CAD + Angina

What is the underlying cause of chronic stable angina in these lectures?

Stable CAD due to atherosclerotic heart disease.

Predictable chest discomfort with exertion that resolves with rest or nitroglycerin suggests what?

Stable angina.

Chest discomfort at rest or with a significant change in its previous pattern suggests what?

Unstable angina.

What process links plaque rupture to ACS?

Intravascular thrombosis, sometimes accompanied by coronary vasospasm.

What determines the outcome after coronary plaque rupture?

Whether the vessel becomes fully occluded.

What follows complete coronary occlusion?

Acute myocardial necrosis.

How severe must coronary stenosis generally be to reduce myocardial oxygen supply at rest?

More than 90%.

What happens to LDL after it enters the arterial intima?

It becomes oxidized.

What are foam cells?

Macrophages that have ingested LDL.

What plaque cap characteristic increases rupture risk?

A very thin fibrous cap.

What plaque lipid characteristic increases rupture risk?

High lipid content.

What inflammatory cell concentration increases plaque rupture risk?

A high concentration of macrophages.

Do most infarctions occur at sites of preexisting critical stenosis?

No.

How can a ruptured plaque heal without causing complete occlusion?

It may restabilize with more severe stenosis.

How can anemia or hyperthyroidism precipitate angina?

By increasing myocardial metabolic demands.

Which severe valvular disorders can cause angina?

Severe aortic stenosis or aortic regurgitation.

Which myocardial structural abnormality can cause angina?

Severe hypertrophy.

What is the typical location of ischemic chest discomfort?

Retrosternal or left precordial.

Where does stable angina most often radiate?

The left shoulder and upper arm.

Which fingers may receive radiating anginal discomfort?

The fourth and fifth fingers.

What is Levine sign?

A clenched fist held over the chest.

Is ischemic chest pain typically reproducible with palpation?

No.

Is ischemic chest pain typically related to position?

No.

What associated symptoms may accompany myocardial ischemia?

Dyspnea, dizziness, nausea, diaphoresis, or impending doom.

What proportion of MI patients do not have chest pain in the lecture?

One third.

Why might a patient with angina prefer sitting upright?

Recumbency increases preload and myocardial work.

What exposures lower the threshold for stable angina?

Meals, excitement, cold, morning hours, and strong emotions.

How quickly does exertional stable angina usually subside if the patient promptly rests?

Within 3 minutes.

How long may stable angina following a meal or emotional distress last?

15–20 minutes.

Anginal pain fails to resolve promptly with rest or nitroglycerin: What should be suspected?

Development of ACS.

What resting ECG finding is most common in stable angina?

A normal ECG.

What characteristic ECG change occurs during stable angina?

Horizontal or downsloping ST-segment depression.

What happens to ischemic ST depression after the ischemia disappears?

It reverses.

What T-wave changes may occur with stable angina?

Flattening or inversion.

What can cause an apical systolic murmur during an anginal episode?

Transient mitral regurgitation from papillary muscle dysfunction.

Hypotension during angina may indicate what?

More severe ischemia or inferior ischemia.

What reflex is associated with hypotension during inferior ischemia?

The Bezold-Jarisch reflex.

Is there a specific laboratory test for chronic stable angina?

No.

Which biomarkers does the angina lecture name for evaluating ACS?

Troponin and CK-MB.

Why obtain a CBC during an angina evaluation?

To assess for anemia.

Why obtain lipids and blood glucose during an angina evaluation?

To identify CHD risk factors.

Suspected CAD with low-to-intermediate pretest probability: Next testing approach?

Noninvasive stress testing.

Suspected CAD with high pretest probability: Next testing approach?

Cardiac catheterization.

What is the definitive diagnostic procedure for CAD?

Coronary angiography.

What is the most commonly used noninvasive procedure for inducible ischemia in angina?

Exercise ECG.

How does the Bruce exercise protocol progress?

Treadmill speed and elevation increase every 3 minutes.

What limits exercise during the Bruce protocol?

Patient symptoms.

What exercise ECG finding defines a positive test in the lecture?

1 mm horizontal or downsloping ST depression measured 80 milliseconds after the J point.

How often is exercise ECG positive in patients with significant CAD?

60–80%.

What false-positive rate is reported for exercise ECG?

10–30%.

At what degree of ST depression are false-positive exercise ECG results uncommon?

2 mm.

Exercise causes 2 mm ST depression at a low workload: What is the implication?

More severe CAD and a poorer prognosis.

Exercise causes 2 mm ST depression at a low workload: Next step?

Refer for cardiac catheterization.

Exercise ECG results conflict with clinical suspicion: Next step?

Stress imaging.

Anginal pain occurs with minimal activity: Should exercise testing be performed?

No.

What valvular condition is a relative contraindication to exercise ECG?

Symptomatic severe aortic stenosis.

What is the reported risk of infarction or death from exercise testing?

1 per 1,000 tests.

What can exercise ECG assess in a patient with known CAD?

Prognosis.

How can exercise ECG help assess angina treatment?

By evaluating the response to therapy.

An abnormal resting ECG makes exercise ECG interpretation difficult: Preferred testing approach?

Myocardial stress imaging.

Which imaging categories are included in myocardial stress imaging?

Scintigraphy, echocardiography, and MRI.

What can stress imaging determine about the location of ischemia?

The myocardial region affected.

What tissue distinction can stress imaging make?

Ischemic versus infarcted myocardium.

Why perform stress imaging after revascularization?

To assess the completeness of revascularization.

What can cardiac PET assess in previously injured myocardium?

Myocardial viability.

Which test can evaluate coronary arteries without invasive angiography?

Multislice CT angiography.

Which CT technique can quantify coronary artery calcification?

Electron beam CT.

What coronary narrowing is considered hemodynamically significant in the lecture?

More than 50% of the luminal diameter.

How severe are most symptomatic coronary lesions?

More than 70% narrowing.

Which additional angiographic assessment can accompany coronary angiography?

Left ventricular angiography.

What does left heart catheterization with coronary angiography assess?

Cardiac valves, LV function, and the presence and severity of CAD.

What is the medication of choice for an acute stable-angina episode?

Sublingual nitroglycerin.

How quickly does sublingual nitroglycerin usually relieve angina?

Within 1–2 minutes.

How does nitroglycerin affect vascular tone?

It decreases arteriolar and venous tone.

How does nitroglycerin affect preload and afterload?

It reduces both.

How does nitroglycerin affect myocardial oxygen demand?

It lowers demand.

How should sublingual nitroglycerin initially be taken for angina?

Place one tablet under the tongue when symptoms appear.

At what interval may sublingual nitroglycerin be repeated in the lecture?

Every 3–5 minutes.

Angina has not responded to nitroglycerin after 5 minutes: What action is instructed?

Call 911.

Chest pain persists despite three nitroglycerin tablets: What should be suspected?

Acute MI.

Chest pain lasts longer than 20 minutes: What should be suspected?

Acute MI.

How can nitroglycerin prevent predictable exertional angina?

Take it before an activity likely to provoke symptoms.

What limits long-acting nitrate use?

Tolerance and headache.

What is first-line preventive drug therapy for most patients with chronic stable angina?

A beta-blocker.

Which antianginal class is described as prolonging life in patients with coronary disease?

Beta-blockers.

Does ranolazine affect heart rate or blood pressure?

No.

What is ranolazine used to treat?

Chronic angina.

What is the usual ranolazine dose in the lecture?

500 mg twice daily.

Is ranolazine used for acute anginal episodes?

No.

What ECG abnormality contraindicates ranolazine?

QT prolongation.

What organ disease contraindicates ranolazine?

Significant liver or kidney disease.

What daily aspirin dose is recommended for CAD unless contraindicated?

81 mg.

What clopidogrel dose is listed as an alternative antiplatelet regimen?

75 mg daily.

Which patients may receive DAPT to reduce cardiovascular events?

Selected high-risk patients with a recent MI or stent.

What rivaroxaban regimen may be added to aspirin in selected high-risk CAD patients?

2.5 mg twice daily.

What does secondary prevention of CAD aim to prevent?

Progression, complications, and recurrent events.

Who should receive a statin according to the CHD lecture?

All patients at significant cardiovascular risk, regardless of cholesterol level.

What effect can LDL lowering have on atherosclerosis?

It delays progression and may produce regression.

Which high-risk patients are specifically identified for ACE inhibitor therapy?

Patients with clinical atherosclerotic disease or diabetes plus additional risk factors.

Which diabetes drug classes have cardiovascular benefit in the lectures?

SGLT-2 inhibitors and GLP-1 receptor agonists.