[02.10] CMD - Coronary Artery Disease V2.pdf

Heartburn

What is the atypical chest pain description of the 56-year-old male patient in the case study?

Six

What was the coronary calcium score of the patient in the case study?

Left anterior descending artery

Which artery has calcium deposits shown as a yellow dot on the case study CT calcium score?

Red

What color arrowhead points to the left anterior descending artery on the case study coronary CT angiogram?

Yellow

What color arrowhead points to the left circumflex artery on the case study coronary CT angiogram?

Blue

What color arrowhead points to the right coronary artery on the case study coronary CT angiogram?

60 to 80%

What is the percentage range of stenosis in the proximal LAD of the case study patient on CCTA?

90%

What is the percentage stenosis of the proximal LAD seen on the conventional coronary angiogram of the case study patient?

Chronic coronary syndrome

What does the acronym CCS stand for in the context of stable ischemic heart disease?

Inadequate supply of blood and oxygen

What is the basic definition of ischemic heart disease regarding myocardial perfusion?

Heart rate, myocardial contractility, and myocardial wall tension

What are the three major determinants of myocardial oxygen demand?

Atherosclerotic disease of an epicardial coronary artery

What is the most common cause of myocardial ischemia?

Microvascular disease

What is the underlying pathophysiology in up to one third of symptomatic patients with no significant epicardial disease?

118,936 cases

How many cases of death in the Philippines were caused by IHD, representing 18.9% of total deaths?

18.9%

What percentage of total deaths in the Philippines is attributed to ischemic heart disease?

Coronary vasospasm and microvascular disease

What are two non-atherosclerotic causes of myocardial ischemia listed in the text?

Oxygen-carrying capacity of the blood and coronary blood flow

What two parameters are required to maintain an adequate supply of oxygen to the myocardium?

Diastolic dysfunction

What relaxation-related dysfunction is usually the first event that occurs in the ischemic cascade?

Systolic dysfunction

What contraction-related dysfunction is typically the end-stage event of the ischemic cascade?

Sudden cardiac death

What is sometimes the very first clinical manifestation of ischemic heart disease in asymptomatic patients?

Male

What gender constitutes approximately 70% of all patients with angina pectoris?

70%

What is the approximate percentage of angina pectoris patients who are male?

Male over 50 and female over 60

What are the typical age and gender thresholds of typical angina patients?

Menopause

What physiological state in females over 60 represents a risk factor because hormone protection is lost?

Mabigat

What local Filipino term meaning heaviness is often used by patients to describe chest discomfort?

Sinasakal

What local Filipino term meaning choking or smothering is commonly used to describe anginal pressure?

Levine's sign

What sign is characterized by a patient placing a hand or clenched fist over the sternum to indicate squeezing substernal discomfort?

2 to 5 minutes

What is the typical duration of a stable angina chest pain episode?

Ulnar surfaces of the forearm and hand

Which specific surfaces of the arm and hand are classic sites for anginal radiation?

Angina decubitus

What term describes anginal episodes that occur specifically when the patient is in a recumbent position?

Nocturnal angina

What term describes typical chest discomfort and dyspnea that awakens a patient at night?

1 to 5 minutes

How quickly is typical exertional angina relieved by slowing activities, rest, or sublingual nitroglycerin?

Three

How many doses of sublingual nitroglycerin should a patient try before being advised to go immediately to the emergency room if pain persists?

Strenuous, rapid, or prolonged exertion

At what exertion level does a patient classified as Canadian Cardiovascular Society Class I experience angina?

Slight limitation of ordinary activity

What degree of limitation characterizes Canadian Cardiovascular Society Class II angina?

More than two blocks

How many blocks can a Canadian Cardiovascular Society Class II patient walk on level ground before experiencing angina?

One flight of stairs

How many flights of stairs can a Canadian Cardiovascular Society Class II patient climb at a normal pace in normal conditions before angina?

Marked limitation of ordinary physical activity

What degree of limitation characterizes Canadian Cardiovascular Society Class III angina?

One to two blocks

How many blocks can a Canadian Cardiovascular Society Class III patient walk on level ground in normal conditions before angina?

Inability to carry on any physical activity without discomfort

What characterizes Canadian Cardiovascular Society Class IV angina?

Dyspnea, nausea, fatigue, and faintness

What are four classic symptoms referred to as anginal equivalents of myocardial ischemia?

Intermittent claudication, stroke, or transient ischemic attacks

What are three peripheral vascular presentations that should be checked in patients with suspected coronary atherosclerosis?

Namumulikat

What local Filipino term describes the walking-induced muscle aching or claudication associated with peripheral arterial disease?

Less than 55 years in first-degree male relatives

What is the age threshold defining a family history of premature coronary heart disease in male relatives?

Less than 65 years in female relatives

What is the age threshold defining a family history of premature coronary heart disease in female relatives?

Greater than or equal to 140/90 mmHg

What blood pressure measurement threshold or use of antihypertensives defines the major risk factor of hypertension?

Less than 1.0 mmol/L or less than 40 mg/dL

What measurement threshold defines a low HDL cholesterol risk factor in patients?

Greater than or equal to 1.6 mmol/L or greater than or equal to 60 mg/dL

What HDL level is viewed as a negative or protective cardiovascular risk factor?

Greater than or equal to 30 kg/m2

What body mass index threshold defines the lifestyle risk factor of obesity?

Ketogenic diet

What specific popular diet is explicitly listed as an example of an atherogenic diet risk factor?

Lipoprotein a, prothrombotic factors, proinflammatory factors, impaired fasting glucose, and subclinical atherosclerosis

What are the five emerging risk factors listed for coronary atherosclerosis?

Microvascular coronary disease and abnormal cardiac nociception

What are the two potential etiologies of persistent chest pain in patients with no flow-limiting epicardial obstructions?

Coronary reactivity testing

What invasive testing evaluates microvascular coronary disease in response to vasoactive agents?

Intracoronary adenosine, acetylcholine, and nitroglycerin

What are the three vasoactive agents used during coronary reactivity testing?

Imipramine

What tricyclic antidepressant is used to manage abnormal cardiac nociception?

Abdominal aortic, carotid, and femoral

Over which three anatomical artery sites should clinicians listen for bruits to check for systemic atherosclerosis?

Xanthelasma

What term describes yellow cholesterol deposits located around the eyelids and below the eyes?

Tendon xanthoma

What term describes hard, round, yellowish-whitish cholesterol nodules typically located behind the heels over the Achilles tendon?

Left ventricular dyskinesia

What abnormal cardiac contraction pattern may palpation of the cardiac impulse reveal in patients with stable angina?

S3

What abnormal heart sound is heard on auscultation in patients with acute cardiac congestion or heart failure?

S4

What abnormal heart sound is heard on auscultation in patients with a stiff left ventricle from chronic hypertension?

Mitral regurgitation

What valve pathology produces a mid or apical systolic murmur when acute ischemia impairs papillary muscle function?

Left lateral decubitus

In what physical position is a mid or apical systolic murmur of mitral regurgitation best appreciated?

Protuberant abdomen

What physical exam finding may indicate that a patient has metabolic syndrome and is at increased risk for atherosclerosis?

ECG

What is the very first diagnostic test that should be ordered when coronary artery disease is suspected?

Q waves in the inferior leads

What specific ECG finding can indicate a history of an old inferior myocardial infarction on a resting cardiogram?

Left Anterior Descending Artery

What is the most common epicardial artery involved in patients with typical angina pectoris?

Anterior chest leads V1 to V6

Which specific ECG leads should be checked to evaluate a potential lesion in the left anterior descending artery?

Left ventricular hypertrophy

What structural ECG finding is a significant indication of increased risk of adverse outcomes from ischemic heart disease?

ST-segment depression and T-wave inversion

What two transient ECG changes accompany episodes of angina pectoris and indicate active myocardial ischemia?

ST-segment elevation

What is the worst ECG finding to see at the emergency room level in a patient presenting with acute chest pain?

ECG treadmill exercise test

What is the cheapest and most accessible diagnostic stress test to perform following a normal resting ECG?

Three minutes

What is the duration of each individual stage of walking or running in a standard treadmill exercise test?

Physiologic imaging

Is an ECG treadmill exercise test classified as an anatomical or a physiologic imaging study?

Abnormal ST depression

What specific ECG change during peak exercise indicates a positive exercise treadmill test?

Fall in systolic blood pressure greater than 10 mmHg

What blood pressure change is an indication to immediately discontinue an exercise stress test?

0.2 mV or 2 mm

An exercise stress test is discontinued if ST-segment depression exceeds what value?

Flat or downsloping depression greater than 0.1 mV

An ischemic ST-segment response is defined as what type of depression below baseline?

0.08 seconds

An ischemic ST-segment response on an exercise ECG must last longer than what duration threshold?

220 minus age multiplied by 85%

What mathematical formula defines the target heart rate that must be achieved for an exercise stress test to be diagnostic?

Non-diagnostic

How is a negative exercise stress test categorized if the target heart rate was not achieved?

Digitalis

What cardiotonic drug increases the incidence of false-positive results on exercise ECG stress tests?

Left bundle branch block, paced ventricular rhythm, and WPW

What are three intraventricular conduction or preexcitation abnormalities that increase false-positive stress tests?

Rest angina within 48 hours

What symptomatic timeline represents a major contraindication to performing an exercise stress test?

Unstable rhythm, severe aortic stenosis, acute myocarditis, uncontrolled heart failure, severe pulmonary hypertension, and active infective endocarditis

What are six cardiac contraindications to performing an exercise stress test?

Echocardiogram, Nuclear Perfusion Scan, Cardiac MRI, and Cardiac PET Scan

What are four sensitive cardiac imaging modalities performed when the resting ECG is abnormal?

Echocardiogram

Which cardiac imaging modality is noted as being slightly cheaper compared to nuclear, MRI, or PET scans?

Pharmacologic stress imaging

What diagnostic approach is used when a patient cannot exercise due to musculoskeletal disease, dyspnea, or deconditioning?

Adenosine or Dipyridamole

What two vasodilators are administered during pharmacologic stress perfusion imaging?

Dobutamine

What pharmacological agent is infused at escalating doses to evaluate for wall motion abnormalities during a stress echocardiogram?

Hypokinesia

What contractile abnormality seen on a dobutamine stress echocardiogram represents a positive test?

Anterior septum

In which cardiac territory does the left anterior descending artery supply blood on a cardiac MRI?

Conventional Coronary Angiogram

What is another name for a coronary arteriography study?

Anatomical

Is a conventional coronary angiogram classified as a physiological or an anatomical evaluation?

Diagnostic and therapeutic

What dual clinical roles does coronary arteriography fulfill because a stent can be placed immediately during the procedure?

Radial artery

Which access site is preferred for modern coronary arteriography because it reduces arterial puncture risk and hematomas?

Femoral artery

Which access site used in the past for coronary angiography required the patient to lie flat with a sandbag on the groin for 6 hours?

Less than 1%

What is the risk of iatrogenic complications, such as dissection, rupture, heart attack, or stroke, during coronary angiography?

Less than 5%

According to the 2024 ESC guidelines, what clinical likelihood score of obstructive CAD defines a patient as very low risk?

Defer further testing

What is the recommended diagnostic approach for patients with a very low risk score of less than 5% under the 2024 ESC guidelines?