Coronary Heart Disease

Front 1

List DDx for patients with chest pain.

Back 1

Unstable angina
Coronary Artery Syndrome
GERD
Stable angina
Musculoskeletal pain (Costochondritis)
Pleurisy
Panic Attack
Pneumonia
Herpes Zoster

Front 2

What is the formula for calculating 'Pack Years' for smokers?

Back 2

Pack Years = (Cigarettes per day X number of years smoked) / 20
*Assumes 20 cigarettes/pack

Front 3

The ability of the coronary artery to increase blood flow in response to increased cardiac metabolic demand.

Back 3

Coronary Flow Reserve (CFR)

Front 4

Each year, more than _________ Americans have new or recurrent myocardial infarctions; ____ _________ of those die within the first 24 hours, and many of those who survive suffer significant morbidity.

Back 4

1.6 million
one third

Front 5

The __________ artery passes down through the groove between the two ventricles, giving off diagonal branches, which supply the left ventricle, and perforating branches, which supply the anterior portion of the interventricular septum and the anterior papillary muscle of the left ventricle

Back 5

Left Anterior Descending

Front 6

The __________ ______ of the left coronary artery passes to the left and moves posteriorly in the groove that separates the left atrium and ventricle, giving off branches that supply the left lateral wall of the left ventricle.

Back 6

Circumflex branch

Front 7

The ________ ________ artery usually moves to the back of the heart, where it forms the ________ ___________ artery, which normally supplies the posterior portion of the heart, interventricular septum, sinoatrial (SA) and atrioventricular (AV) nodes, and posterior papillary muscle.

Back 7

Right coronary artery
Posterior descending

Front 8

List three factors that influence blood flow in the coronary vessels that supply the myocardium with oxygen.

Back 8

(1) the aortic pressure
(2) autoregulatory mechanisms
(3) compression of the intramyocardial vessels by the contracting heart muscle

Front 9

What are the three major determinants of increased myocardial oxygen demand (MVO2)?

Back 9

Increased heart rate
Increased myocardial contractility
Increased myocardial wall stress or tension

Front 10

Which of the following is not an indicator of CAD during a stress test:
Chest pain
Severe shortness of breath
Arrhythmias
ST-segment changes on the ECG
Increase in blood pressure

Back 10

A DECREASE in blood pressure during a stress test indicates CAD as opposed to an 'increase'.

Front 11

List three drugs used for pharmacological stress testing of the heart.

Back 11

dipyridamole (blocks adenosine reabsorption)
adenosine (potent vasodilator)
dobutamine (increases myocardial contractility and stroke volume)

Front 12

Which form of echocardiography is particularly useful in assessing valve function?

Back 12

Transesophageal echocardiography

Front 13

Which form of echocardiography uses ultrasound to record blood flow within the heart?

Back 13

Doppler echocardiography

Front 14

Coronary Flow Reserve depends on artery resistance, extravascular resistance (interstitial fluid) and blood composition. Name the two diseases that can alter blood composition thus decreasing CFR.

Back 14

Anemia
Carbon Monoxide poisoning

Front 15

What it the most common cause(s) of coronary heart disease?

Back 15

Atherosclerosis (w/wo thrombosis)

Front 16

Myocardial perfusion imaging is used to visualize the regional distribution of blood flow. This is an example of ______ _________ _________.

Back 16

Nuclear Cardiac Imaging

Front 17

This form of Coronary Artery Disease represents a spectrum of acute ischemic heart diseases ranging from unstable angina to myocardial infarction resulting from disruption of an atherosclerotic plaque that did not significantly compromise the coronary lumen before the event.

Back 17

Acute Coronary Syndrome (ACS)
(disruption of an atherosclerotic plaque)

Front 18

This form of coronary artery disease is characterized by recurrent and transient episodes of myocardial ischemia and stable angina that result from narrowing of a coronary artery lumen due to atherosclerosis and/or vasospasm.

Back 18

Chronic ischemic heart disease
(narrowing of a coronary artery lumen)

Front 19

List the three presentations of Acute Coronary Syndrome (ACS).

Back 19

1) Unstable angina
2) Non-ST-segment elevation (non-Q-wave) myocardial infarction
3) ST-segment elevation (Q-wave) myocardial infarction.

Front 20

When the acute injury is __________ the overall ST vector is shifted in the direction of the outer epicardium, resulting in ST-segment elevation

Back 20

transmural

Front 21

When the injury is confined primarily to the ___________, the overall ST segment is shifted toward the inner ventricular layer, resulting in an overall depression of the ST segment.

Back 21

Subendocardium

Front 22

Of all the serum biomarkers the ________ _________ have high specificity for myocardial tissue and have become the primary biomarker tests for the diagnosis of myocardial infarction.

Back 22

troponin assays

Front 23

There are three isoenzymes of _______ _________, with the ____ isoenzyme being highly specific for injury to myocardial tissue

Back 23

Creatine kinase (CK)
MB

Front 24

Serum levels of CK-MB exceed normal ranges within ___ to ___ hours of myocardial injury

Back 24

4-8

Front 25

A small molecule that is released quickly from infarcted myocardial tissue and becomes elevated within 1 hour after myocardial cell death.

Back 25

Myoglobin

Front 26

T/F Myoglobin is cardiac specific.

Back 26

False: myoglobin is found in cardiac and skeletal muscles making it a less specific biomarker for the diagnosis of ACS.

Front 27

Persons who have no evidence of serum markers for myocardial damage are considered to have ____ ________, whereas a diagnosis of ___________ is indicated if a serum marker of myocardial injury is present.

Back 27

Unstable angina (UA)
Non S-T Segment Elevation Myocardial Infarction (NSTEMI)

Front 28

Inflammation can play a prominent role in plaque instability, with inflammatory cells releasing __________ that cause the fibrous cap to become thinner and more vulnerable to rupture or erosion.

Back 28

cytokines

Front 29

List two factors that can cause an acute ischemic event leading to UA and or NSTEMI.

Back 29

1) increase in myocardial oxygen demand precipitated by tachycardia or hypertension
2) a decrease in oxygen supply related to a reduction in coronary lumen diameter due to platelet-rich thrombi or vessel spasm

Front 30

Patients describe the persistent and severe course of pain associated with UA/NSTEMI as (at least one of three)...

Back 30

(1) it occurs at rest (or with minimal exertion), usually lasting more than 20 minutes (if not interrupted by nitroglycerin)
(2) it is severe and described as frank pain and of new onset (i.e., within 1 month)
(3) it is more severe, prolonged, or frequent than previously experienced

Front 31

__________ infarcts involve the full thickness of the ventricular wall and most commonly occur when there is obstruction of a single artery

Back 31

Transmural

Front 32

_____________ infarcts involve the inner one third to one half of the ventricular wall and occur more frequently in the presence of severely narrowed but still patent arteries.

Back 32

Subendocardial

Front 33

The onset of STEMI usually is _______, with pain as the significant symptom. The pain typically is severe and ________, often described as being constricting, suffocating, or like “someone sitting on my chest.”

Back 33

Abrupt/Crushing

Front 34

Unlike that of ________, the pain associated with STEMI is more prolonged and not relieved by rest or nitroglycerin, and narcotics frequently are required.

Back 34

Angina

Front 35

When experiencing STEMI the elderly may complain of ______ __ _______ more frequently than chest pain.

Back 35

Shortness of breath

Front 36

List the clinical manifestations of STEMI.

Back 36

Abrupt onset
Crushing pain that radiates to left arm, neck and/or jaw
Nausea and vomiting
Fatigue and weakness
Tachycardia, restlessness, anxiety, feelings of doom
Clammy, diaphoretic skin
Hypotension (a poor prognostic sign)

Front 37

The majority of deaths from STEMI are due to the sudden development of ________ _____________.

Back 37

ventricular fibrillation

Front 38

These three diagnostic ECG tracings are absent in as much as half of persons with STEMI who present with chest pain.

Back 38

ST-segment elevation
Prolongation of the Q wave
Inversion of the T wave

Front 39

A new ____ ____ _____ ____ serves as a criterion for STEMI and indicates a need for rapid reperfusion.

Back 39

Left Bundle Branch Block (LBBB)

Front 40

NSTEMI, patients with ACS but without ST segment elevation receive the following treatments in the ER.

Back 40

1) Rest
2) MONA
3) Beta blockers

Front 41

MONA

Back 41

M - morphine (pain management)
O - oxygen
N - nitrates (nitroglycerine)
A - antiplatelets/anticoagulants (e.g. asprin)

Front 42

Describe the dosing of morphine in the ER to relieve pain associated with ACS.

Back 42

Initial dose 2-4 mg IV
Increase 2-8 mg IV at 5-15 min intervals PRN

Front 43

Persons with ECG evidence of infarction should receive immediate reperfusion therapy with a _________ agent or _________ ___________ _________.

Back 43

Thrombolytic
Percutaneous Coronary Intervention (PCI)

Front 44

Current American College of Cardiology (ACC)/AHA guidelines recommend the maintenance of strict _________ control during STEMI.

Back 44

glucose

Front 45

The vasodilating effects of nitroglycerine reduce __________ and _______ thereby reducing oxygen consumption.

Back 45

Preload (decrease venous return)
Afterload (decrease arterial blood pressure)

Front 46

Control of pain in STEMI is accomplished through a combination of therapies including...

Back 46

nitrates
analgesics (e.g., morphine)
oxygen
β-adrenergic blocking agents.

Front 47

___ ______ should not be given in STEMI caused by cocaine use because it could accentuate coronary spasm.

Back 47

Beta Blockers

Front 48

For patients who are unable to take aspirin because of hypersensitivity or gastrointestinal intolerance, ________ may be prescribed.

Back 48

clopidogrel (Plavix)

Front 49

The term reperfusion refers to reestablishment of blood flow during STEMI via...

Back 49

Pharmacologic agents (fibrinolytic therapy)
Percutaneous coronary intervention (PCI)
Coronary artery bypass grafting (CABG)

Front 50

__________ agents interact with plasminogen to generate plasmin, which lyses fibrin clots and digests clotting factors V and VIII, prothrombin, and fibrinogen

Back 50

Fibrinolytic

Front 51

The ability of the coronary arteries to increase blood flow in response to increased cardiac metabolic demand.

Back 51

Coronary Flow Reserve (CFR)

Front 52

In health people the maximal coronary blood flow after full dilation of the coronary arteries is roughly _____ times the resting coronary blood flow.

Back 52

4-6

Front 53

List three causes of myocardial ischemia.

Back 53

1) Occlusion (e.g. epicardial coronary artery stenosis)
2) Resistance (e.g. constriction or spasm of coronary arteries)
3) Decreased capacity of blood to carry oxygen

Front 54

List two causes of unstable or vulnerable plaque.

Back 54

Lipid insudation
Inflammation

Front 55

List three major determinants of plaque vulnerability.

Back 55

1) Large lipid core with thin fibrous cap
2) Inflammatory environment
3) Loss of smooth muscle cells (healing and stabilization)

Front 56

During ischemia, ATP is degraded to ________, which, after diffusion to the extracellular space, causes arteriolar dilation to regulate coronary blood flow.

Back 56

adenosine

Front 57

Adenosine induces the pain of angina mainly by stimulating the _____ __________ in cardiac afferent nerve endings.

Back 57

A1 receptors

Front 58

List vasoactive factors involved in metabolic regulation of coronary blood flow.

Back 58

Adenosine
Nitric Oxide
Prostoglandins
K-ATP channels
Oxygen/Carbon dioxide tensions

Front 59

Name the most common site of pathologic atherosclerotic lesions.

Back 59

Coronary arteries

Front 60

A fixed coronary obstruction that produces a disparity between coronary blood flow and metabolic demands of the myocardium.

Back 60

Chronic Stable Angina

Front 61

Name the initial manifestation of ischemic heart disease in approximately half of persons with CHD.

Back 61

Unstable angina

Front 62

Angina due to dysfunction of small coronary arteries and arterioles.

Back 62

Microvascular angina

Front 63

Name four diseases believed to cause microvascular abnormalities with subsequent reduction in CFR.

Back 63

DM
HTN
SLE
PAN

Front 64

Resting angina associated with ST-segment elevation caused by focal coronary artery spasm.

Back 64

Variant Angina Pectoris (Prinzmetal's Angina)

Front 65

List four possible mechanisms for Prinzmetal's angina.

Back 65

1) Focal deficiency of nitric oxide production
2) Hyperinsulinemia
3) Low intracellular magnesium levels
4) Nicotine, cocaine or meth use

Front 66

Angina or Atypical Chest pain?
Intensity that changes with respiration, cough, or change in position...

Back 66

Atypical

Front 67

Angina or Atypical Chest pain?
Sharp pain or pain lasting only a few seconds

Back 67

Atypical

Front 68

Angina or Atypical Chest pain?
Pain above the mandible and below the epigastrium

Back 68

Atypical

Front 69

Angina or Atypical Chest pain?
Pain in the epigastrium, back, neck, jaw, or shoulders

Back 69

Angina

Front 70

Angina or Atypical Chest pain?
Radiation of pain to arms, shoulders, and neck

Back 70

Angina

Front 71

Angina or Atypical Chest pain?
Pain precipitated by exertion, eating, exposure to cold, or emotional stress.

Back 71

Angina

Front 72

Angina or Atypical Chest pain?
Duration 1-5 minutes and is relieved by rest or nitroglycerin.

Back 72

Angina

Front 73

The New York Heart Association classification of angina pectoris:
No limitation of physical activity (Ordinary physical activity does not cause symptoms.)

Back 73

Class I

Front 74

The New York Heart Association classification of angina pectoris:
Slight limitation of physical activity (Ordinary physical activity does cause symptoms.)

Back 74

Class II

Front 75

The New York Heart Association classification of angina pectoris:
Moderate limitation of activity (Patient is comfortable at rest, but less than ordinary activities cause symptoms.)

Back 75

Class III

Front 76

The New York Heart Association classification of angina pectoris:
Unable to perform any physical activity without discomfort, therefore severe limitation (Patient may be symptomatic even at rest.)

Back 76

Class IV

Front 77

Unstable angina is defined as ____________ (≤ 2 mo of initial presentation) of at least NYHA ________ severity, significant recent increase in_______ and _______ of angina, or angina at _______.

Back 77

New onset angina/Class III
frequency/severity
rest

Front 78

Chronic ischemic heart disease includes (3)...

Back 78

Chronic stable angina
Silent myocardial ischemia
Variant angina

Front 79

Exercise stress tests have lower sensitivity and specificity in _____ and in patients with __________.

Back 79

Women
LBBB

Front 80

Exercise stress testing producing horizontal or down-sloping ST-segment depression of at least ________, measured 80 milliseconds from the J point, is considered the characteristic ischemic response.

Back 80

1 mm

Front 81

Stress echocardiography can be used to evaluate segmental wall motion during exercise.
A normal myocardium becomes ___________ during exercise; ischemic segments become ______ or ______.

Back 81

hyperdynamic
hypokinetic/akinetic

Front 82

Signs of severe coronary artery disease during exercise stress echocardiography include...

Back 82

1) LV dilation
2) Segmental hypokinesis of the LV wall
3) New or worsening mitral regurgitation

Front 83

Nuclear cardiovascular imaging methods include ________ and __________ and are the most frequently used myocardial perfusion scintigraphy tests. These tests are especially useful in patients with baseline ECG abnormalities.

Back 83

Thallium (Tl) 201
Technetium (Tc) 99m sestamibi

Front 84

Name four absolute contraindications for exercise stress testing.

Back 84

1) symptomatic cardiac arrhythmias
2) severe aortic stenosis
3) acute MI within the previous 2 days
4) acute myocarditis or pericarditis

Front 85

In patients in whom Prinzmetal angina is suspected, provocative testing with ________ _________ during coronary angiography may be useful.

Back 85

ergonovine maleate

Front 86

List treatments for stable angina.

Back 86

1) Nonpharmacologic measures (TLC)
2) Aggressive lipid reduction (statins)
3) BP control
4) Anti-anginal therapy (agents that decrease myocardial O2 demand)

Front 87

List anti-anginal therapy agents

Back 87

Long acting nitrates
Beta blockers (Metoprolol, Atenolol, Nadolol)
Calcium channel blockers (Diltiazem, Amlodipine, Felodipine, nicardipine)

Front 88

Ischemia or No Ischemia?
Chest pain radiating to L arm

Back 88

Ischemia

Front 89

Ischemia or No Ischemia?
Chest pain radiating into both arms

Back 89

Ischemia

Front 90

Ischemia or No Ischemia?
Chest pain radiating into R arm

Back 90

High sensitivity but low specificity

Front 91

Ischemia or No Ischemia?
Reproducible chest pain

Back 91

Possibly not ischemia

Front 92

Ischemia or No Ischemia?
Nausea

Back 92

Ischemia

Front 93

Ischemia or No Ischemia?
Third heart sound

Back 93

Ischemia

Front 94

List serum markers used to evaluate the prognosis of ACS.

Back 94

CK-MB
Troponin
Myoglobin (possibly)
Serum AST

Front 95

What EKG change has the greatest prognostic value in investigating unstable angina.

Back 95

A change in an EKG when compared to a previous (baseline) EKG.
ST depression is also predictive

Front 96

List pharmacotherapies in order of administration for unstable angina.

Back 96

1) Oxygen
2) Nitrates
3) Beta blockers
4) Morphine
5) CCB???

Front 97

What is a common anticoaglulant therapy for ACS.

Back 97

Abciximab (Reopro)
-binds to the glycoprotein (GP) IIb/IIIa receptor of human platelets and inhibits platelet aggregation (Limit use to <24 hours in patients who will have catheterization).

Front 98

If aspirin is contraindicated list two alternatives for anticoagulation therapy for ACS.

Back 98

clopidogrel (Plavix)
Ticlopidine (Ticlid) - neutropenia and aplastic anemia > 3 mnths tx

Front 99

Dosing ASA for ACS

Back 99

325mg stat and qd

Front 100

Dosing Clopidogrel (Plavix) for ACS

Back 100

300mg initially, then 75 mg qd

Front 101

Dosing Abciximab (Reopro) for ACS

Back 101

IV bolus load, then infusion for up to 72 hr. If percutaneous coronary intervention (PCI) occurs during the infusion, continue infusion for 18-24 hr after procedure.

Front 102

Dosing Heparin or Enoxaparin/Lovenox for ACS

Back 102

1 mg/kg SC q12h with aspirin x 2 days

Front 103

Tx for Prinzmetal's angina (variant angina)

Back 103

1) Nitrates
2) CCB (Nifedipine, amlodipine, verapamil, and diltiazem effectively prevent coronary vasospasm and variant angina, and they should be administered in preference to beta-blockers)

Front 104

T/F TIMI risk scores are useful for making treatment decisions.

Back 104

False: TIMI risk scores are useful for prognosis, NOTtreatment decisions.
STEMI patients should be “fast-tracked” to PCI.

Front 105

Intravenous thrombolytic therapy (goal = door-to-needle time of < ___ min)
Direct percutaneous intervention (goal = door-to-balloon time of < ___ min)

Back 105

30 min
120 min

Front 106

When treating STEMI in the ER in addition to starting thrombolytic therapy within 30 minutes the following adjuvant therapies should be implemented.

Back 106

1) Antithrombin (Heparin)
2) Antiplatelet (Aspirin)
3) Nitoglycerine (I.V.)
4) Statin
5) Beta blocker

Front 107

Likelihood of ACS
HIGH/INTERMEDIATE/LOW:
Chest or left arm pain or discomfort as chief symptom
Reproduction of previous documented angina
Known history of coronary artery disease, including myocardial infarction

Back 107

HIGH

Front 108

Likelihood of ACS
HIGH/INTERMEDIATE/LOW:
New transient mitral regurgitation, hypotension, diaphoresis, pulmonary edema or rales

Back 108

HIGH

Front 109

Likelihood of ACS
HIGH/INTERMEDIATE/LOW:
New or presumably new transient ST-segment deviation (> 0.05 mV) or T-wave inversion (> 0.2 mV) with symptoms

Back 109

HIGH

Front 110

Likelihood of ACS
HIGH/INTERMEDIATE/LOW:
Elevated cardiac troponin T or I, or elevated CK-MB

Back 110

HIGH

Front 111

Likelihood of ACS
HIGH/INTERMEDIATE/LOW:
Chest or left arm pain or discomfort as chief symptom
Age > 50 years

Back 111

INTERMEDIATE

Front 112

Likelihood of ACS
HIGH/INTERMEDIATE/LOW:
Fixed Q waves
Abnormal ST segments or T waves not documented to be new

Back 112

INTERMEDIATE

Front 113

Likelihood of ACS
HIGH/INTERMEDIATE/LOW:
T-wave flattening or inversion of T waves in leads with dominant R waves
Normal ECG

Back 113

LOW

Front 114

Likelihood of ACS
HIGH/INTERMEDIATE/LOW:
Chest discomfort reproduced by palpation

Back 114

LOW

Front 115

Likelihood of ACS
HIGH/INTERMEDIATE/LOW:
Probable ischemic symptoms
Recent cocaine use

Back 115

LOW

Front 116

Tx for NSTEMI ACS

Back 116

*) Rest and MONA
1) Antithrombin (Heparin)
2) Antiplatelet (Aspirin)
3) Nitroglycerin (I.V.)
4) Statins and Beta blockers
Note: Antithrobolytics are not shown to be effective until ST elevation is seen on the ECG.

Front 117

Silent myocardial ischemia occurs in ____% of patients with asymptomatic type 2 diabetes mellitus.

Back 117

20%

Front 118

Patients with a defective anginal warning system are at a high risk for ___________.

Back 118

Silent Myocardial Ischemia

Front 119

Type II silent myocardial schemia is the form that occurs in patients with documented ___________.

Back 119

Previous Myocardial Infarct

Front 120

Unfractionated Heparin (UFH) dosing in STEMI

Back 120

Continuous infusion of 80units/kg followed by a drip of 18units/kg/hour

Front 121

______________ have no role in unstable angina. They are reserved for patients who are having myocardial infarctions associated with persistent pain and ST elevation or new bundle branch block (usually LBBB).

Back 121

Thrombolytics
(tPA/Retivase/streptokinase)