Ischemic Heart Disease, CAD, Angina

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58 Terms

1

Intima

What part of the vessel is intimate with the blood, a single layer of epithelial cells, and the metabolically active layer?

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2

Media

What part of the vessel is the thickest layer and made up of the smooth muscle cells and extracellular matrix

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3

Adventitia

What part of the vessel includes the nerves, lymphatics and provides nourishment to the arterial wall?

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4

endothelial dysfunction, lipoprotein entry and modification, leukocyte recruitment, foam cell formation, smooth muscle migration

What are the key components of plaque formation?

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5

endothelial dysfunction

What key component of plaque formation is the primary event in atherogenesis, tends to occur at arterial branch points, and exposure to a toxic chemical environment (smoking, elevated lipid levels, DM)

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6

oxidation, glycation

What happens during the lipoprotein entry and modification stage?

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7

expression of leukocyte adhesion molecules, chemoattractant signals, presence of mostly monocytes and Ts

What happens during the leukocyte recruitment phase of plaque formation?

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8

differentiation into phagocytes, imbibe lipoprotein

What happens during the foam cell formation phase?

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9

proliferation of smooth muscle in the intima (recruited by foam cells)

What happens during the smooth muscle migration phase of plaque formation?

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10

interplaque hemorrhage, plaque instability and erosion

At what point in the history and progression of plaques is there potential for unstable angina and other issues?

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11

fatty streak, fibrous cap, vasa vasorum, fibrous plaque, advanced lesion, interplaque hemorrhage, plaque instability and erosion

Give me the progression story of a plaque?

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12

Fatty streak

What part of the development and progression of plaques do you see endothelial dysfunction, lipoprotein entry/modification, and foam cell formation?

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13

Fibrous cap (plaque progression)

What part of the development and progression of plaques do you see smooth muscle cell migration and matrix synthesis and degradation?

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14

Vasa vasorum

What part of the development and progression of plaques do you see - a chaotic blood supply?

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15

fibrous plaque

What part of the development and progression of plaques do you see - connective tissue and smooth muscle?

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16

advanced lesions

What part of the development and progression of plaques do you see necrotic lipid rich core and calcified regions?

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17

interplaque hemorrhage

What part of the development and progression of plaques do you see neovascularization and increased neovessel permeability?

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18

plaque instability and erosion

What part of the development and progression of plaques do you see increased ischemic events?

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19

acute restriction of blood flow, alteration in vessel wall (calcification, rupture, hemorrhage, embolization, weakening)

What are some complications of plaques

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20

dyslipidemia, tobacco use, HTN, DM, lack of physical activity/obesity, stress, alcohol

What are the AHA modifiable cardiac risk factors?

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21

age, male, genetics

What are the AHA non-modifiable cardiac risk factors?

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22

oxygen content (mostly constant), rate of coronary blood flow

Myocardial oxygen supply is dependent on

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23

diastole

When is the heart perfused?

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24

Ventricular wall stress, heart rate, contractility

What are the 3 determinants of myocardial oxygen demand?

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25

atherosclerosis, endothelial dysfunction, spasm, tachycardia, anemia, hypoxia, vascular/congenital anomalies, aortic stenosis

What are some examples of things that cause supply issues?

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26

tachycardia, hyperthyroidism, myocardial hypertrophy, aortic stenosi

What are some things that can cause demand issues?

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27

reduction in contraction and relaxation, elevation in diastolic pressure, pulmonary congestion/dyspnea, precipitation of dangerous arrythmias

Consequences of ischemia

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28

stable angina, unstable angina, vasospastic angina, silent ischemia

What are the different types of ischemic syndromes?

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29

Stable angina

What type of ischemic syndromes is characterized by fixed obstructive atheromatous plaque and symptoms are triggered by physical exertion//emotional stress?

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30

Unstable

What type of ischemic syndromes is characterized by a sudden increase in tempo/duration with lesser degrees of exertion and increased symptom severity?

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31

LV function (CO/EF), exercise capacity, severity of symptoms

What can predict the mortality of stable angina?

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32

vasospastic angina

What type of ischemic syndromes is characterized by a focal coronary spasm which decreases the supply and occurs at rest - responds to short acting nitrates?

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33

ST elevation on EKG during episode with no stenosis

How do you diagnose vasospastic angina

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34

nifedipine, diatiazem, verapamil, SL nitro, stop smoking

How do you manage vasospastic angina?

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35

Silent ischemia

What type of ischemic syndromes is characterized by a lack of pain and maybe able to be diagnosed via exercise treadmill testing

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36

HTN, DM

What are 2 important risk factors in silent ischemia?

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37

Angina pectoris

What is the most common manifestation of ischemic heart disease and is often described by a “strangling in the chest?”

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38

retrosternal, levine sign, brief duration, relieved by rest/nitrates, described as a squeezing/tightness, radiates to shoulder/neck/jaw/inner arm/epigastrium

Clinical features of stable angina

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39

Pain is pleuritic/sharp/choking, involves the chest wall, positional, tender to palpation, random onset, lasts seconds/min/hours/days, variable response to nitro

What are signs that the chest pain is atypical, noncardiac?

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40

physical exertion, anger, emotional excitement, large meal, cold weather, peripheral vasoconstriction

What might bring on an episode of angina?

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41

increased heart rate, elevated blood pressure, mitral regurgitation, abnormal bulging, S4 gallop

What might you see in a patient during an anginal episode?

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42

normal exam, bruits, diminished pulses

What might you see in a angina pectoris patient during an period of no chest pain?

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43

resting EKG, CXR, hemoglobin, fasting glucose, fasting lipid profile, exercise tolerance test (nuclear and echo), coronary angiography (if high probability of CHD),

Diagnostic studies for angina pectoris

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44

extent of impaired LV contractile function, poor exercise capacity, severity of disease, magnitude of clinical symptoms

What do we need to consideration before we treat angina?

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45

decrease frequency, prevent MI, prolong survival

What are the goals when treating ischemic heart disease?

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46

controlling risk factors, exercise, annual flu vaccine

Management of angina

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47

drug that affect mortality/morbidity, drugs that affect symptoms only

Treatment for stable angina can be grouped into

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48

ASA, beta blockers, ACEI, statins

What drugs affect mortality and morbidity

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49

nitrates, CCBs

Which drugs are for symptoms only

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50

rest, nitrates, alleviation precipitating/aggravating factor

Management of an acute angina episode

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51

primary preventions, lifestyle changes, risk factor reduction, regular exercise, HTN treatment, tobacco cessation, lipid lowering, weight reduction, glycemic control

Management of recurrent angina episodes

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52

Metropolol (prior MI), nifedipine, amlodipine, felodipine, nitrates (symptomatic), lipid lowering agents (everybody), ASA or clopidogrel (ASA allergies), lisinopril (does not improve angina)

1st line meds for angina

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53

PCI, CABG

Revascularization options

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54

inadequate response to meds, unacceptable ADRs, high risk CAD (EF under 50%)

What are the indications for revascularization in the patient with chronic stable angina?

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55

CABG

What type of revascularization is preferred when large amounts of myocardium are at risk?

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56

3 vessels, DM, LAD involvement, large myocardial areas at risk

When should CABG be consider

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57

saphenous vein, left internal mammary artery

What vessels can be used as grafts for CABG?

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58

extent of LV dysfunction, extent of atherosclerosis, risk of plaque rupture, general health and other comorbities

Prognosis of CAD depends on

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