Ischemic Cardiac Disease, MI, stress echo, strain

most common etiology for regional LV dysfunction

CAD

what do the coronary arteries feed?

myocardium

ischemia

demand/supply imbalance

infarction

damaged or dead heart muscle

coronary obstruction >4 hours

necrosis

etiologies of CAD

atherosclerosis, coronary artery spasm, embolus, dissection

what is the gold standard for coronary artery disease?

coronary angiogram

what percentage of blockage is seen on echo?

85%

how long has RWM been used?

since 1970s

how many segments of the LV are there?

17

how many wall segments of the basal section?

6

how many wall segments of the mid section?

6

how many wall segments of the apical section?

4

what does the apical cap represent?

true muscle at extreme top of ventricle where there is no cavity present

which part of the heart does not demonstrate contractile function?

apical cap

which wall segments does the LAD feed?

basal anterior, basal anteroseptal, mid anterior, mid anteroseptal, apical anterior, apical septal, apical cap

which wall segments does the RCA feed?

basal inferoseptal, basal inferior, mid inferoseptal, mid inferior, apical inferior

which wall segments does the LCX feed?

basal inferolateral, basal anterolateral, mid inferolateral, mid anterolateral, apical lateral

nuclear perfusion study

test used in conjunction with a stress test to detect the presence of coronary artery disease

what does the left main coronary artery split into?

LAD and circumflex

first 2 branches off of the aorta

left and right coronary arteries

widow maker

Left anterior descending artery

how much of the LV is perfused by the LAD?

50%

how much of the LV is perfused by the RCA?

35%

how much of the LV is perfused by the LCX?

15%

what can predict the area of coronary artery stenosis?

RWMA

how many views should you confirm the wall segments in?

at least 2

what is each wall segment evaluated for?

wall thickening and motion

how much should a wall normally thicken?

at least 40%

when does normal myocardium thicken?

systole

regional wall scoring: 1

normal

regional wall scoring: 2

hypokinetic

regional wall scoring: 3

akinetic

regional wall scoring: 4

dyskinetic

regional wall scoring: 5

aneurysmal

caveats of RWMA

collateral flow, small infarctions many not affect RWM

what heart abnormalities can lead to paradoxical systolic motion?

LBBB, RV pacer, RV pressure or volume overload

definity

fatty, lipid micro bubbles that define endocardial border

wall motion score index equation

sum of segment scores/# of segments

normal WMSI

1

abnormal WMSI

>1.7 = perfusion deficit >20%

transmural infarction

affects the full thickness of the ventricular wall

EKG of transmural infarction

STEMI

subendocardial infarction

involving innermost layer of heart muscle

EKG of subendocardial infarction

NSTEMI

STEMI percentage

70%

NSTEMI percentage

30%

coronary collaterals

natural bypass vessels connecting coronary arteries to heart tissue

complications of MI

ventricular arrhythmias, LV systolic dysfunction, cariogenic shock

cardiogenic shock

inability to provide enough blood flow to meet body's needs

infarction expansion/acute remodeling

damaged tissue starts to break down causing thinning of the heart wall

when does acute remodeling occur with a MI?

the first 72 hours

peak extend of infarction remodeling

7-14 days

what kind of complication of acute MI can be diagnosed on echo?

all mechanical

when does a free wall rupture usually occur?

within 7 days post MI

Symptoms of free wall rupture

acute hypotension, severe heart failure, loud harsh systolic murmur

echo signs of free wall rupture

thin wall, jet, effusion

treatment for free wall rupture

immediate surgical repair

which papillary muscle ruptures more?

posteromedial

which coronary artery supplies the posteriomedial papillary muscle?

RCA

which papillary muscle is less likely to rupture?

anterolateral

which coronary artery feeds the anterolateral papillary muscle?

LAD and CX

what does a papillary muscle rupture look like?

flail leaflet with attached mass that prolapses into the LA

signs of septal rupture

new systolic murmur, L-R shunt, defect in area of thinned, dyskinetic myocardium

who are septal ruptures more common in?

elderly women without previous MI

Pseudoaneurysm

narrow perforation of the ventricular free wall with a false chamber, usually a saccular or globular shape, partial filling with thrombus

true aneurysm

bulge in the ventricular wall that persists during diastole and systole with akinesis or dyskinesis, lined by thin endocardium

wall motion of both types of aneurysms

akinetic or dyskinetic

when would an aneurysm rupture most likely occur?

within 1 week post MI

pericardial effusion

collection of fluid within the pericardial space between the parietal and visceral layers

when would a pericardial effusion occur?

2-4 days post MI

dressler's syndrome

post MI illness that presents with fever, pericarditis, pericardial effusion, and pleuritis

symptoms of Dressler's syndrome

SOB, sharp and stabbing chest pain

when would Dressler's syndrome usually occur?

1-12 weeks after MI

why would a thrombus occur with MI?

where there is an akinetic/dyskinetic area, the blood pools and causes thrombus

causes of thrombus formation with an MI

reduced LV function, aneurysm, spontaneous contrast

typical formation of a thrombus due to MI

mural in the apex

medial treatment of MI

oxygen, clot busting medications, balloon, stent, CABG

IABP

intra-aortic balloon pump

intra-aortic balloon pump

increase perfusion and reduces afterload

when is the IABP inflated?

diastole to increase perfusion pressure in the coronary arteries

echo role in an MI

LV wall assessment, overall LV function, LV thickness, LVID, MR, PAP, AR, look for thrombus

how many times for likely is the posteriomedial papillary muscle to rupture?

6-10 times

what is papillary muscle dysfunction often associated with?

inferior MI resulting in MR

improper placement of the papillary muscles and incomplete computation of the MV

tenting

what is MR caused by?

disruption of the MV support apparatus

pericarditis

inflammatory process involving the parietal and visceral layers that can lead to a pericardial effusion

implantable cardioverter device

pulse generator implanted under the skin that is able to detect life threatening arrhythmias

LVAD

portable mechanical pump in the apex that delivers blood to the AO via a tube that helps get LV pump blood to the body

TEE is recommended prior to and following LVAD implantation? T or F

True

key risk factors of IHD/CAD

hyperlipedemia, diabetes, HTN, tobacco, male, family history

type 1 MI

spontaneous MI due to plaque, rupture, or thrombotic occlusion of CA

goal of MI treatment

restore normal coronary blood flow and salvage functional myocardium

angina pectoris

chest pain fue to IHD

stable angina pectoris

CP that is predictable, triggered by emotional stress, lasts seconds to minutes, relieved by rest or nitroglycerin

unstable angina pectoris

CP that is unpredictable, at rest or with little exertion, lasts longer than stable

signs and symptoms of MI

asymptomatic, SOB, sweating, tachy, new murmur, angina, cariogenic shock

what is a new murmur due to MI caused by?

ischemic MR or ischemic VSD

which coronary arteries can be visualized on TTE and TEE?

prox L and R main coronary arteries

is ischemia reversible or irreversible?

a reversible imbalance