Stable Ischemic Heart Disease/Chronic Coronary Artery Disease

Question 1

Normal arterial wall

Answer 1

Intima - single layer of endothelial cells

Media - thickest layer…contains smooth muscle cells

Adventitia - contains nerves, lymphatics, and BVs

Question 2

Glagov phenomenon

Answer 2

Early plaque grwoth shows outward remodeling of the vessel wall so that lumen diameter is preserved

Question 3

ACS vs. SIHD

Answer 3

ACS - plauqe…palque rupture…platelet agg and act of caog cascade…thrombus formation…sudden dec in supply…onset of sx

SIHD - atheroscleortic plaque…slow dec in lumen size…gradual dec in myocardial BF…slow progression in sx

Question 4

Typical angina
Atypical angina
Noncardiac chest pain

Answer 4

1) substernal chest discomfort with characteristic quality and duration and is 2) provoked by exertion or emotional stress and 3) relieved by rest or nitroglycerin

Atypical - 2 of above

Noncardiac - 1 or none

Question 5

Rest angina

New onset angina

Inc angina

Answer 5

Rest - rest and longer than 20 minutes

New - anginga on class 3 with onset within 2 mos of intial presentation

Inc - previously dx that is more frequent, longer in duration, or lower in threshold

Question 6

Other fts of angina

Answer 6

Anything that inc demand or dec supply should make worse

Pleuritic, positional, palpable, prolonged is NOT consistent iwth ischemia

Question 7

Men vs. women

Answer 7

Older men are more likely related to angina than women

Question 8

ECG indicaiton

Answer 8

Everyone with resting chest pain should get resting ECG

Question 9

What to do next?

Answer 9

If stable, perform diagnostic test

If unstable, go ahead and tx

Question 10

Group to get stress test with

Answer 10

middle - 45 y/o asx man with hypercholesterolemia, HTN, and diabetes

Question 11

Pros and cons of cardiac CT

Answer 11

Extremely rapid, non-invasive, phenomenal spaital resolution

Radiation epsoure, neprhotoxic contrast, motion/HR artifacts…ONLY the anatomy, NO physiology

Question 12

Cardiac catheterization

Answer 12

Invasive (low but real risk)
Costly
Nephrotiox contrast
Radiation
Can be therapeutic as well with PCI 
Gold standard***

This is another anatomical test

Question 13

Time line of ischemia

Answer 13

Normal —-perfusion prob—regional diastolic dys—-regional systolic dys—-ischemic ECG changes—-angina pectoris

Question 14

Able to exercise

Answer 14

If you can exercise, you SHOULD for the stressor

Question 15

Prognositc with EKC

Answer 15

ST changes - diagnosit
Duke treadmill score
Exercise capacity
HR recorvery (normal over 12 beats)
Drop in BP

Question 16

Nuclear imaging

Answer 16

Pros - non-invasive and non-neprhotoxic, primarily perufison, some info on txn, less limited by body abitus

Cons - radiation exposure, expensive upfront, most commonly done with exercise or vasodilator, limited structural info, limited by HR variability

Question 17

How to do nuclear

Answer 17

Administer

Resting images

Stress

Re-image

Question 18

Infarction and ischemia on nuclear

Answer 18

Infarct - defusion at rest adn at stress

Ischemia - defect at stress only

Question 19

Stress echo pro and ocn

Answer 19

No radiation and no neprhotixic, limited risk, non-invasive, echo readily available

Con - tech challenging, exercise or inotrope, more diff to interpret, limited by body habitus

Question 20

Stress MRI

Answer 20

Pro - rapid, no radiation, caridac perfusion with both anatomy and physioly, comprehensive

Cons - no anatomy, only vaosdilator challeneges, pt ability, limited by HR and pt tolerance

Question 21

Med tx of SIHD

Answer 21

Aspirin (clopidogrel if allergic)
Statins
Antianginals 
Lifestyle mods 
PCI improves chest pain but NOT mortality