Coronary Artery Disease

___________, the initial pathological step in coronary artery disease, is intimal thickening and the formation of an intimal Xanthoma (or atherosclerotic plaque).

Atherosclerosis

What is the leading cause of death for both men and women across most racial and ethnic groups in the United States?

Coronary Artery Disease (or Heart Disease)

A 66-year-old male with chest pain is evaluated in the emergency department, using the TIMI risk score. What are the components of the TIMI risk score?

• Age >65 y.o →1 pt

• 3+ cardiac risk factors → 1 pt

• Known CAD w > 50% stenosis → 1 pt

• Aspirin use past 7 days → 1 pt

• Sever angina past 24 hrs → 1 pt

• Elevated troponin → 1 pt

• ST deviation > 0.5 mm → 1 pt

What are the risk categories for TIMI?

• Low risk: 0-2

• Intermediate risk: 3-4

• High Risk: 5+

__________ is a risk score method that is used to quantify the probability of chest pain being cardiac (MACE), using EKG and troponin.

Heart score

What are the risk categories for a Heart score?

• Low risk: 0-3

• Intermediate risk: 4-6

• High risk: 7+

What is the Diamond classification for chest pain?

1. Substernal left sided chest pain

2. Provoked by exertion/emotional stress

3. Relieved by Nitroglycerin (NTG)

What causes the referred chest pain to other areas of the body?

Phrenic nerve innervation to the pericardium originates from C3-C5.

_________ is when blood flow to the myocardium is obstructed by partial or complete blockage of coronary artery by plaque burden or thrombus; myocardial demand is greater than supply.

Myocardial ischemia

___________ is heart muscle cell or tissue death (necrosis) due to prolonged blockage of the coronary artery.

Myocardial infarction

_________ is chest pain caused by myocardial ischemia.

Angina pectoris

___________ are other symptoms associated with myocardial ischemia; shortness of breath, diaphoresis, N/V.

Angina equivalent

__________ is a sudden or gradual chest pressure/tightness that is reminiscent of previous MI and associated with an “impending doom”; “elephant sitting on chest”. (worse w/exertion)

Typical angina

__________ is a sharp or knife-like pleuritic chest pain, that is reproducible with movement or palpation and radiates above the mandible of into the lower extremities. (Common in women, diabetics, older adults)

Atypical angina

__________ involves normal angina features that are usually episodic (resolves w/in 3 min), occurs w/exertion and improves w/rest, and is relieve by NTG; demand ischemia. (crescendo-decrescendo)

Stable angina

_________ is the sudden onset of severe angina features that lasts >20 min and occurs during rest; not relieved by NTG. (Crescendo pattern)

Acute unstable angina

__________ is transient coronary artery occlusion that occurs at rest and is caused by vasospasm, with negative troponin and little to no plaque burden or stenosis; supply ischemia. (common in smokers/drug abuse)

Vasospastic angina

What diagnostic test is indicated for functional assessment of myocardial perfusion and risk stratification in suspected stable angina?

Cardiac stress testing

 A 58-year-old male experiences substernal chest pressure during brisk walking that resolves within 3 minutes of rest or sublingual nitroglycerin. Which oral medication class serves as first-line therapy to lower heart rate and prolong life post-MI in stable CAD?

Beta-blockers

What are the characteristic EKG and cardiac biomarker findings during an acute attack of vasospastic angina?

Transient ST-segment elevations with negative troponins

A 42-year-old female smoker presents with episodic substernal chest pain occurring at rest in the early morning. Coronary angiography shows no significant obstructive stenosis. What class of medications serves as first-line chronic prophylactic therapy?

Calcium channel blockers ± long-acting nitrates

Unstable angina and NSTEMI both present with partial thrombus occlusion, but NSTEMI is uniquely distinguished by elevated __________.

Cardiac troponins

What specific EKG abnormalities are characteristic of Unstable Angina and NSTEMI?

• T-wave inversions (>1 mm)

• Horizontal/Downsloping ST-segment depressions (>0.5 mm)

A 62-year-old female presents with chest pain at rest lasting 25 minutes. EKG shows horizontal ST depressions in leads V4–V6, and initial troponin is elevated. What treatment regimen should be initiated immediately?

• Dual Antiplatelet Therapy: Aspirin + P2Y12 inhibitor

• Anticoagulation: LMWH or UFH

What are the classes for CCS grading of angina pectoris?

• Class 1 - angina during strenuous or prolonged physical activity

• Class 2 - angina only during vigorous physical activity (slight limitation)

• Class 3 - angina symptoms with everyday living activities (mod. limitation)

• Class 4 - inability to perform any activity w/o angina; at rest (severe limitation)

What are the 3 diagnostic presentations of Acute Coronary Syndrome?

1. Unstable angina

2. Non-ST elevation MI (NSTEMI)

3. ST-elevation MI (STEMI)

STEMI is caused by complete transmural coronary occlusion, defined on EKG as J-point ST elevation >1 mm in at least _______________.

two anatomically contiguous leads

 What is the gold standard diagnostic procedure for acute STEMI, and what is the recommended door-to-balloon time?

Percutaneous Coronary Intervention (PCI) via cardiac catheterization; <90 minutes

 A 55-year-old male presents to a rural hospital without PCI capabilities 1 hour after onset of crushing chest pain. EKG confirms an anterior STEMI. Transfer time to the nearest catheterization lab is 3 hours. What secondary revascularization therapy is indicated, and what is the door-to-needle time goal?

Fibrinolytic/Thrombolytic therapy (tPA); <30 minutes

What is the classic triad of a right-sided MI?

1. Distended neck veins

2. Clear lung fields

3. Hypotension

Patients experiencing an acute right-side MI have compromised stroke volume and are strictly preload dependent, requiring __________.

early IV fluid resuscitation

A 60-year-old male with an inferior wall STEMI develops a blood pressure drop to 80/50 mmHg after receiving sublingual nitroglycerin. Right-sided EKG confirms ST elevation in lead V4R. What class of anti-ischemic medications is strictly contraindicated in this patient?

Nitrates and Diuretics

The most common cause of sudden cardiac death within the first 24 to 48 hours following an acute myocardial infarction is ____.

Ventricular tachycardia or Ventricular fibrillation

What autoimmune complication presents 2 to 10 weeks post-MI with a triad of fever, pleuritic chest pain, and pericardial effusion?

Dressler syndrome

A 64-year-old male undergoes successful drug-eluting stent (DES) placement in the LAD following an NSTEMI. What is the mandatory minimum duration of Dual Antiplatelet Therapy (DAPT) post-procedure?

12 months

Which surgical procedure is the gold standard for patients with left main coronary disease or severe 3-vessel disease with LV dysfunction or diabetes?

Coronary Artery Bypass Grafting (CABG)