Treatment of Angina and CAD -Adje

Question 1

age more likely to get ischemic heart disease with coronary heart disease?

Answer 1

65 or older

-higher risk in american Indians/Alaska natives

Question 2

normal myocardium

Answer 2

• extracts more O2 than any other organ in the body
• get angina pectoris if O2 supply does not meet demand*
• ischemic heart disease with decreasing O2 carrying capacity or blood supply
• adenosine hypothesis = relaxation of smooth muscle vascular and coronary arteries

Question 3

endothelial factors produced in normal myocardium**

Answer 3

• NO* produces nitroglycerin –> relaxes vascular smooth muscle decreasing coronary artery resistance
• vascular smooth muscle contains alpha/beta receptors that lead to vasoconstriction/dilation*
• antithrombotic action

Question 4

most common cause of myocardial ischemia**

Answer 4

atherosclerosis***
-narrows the vessels

-in ACS (unstable angina and NSTEMI) –> disrupt atherosclerotic plaque –> platelet aggregation and thrombus formation

Question 5

reversible vs. irreversible myocardial damage*

Answer 5

• angina –> reversible from stenosis or spasm

- MI –> irreversible from complete coronary occlusion (permanent)

Question 6

stable angina

Answer 6

• predictable transient discomfort in the chest**
• worse with exertion, better with rest
• nitroglycerin helps

Question 7

unstable angina

Answer 7

• similar to stable angina
• occurs at rest, lasts for >10 min
• more severe/frequent discomfort
• NOT relieved by nitroglycerin**
• troponins NEG**, unlike NSTEMI

Question 8

Prinzmetal angina

Answer 8

• spasm with no atherosclerotic lesions*
• occurs at rest
• RELIEVED by nitroglycerin*

-can have silent ischemia (no discomfort) –> common in diabetic neuropathy

Question 9

modifiable risk factors***

Answer 9

Tobacco smoking
Hypertension
Diabetes mellitus
High total and LDL cholesterol
Low HDL cholesterol
Obesity (central abdominal)
Lack of physical activity

-dyslipidemia with obesity and diabetes –> can give HMG-CoA reductase inhibitors (statins)

Question 10

non-modifiable risk factors***

Answer 10

Aging
Gender
Ethnic background
Family history of premature coronary heart disease

Question 11

statins**

Answer 11

-powerful treatment on atherosclerosis and ischemic heart disease

Question 12

EKG findings

Answer 12

• ST segment depression, T wave flattening or inversion
• ST segment elevation with transmural ischemia
• may be normal in chronic cases
• Q waves show previous MI

Question 13

stress testing

Answer 13

1. exercise with EKG
   - duration is symptom limited (85% of max predictive HR for age/sex)
   - stop with ST depression 2mm or drop in SBP >10
   - + if ST segment depression is >0.1 mV below baseline lasting longer than 0.08 sec
2. pharmacologic
   - for peripheral vascular or MSK disease, exertional dyspnea, or deconditioning

Question 14

when do you use a CT to examine the heart?

Answer 14

• detect atherosclerotic plaque changes –> calcification

- use Agatston score to measure Ca2+ level

Question 15

indications for coronary arteriography***

Answer 15

1. chronic stable angina with severe symptoms and being considered for PCI or CABG
2. to confirm/rule out IHD
3. angina pectoris after surviving cardiac arrest
4. ischemia with evidence of ventricular dysfunction on other testing
5. risk of coronary events with severe ischemia signs on other testing
6. people with high risk jobs or someone about to undergo high risk surgery

Question 16

what is the preferred cardiac biomarker for myocyte necrosis?

Answer 16

-troponin** - more sensitive and specific than CK-MB

Question 17

nitroglycerin mechanism of action***

Answer 17

-drug of choice for acute angina pectoris (short acting)

• MOA: nitrates relax smooth muscle relieving ischemia in 2 ways
  1. vasodilate veins –> decrease venous return –> decrease LVEDV (preload) relieving wall stress –> less O2 consumption –> relieve ischemia
  2. vasodilate coronary arteries –> increases coronary blood flow –> increase O2 supply
• good in coronary vasospasm

Question 18

long term treatment to prevent recurrent acute angina attack

Answer 18

1. long acting nitrates
2. beta blockers***- reduce cardiac O2 demand by blocking beta1,2 receptors
   - block beta1 –> decrease ventricular contraction and HR –> less O2 demand
3. Ca2+ channel blockers - vasodilators/reduce contractility
4. ranolazine

Question 19

treatment to prevent acute cardiac ischemia

Answer 19

1. antiplatelet therapy –> aspirin (help stabilize plaque), clopidogrel
2. lipid regulating therapy –> HMG-CoA reductase ihibitors (statins) (also stabilize plaque)
3. ACE inhibitors

Question 20

mechanical revascularization

Answer 20

1. PCI
   - balloon-tipped catheter
2. CABG
   - vein graft –> great saphenous vein
   - artery graft –> internal mammary aka internal thoracic artery

Question 21

when are coronary arteries getting perfused?**

Answer 21

during DIASTOLE

-less perfusion during rapid ejection period