symptoms of chronic IHD (5)?

Answer 16

1. Dyspnea
2. Non chest locations of discomfort (exertional or at rest), mid-epigastric or abdominal
3. Diaphoresis
4. Excessive fatigue and weakness
5. Dizziness and syncope.

Question 17

Why does the threshold of activity level that provokes angina attacks vary among patients?

Answer 17

Fixed CA stenosis/fixed O2 supply; produces ischemia because of increased oxygen demand.

Question 18

What is Levine’s Sign - description and what it means.

Answer 18

Substernal discomfort, clinched fist - discomfort that goes along with ANGINA.

Question 19

What situations may precipitate angina?

Answer 19

Eating a heavy meal or cold exposure.

Question 20

FHx in angina

Answer 20

premature IHD

Question 21

PE in angina; signs of risk factors

Answer 21

Often normal, BUT:
Xanthelasma
Xanthomas
Diabetic skin lesions,
Nicotine stains
Pale
*Absent peripheral pulses!

Question 22

What is xanthelasma and what does it indicate?

Answer 22

Soft, yellowish lipid deposits on eyelids. Indicative of angina.

Question 23

What four things can MIMIC angina in absence of CAD?

Answer 23

1) AS
2) AI
3) Pulmonary HTN
4) Hypertrophic Cardiomyopathy

Question 24

What is Acute Coronary Syndrome (ACS)?

Answer 24

UNSTABLE ANGINA and NSTEMI.

Question 25

What is UA?

Answer 25

Unstable angina - new or worsening chest pain. Pain lasting longer than 20 minutes, less effort to provoke (sometimes wakes from sleep), more meds to relieve, no evidence of myocyte necrosis (no cardiac enzyme elevation).

Question 26

What is NSTEMI?

Answer 26

NSTEMI ACS - Non-ST Elevation Myocardial Infarction: | Chest pain WITH elevation of cardiac enzymes and WITHOUT ST elevation.

Question 27

What is the pathology of ACS?

Answer 27

Most have an atherosclerotic plaque rupture or erosion; platelet aggregation and thrombus leading to partial occlusion of artery.

Question 28

Is ST-elevation or depression more common in STABLE ANGINA?

Answer 28

ST-depression more common = subendocardial injury ischemia

Question 29

How does the magnitude of ST-depression correlate with prognosis in UA/NSTE ACS?

Answer 29

ST depression: 1mm+ in 2 or more leads >> 4x as likely to die within 1 year. 2mm+ >> 6x as likely to die within 1 year. 2mm+ in more than 1 region of ECG >> mortality is 10 fold.

Question 30

DDx of NSTE ACS?

Answer 30

``` PE - ECG changes, elevated troponin Aortic Dissection VHD Myocarditis-pericarditis Stress Cardiomyopathy (Takotsubo Syndrome) = deeply inverted T wave ```

Question 31

Labs in CAD

Answer 31

``` Inc. Troponin w/in 2-4 hrs. Inc. CK-MB w/in 3-6 hrs. Inc. BNP = increased mortality CRP Fasting Lipid Profile ```

Question 32

Prognosis: Signs of high risk for coronary event.

Answer 32

1) Postive stress test at low workload 2) ST depression greater than 5 min after completion of test 3) Decrease in BP - syst fall more than 10mmHg during exercise. 4) VT during exercise 5) Reduce dEF during exsercise (Stress echo)

Question 33

Stress Testing CI

Answer 33

``` Recent MI or acute MI. Unstable arrhythmias Acute PE Aortic disseciton Unstable angina Severe AS Decompensated HF Endocarditis DVT ```

Question 34

Tests for Coronary Event Prognosis

Answer 34

Stress Test Pharmacological Stress Test Nuclear Myocardial Perfusion Imaging (LBBB, LVH, digitalis effect) Stress Echo CXR *Coronary Angiography: (cardiac Cath) *Percutaneous Coronary Intervention and Coronary Artery Bypass Graft (PCI and CABG)

Question 35

What's coronary angioplasty used for?

Answer 35

Gld std for CAD if pt is considered for revascularization with PCI or CABG.

Question 36

What is PCI? | What is CABG?

Answer 36

Both: Myocardial revascularization PCI - 90% successful in 1 - 2 VESSEL DISEASE, followed by stent insertion. CABG - for LAD or 3 VESSEL DISEASE

Question 37

Pharmacologic interventions to prevent MI/Death/Reduce symptoms.

Answer 37

``` Aspirin BB ACEi - good for DM/renal Statin Nitro/Nitrates - drug of choice! (SL) CCB - use Verapamil cautiously in HF ```

Question 38

Aspirin tx MOA

Answer 38

COX-i leading to TXA2-i platelet activation

Question 39

BB tx MOA, special, CI

Answer 39

MAO - bind cats to beta-receptor to DECREASE HR, workload, contractibilty/O2 demand, ischemia and symptoms, - DECREASES MI MORTALITY CI - decompensated HF, hypoT, advanced AV block

Question 40

ACEi tx MOA, special, uses

Answer 40

Blocks conversion of Ang1 to Ang2 - DECREASES MI MORTALITY - Use in DIABETICS and LV systolic dysfunction

Question 41

Nitrates tx MOA, special, uses

Answer 41

Vasodilators vascular smooth msucle. Dec preload Need 8-12 hours of nitrate free to dec. nitrate intolerance. CI - DO NOT take with PDEi

Question 42

CCB tx MOA, special, uses

Answer 42

- Vasodilate - Dec. HR - verpamil has negative ionotropic effect. Ranolazine inhibits inward Na during repol and dec. intracellular Ca

Question 43

What is variant (prinzmetal) angina?

Answer 43

Transient ST elevation with spasms of coronary artery. Chest pain at rest. Relieved by nitro. Rx: DHP CCB (amlodipine)

Question 44

Lipid profile goals for adults with prior events.

Answer 44

LDL-C less than 70mg/dl HDL-C greater than 60mg/dl TG high is 150mg/dl

Question 45

Pharm tx of CAD/angina

Answer 45

``` Statins for hyperlipidemia. ASA Nitrates BB ACE Ranexa (Ranolazine) ```

Question 46

Non-pharm tx of CAD/angina

Answer 46

Diet Protect against atherosclerosis with 2g Na and reduced alcohol Exercise