Cp2.5, Dr Johnston, Angina Stable And Unstable

Front 1

O2 supply can be affected by what several things?

Back 1

aortic diastolic pressure(coronaries fill during aorta diastole), coronary vascular resistance
heart rate
collateral flow (develop in the event of blockage)

Front 2

O2 demand is affected by what things?

Back 2

exercise, excitement, illness
LV wall tension (systolic component, wall works harder)
contractility, HR, afterload

Front 3

ischemia can occur in 2 circumstances

Back 3

1) decreased O2 carrying capacity of blood (anemia, carboxyhemoglobin)
2) O2 demands are increased (LVH from aortic stenosis)

Front 4

What are the effects of ischemia (general)

Back 4

leads to disturbances in mechanical, biochemical and electrical function.

Front 5

examples of mechanical effects of ischemia

Back 5

Heart failure, left, right or both
Angina-if ischemia is prolonged cell death occurs
segmental akinesis=wall not moving or diskinesis=moving ineffectively

Front 6

Biochemical effects of ischemia

Back 6

Fatty acids can't be oxidized, increased lactate production, reduced pH with metabolic acidosis

Front 7

Electrical effects of ischemia

Back 7

T waves become inverted, or prominent upright (bigger) T waves. ST segment depression (subendocardial) or elevated (subepicardial) Vtach, V fib

Front 8

What is the most common cause of ischemia

Back 8

atherosclerosis (of epicardial coronaries) Decreased CA lumen, decreaed perfusion, limited increase is possible so see effects when demand is increased (4 E's)

Front 9

What are some of the altered functions we will see in atherosclerosis?

Back 9

constriction of vessels, clot formation, abnormal interaction with platelets, stenosis. 75-80% is significant. plaques are subject to fissuring, hemorrhage and thrombosis. this reduces flow, worsens ischemia and leads to necrosis. location determines quantity of myocardium affected.

Front 10

risk factors for CAD

Back 10

HTN, Smoking, high lipids, Diabetis, obesity, age, gender, physical inactivity, family Hx

Front 11

which pts do we need to aggressively treat according to NCEP guideline III

Back 11

those pts with high LDL levels. Goal is LDL 70 or less
HDL 60 or higher
TG less than 150
TC less than 200

Front 12

A 1% decrease in TC yields a ___ % decrease in CAD risk

Back 12

3%

Front 13

Metabolic syndroms is defined as 3 of 5 of these factors:

Back 13

1) Obesity (40 inch abd men, 35 inch abd, women)
2) Low HDL ( <40 men, <50 women)
3) High TG (>150)
4) High BP (systolic >130 or diastolic >85)
5) High fasting glucose (>110mg/dl)

Front 14

What BMI is considered obese? Overweight? Desirable?

Back 14

21-24=desirable
25-29= overweight
>30=obese

Front 15

What family hx specifics raise risk of CAD?

Back 15

relatives with ischemic heart disease. 1st degree male relatives <45-55 y/o. 1st degree female relatives <55-65

Front 16

difference between stable and unstable angina

Back 16

unstable is progression of symptoms or symptoms that happen during rest

Front 17

recumbent or angina decubitus

Back 17

angina that occurs at night

Front 18

Levine's sign

Back 18

substernal clinched fist

Front 19

Symptoms of angina

Back 19

heaviness, sqeeze, smothering...
crescendo/decreshendo pattern lasts 1-30 minutes, may radiate into L shoulder down ulnar surface/forearm/hand/both arms,
may radiate into neck, jaw, teeth, back. may be precipitated by heavy meal, cold exposure. Any neck discomfort in cardiac pt is angina unless proved otherwise

Front 20

Differential Dx for angina

Back 20

chest wall syndrome, intercostal neuritis (herpes zoster, diabetis), GERD, esophageal spasm, Pneumothorax, PE, pneumonia, PUD

Front 21

Anginal equivalent

Back 21

is ischemia but not described as pain. described as dyspnea, fatigue, faintness

Front 22

Signs on PE that are risk factors for Angina

Back 22

pale, absent peripheral pulses, nicotine stains, zanthomas=lipid deposits over tendons
xanthelasma=soft, yellowish spots on eyelids
diabetic skin lesions.
these pts are prone to claudication

Front 23

What heart sounds might be present in angina

Back 23

S3, S4 or both

Front 24

what diseases can mimic angina in the absence of CAD

Back 24

Aortic stenosis, aortic insufficiency, pulmonary HTN, Hypertrophic cardiomyopathy

Front 25

What is the most specific test for picking up ischemic heart disease

Back 25

Troponin I

Front 26

What are the contraindications for stress tests

Back 26

MI <4 days ago, unstable angina < 2 days ago, unstable cardiac rhythm, severe atrial stenosis, endocarditis, DVT, pulmonary emobolus, uncontrolled heart failure

Front 27

PCI/PCTA

Back 27

percutaneous coronary intervention/ angiography. 90% sucessful, stent insertion. restenosis occurs in 6 months for 30-45% of patients)

Front 28

indications for CABG

Back 28

1)left main coronary disease
2) at least 3 vessel disease and depressed LV function

Front 29

What 2 veins are often used in CABG

Back 29

1) saphenous vein-rate of closure 20% at 1 year and 50% at 5 years
2) internal mammary artery-potency rate is 90% at 5 years

Front 30

treatment for CAD/angina (non pharmaceutical)

Back 30

lose weight, get BP under control, thyroid under control, stop smoking, encourage rehab/exercise

Front 31

most patients with CAD/angina are treated with which drugs?

Back 31

ASA, B blocker, Nitrates, statins

Front 32

pathophysiology of unstable angina

Back 32

rupture of atherosclerotic plaque from inflammation/mediators released. activation of platelets, clotting factors, thrombus

Front 33

what additional treatment will be added to pts with unstable angina?

Back 33

glycoprotein inhibitors

Front 34

ASA for CAD/angina

Back 34

irreversible COX inhibitor, inhibits platelets, decreases mortality, decreases reinfarction. for stable angina 81-325 mg. for unstable angina 162-325 mg

Front 35

Plavix for CAD/angina

Back 35

blocks surface receptors involved in ADP induced platelet aggregation. 300 mg loading dose then 75 mg/day. can be comibined with ASA for unstable angina

Front 36

platelet glycoprotein inhibitors

Back 36

give to ACS patients (unstable angina and NSTEMI) for whom cath and PCI is planned. blocks platelet receptors 11b/111a. Impairs fibrinogen binding to inhibit platelet aggregation (agrastat, repro, integralin)

Front 37

Nitrates

Back 37

bind to guanylate cyclase in vascular smooth muscle. front line therapy. dilates coronary arteries and veins. lowers end diastolic pressure. prophylactic use for events that cause angina

Front 38

MONA

Back 38

morphine, Oxygen, Nitro, ASA (also can add H for heparin) MONA-H

Front 39

when should you not give a B-blocker

Back 39

higher than 1st degree AV block, hypotension, heart failure