Internal Medicine: Cardio - Ischemic Heart Disease

Front 1

Stable Angina Pectoris

Back 1

Coronary ischemia due to imbalance between blood supply and oxygen demand due to fixed atherosclerotic lesions in arteries

*Occurs with INCREASED OXYGEN DEMAND

Front 2

Risk factors for Stable Angina Pectoris

Back 2

1) DM
2) Hyperlipidemia - elevated LDL
3) HTN
4) Cigarette smoking
5) Age
6) Low HDL
7) Hyperhomocysteinemia

Front 3

Normal cardiac ejection fraction

Back 3

>50%

Front 4

Clinical features of stable angina

Back 4

1) Chest pain or substernal pressure lasting less than 10-15 minutes
2) Brought on by exertion or emotion
3) Relieved with rest or nitroglycerin

Front 5

Diagnosis of coronary artery disease

Back 5

1) Resting EKG
2) Stress EKG / Stress Echocardiogram
3) Pharmacologic stress test (if unable to exercise)
4) Holter monitoring (ambulatory EKG)
5) Cardiac catheterization with coronary angiography

*If stress studies +, proceed to catheterization

Front 6

Metabolic Syndrome X

Back 6

Obesity, plus any 2 of the following:
1) Hypercholesterolemia
2) Hypertriglyceridemia
3) DM
4) Hyperuricemia
5) HTN

Front 7

Stress test considered positive with any of these findings...

Back 7

1) S-T segment depression
2) Chest pain
3) HYPOtension
4) Significant arrhytmias

Front 8

Syndrome X

Back 8

Exertional angina with NORMAL coronary arteriogram
Exercise testing and nuclear imaging show evidence of MI

*Excellent prognosis

Front 9

Medications used for pharmacologic stress test

Back 9

1) IV adenosine
2) Dipyramidole
3) Dobutamine

*Adenosine and Dypyramidole cause generalized coronary vasodilation
*Dobutamine increases myocardial oxygen demand (HR, BP, contractility)

Front 10

Treatment of CAD

Back 10

1) Risk factor modification
2) Medical therapy (aspirin, beta-blockers, nitrates, Ca2+ channel blockers, ACEI [for CHF])
3) Revascularization (PTCA or CABG)

Front 11

Coronary artery disease: Severe disease

Back 11

1) Decreased ejection fraction (EF)
2) Three-vessel disease
3) Left main or LAD disease

Front 12

Indications of Percutaneous Transluminal Coronary Angioplasty (PTCA)

Back 12

Indicated with one- or two-vessel disease (proximal lesions)

*Restenosis occurs in 40% within 6 months --> rate reduced with stent placment

Front 13

Unstable Angina Pectoris (USA)

Back 13

Coronary artery blood supply is decreased secondary to reduced resting coronary flow

**Oxygen demand is unchanged --> Indicates stenosis that enlarged via thrombosis, hemorrhage, or plaque rupture**

Front 14

Characteristics of USA

Back 14

1) Chronic angina with increasing frequency, duration, or intensity of chest pain
2) New-onset angina that is severe and worsening
3) Angina at rest

Front 15

First-line therapy for USA

Back 15

1) Beta-blockers
2) Nitrates

*Aspirin, Low-molecular-weight heparin (LMWH), and Glycoprotein IIb/IIIa inhibitors helpful adjuncts

Front 16

Variant (Prinzmetal's) Angina

Back 16

Transient coronary vasospasm accompanied by fixed atherosclerotic lesion
Angina at rest, associated with ventricular dysrhythmias

*Transient S-T segment elevation

Front 17

Coronary angiogram of variant angina

Back 17

Displays coronary vasospasm

*Pt given Ergonovine (to provoke chest pain)

Front 18

Treatment of variant angina

Back 18

1) Calcium channel blockers
2) Nitrates

Front 19

Myocardial Infarction (MI)

Back 19

Necrosis of myocardium resulting from interruption of blood supply
Usually due to acute coronary thrombosis

*30% mortality rate

Front 20

Clinical features of MI

Back 20

1) Chest pain (substernal "crushing" pressure) that radiates to jaw, neck, arm on left side
2) May be asymptomatic
3) Dyspnea, Diaphoresis, Weakness / Fatigue, N/V, Syncope, Sense of impending doom
4) Sudden Cardiac Death (V-fib)

Front 21

EKG markers for ischemia/infarction

Back 21

1) Peaked T waves
2) S-T segment elevation (transmural injury)
3) Q waves
4) T wave inversion

Front 22

Categories of cardiac infarcts

Back 22

1) ST segment elevation - transmural (entire thickness of wall)
2) Non-ST segment elevation - subendocardial (inner one third to one half of wall)

*Types differentiated by cardiac enzymes

Front 23

Cardiac enzymes

Back 23

1) Creatine kinase-MB (CK-MB) - increases within 4-8 hrs of MI; returns to normal in 2-3 days
2) Troponins (I&T) - increases within 3-5 hrs; returns to normal in 5
-14 days

*Troponins are most important markers of MI

Front 24

Medical therapy shown to reduce mortality after MI

Back 24

1) Aspirin - inhibtis platelet aggregation on top of thrombus
2) Beta-blockers - blocks contractility and reduces afterload
3) ACE Inhibitors

*Statins, Nitrates, Morphine, Heparin & Oxygen used also

Front 25

Complications of MI

Back 25

1) Pump failure (CHF)
2) Arrhythmias
3) Recurrent infarction
4) Mechanical complications (rupture of free wall, interventricular septum, papillary muscle, etc)
5) Acute pericarditis
6) Dressler's Syndrome

Front 26

MCC of in-hospital mortality post MI

Back 26

Pump failure (CHF)

*Mild: Tx with ACEI or diuretic
*Severe: Invasive hemodynamic monitoring

Front 27

Management of 2nd degree (type 2) or 3rd degree AV block in setting of anterior MI

Back 27

Emergent placement of temporary pacemaker, followed by placement of permanent pacemaker

Front 28

Free wall rupture post MI

Back 28

Occurs during first 2 weeks
90% mortality via hemopericardium and tamponade
Treated with hemodynamic stabilization, pericardiocentesis, and surgical repair

Front 29

Valvular dysfunction caused by papillary muscle rupture

Back 29

Mitral Regurgitation

*Valve replacement necessary

Front 30

Ventricular Pseudoaneurysm

Back 30

Incomplete free wall rupture

*Surgical emergency --> leads to free wall rupture

Front 31

Treatment of post-MI acute pericarditis

Back 31

Aspirin

*NSAIDS and corticosteroids contraindicated

Front 32

Dressler's Syndrome

Back 32

Fever, malaise, pericarditis, leukocytosis, and pleuritis occurring weeks to months after MI

*Aspirin is most effective therapy

Front 33

Differential Diagnosis of Chest Pain: Heart

Back 33

1) MI
2) Angina
3) Pericarditis
4) Aortic dissection

Front 34

Differential Diagnosis of Chest Pain: Lungs

Back 34

1) Pleuritis
2) Pulmonary embolism
3) Pneumothorax
4) Pneumonia
5) Status asthmaticus

Front 35

Differential Diagnosis of Chest Pain: GI

Back 35

1) GERD
2) Diffuse esophageal spasm
3) Peptic ulcer disease
4) Esophageal rupture

Front 36

Differential Diagnosis of Chest Pain: Chest Wall

Back 36

1) Costochondritis
2) Muscle strain
3) Rib fracture
4) Herpes zoster
5) Thoracic outlet syndrome

Front 37

Differential Diagnosis of Chest Pain: Psychiatric / Drugs

Back 37

1) Panic attacks
2) Anxiety
3) Somatization

*Cocaine use can cause angina

Front 38

Systolic dysfunction in Congestive Heart Failure (CHF)

Back 38

1) Impaired contractility
2) Cardiomyopathy
3) Myocarditis

Front 39

Diastolic dysfunction in CHF

Back 39

1) HTN leading to hypertrophy (MCC)
2) Valvular diseases
3) Restrictive cardiomyopathy (i.e., amyloidosis, sarcoidosis, hemochromatosis)

Front 40

Clinical features of CHF

Back 40

1) Dyspnea
2) Orthopnea
3) Paroxysmal nocturnal dyspnea
4) Nonproductive nocturnal cough
5) Confusion and memory impairment (inadequate brain perfusion)
6) Diaphoresis and cool extremities at rest

Front 41

Orthopnea

Back 41

Difficulty breathing in recumbent position

*Due to increased distribution of blood to the pulmonary circulation when laying down

Front 42

Paroxysmal Nocturnal Dyspnea (PND)

Back 42

Awakening after 1 -2 hours of sleep due to acute shortness of breath

Front 43

Signs of left-sided heart failure

Back 43

1) Displaced PMI
2) S3 gallop (best heard at apex with bell of stethoscope)
3) S4 gallop
4) Crackles / rales at lung bases
5) Dullness to percussion and decreased vocal fremitus (pleural effusion)
6) Increased intensity of pulomonic component of 2nd heart sound (left upper sternal border)

Front 44

Signs/symptoms of right-sided heart failure

Back 44

1) Peripheral pitting edema
2) Jugular venous distention
3) Nocturia (due to increased venous return w/ leg elevation
4) Hepatomegaly/hepatojugular reflex
5) Ascites
6) Right ventricular heave

Front 45

Diagnosis of CHF

Back 45

1) CXR
2) EKG
3) Stress testing
4) Cardiac catheterization
5) Echo (EF, r/o pericardial effusion)
6) Radionuclide ventriculography w/ technetium-99m

Front 46

New York Heart Association (NYHA) Classification of CHF

Back 46

Class I: Symptoms w/ vigorous activity; asymptomatic at rest
Class II: Symptoms w/ prolonged or moderate exertion; slight limitation of activities
Class III: Symptoms w/ usual daily activities; markedly limitation
Class IV: Symptoms at rest; incapacitating

Front 47

Possible CXR findings in CHF

Back 47

1) Cardiomegaly
2) Kerley B lines - short horizontal lines near periphery of lung
3) Prominent interstitial markings
4) Pleural effusion

Front 48

Treatment options for CHF

Back 48

1) Salt restriction (>4g /day)
2) Diuretics (symptomatic relief)
3) ACEI
4) Angiotensin II receptor blockers
5) Digitalis (+ inotropic agent; EF<30%)

*Hydralazine & Isosorbide dinitrates used in patients who cannot tolerate ACEI
6)

Front 49

Signs of digoxin toxicity

Back 49

1) GI: n/v, anorexia
2) Cardiac: AV block. AFib, ectopic ventricular beats
3) CNS: visual disturbances, disorientation

Front 50

Carvedilol

Back 50

Non-selective beta blocker/alpha-1 blocker
Used in tx of CHF

*Better improvement than Metoprolol

Front 51

Useful in differentiating between dyspnea caused by CHF and COPD

Back 51

B-type natriuretic peptide (BNP)

*Released from cardiac ventricles in response to volume expansion and pressure overload