Cardiology and Ischemic Heart Disease Chapter 24 Paauw

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What causes myocardial ischemia?: Myocardial ischemia occurs when myocardial oxygen demand exceeds oxygen delivery.
Conditions that exacerbate cardiac ischemia fall into 2 major categories: 1. 2.: Conditions that exacerbate cardiac ischemia fall into 2 major categories:
1. DECREASED OXYGEN SUPPLY
2. INCREASED OXYGEN DEMAND
DECREASED OXYGEN SUPPLY 1. Cardiac causes 2. Noncardiac causes: DECREASED OXYGEN SUPPLY
1. Cardiac causes:
Coronary atherosclerosis
Coronary artery spasm
2. Noncardiac causes:
Anemia
Hypoxemia
Hypovolemia
Hemoglobinopathy (e.g. sickle cell anemia)
INCREASED OXYGEN DEMAND 1. Cardiac causes 2. Noncardiac causes: INCREASED OXYGEN DEMAND
1. Cardiac causes
Cardiac hypertrophy
Tachyarrhythmia
2. Noncardiac causes
Exercise
Sinus tachycardia
Hyperadrenergic states (e.g. anxiety, cocaine)
Hyperthyroidsim
Ischemic heart disease is the leading cause of death and disability in the US, and is most commonly caused by ____________ .: Ischemic heart disease is the leading cause of death and disability in the US, and is most commonly caused by CORONARY ATHEROSCLEROSIS.
While myocardial ischemia typically results in clinical syndromes of stable angina, unstable angina, or acute myocardial infarction, many patients with coronary artery disease (CAD) have episodes of ischemia that are atypical or even ___________ .: While myocardial ischemia typically results in clinical syndromes of stable angina, unstable angina, or acute myocardial infarction, many patients with coronary artery disease (CAD) have episodes of ischemia that are atypical or even ASYMPTOMATIC.
Stable angina refers to ischemic chest pain that is reliably provoked by ________ and relieved by ________ or __________ .: Stable angina refers to ischemic chest pain that is reliably provoked by EXERTION and relieved by REST or NITROGLYCERIN.
Most patients with stable angina have one or more ____________ in their coronary arteries causing focal vessel narrowing.: Most patients with stable angina have one or more ATHEROSCLEROTIC PLAQUES in their coronary arteries causing focal vessel narrowing.
In stable angina, blood supply may be adequate at rest, but not with _____________ .: In stable angina, blood supply may be adequate at rest, but not with INCREASED DEMAND OF EXERTION.
Atherosclerotic plaques may destabilize and rupture. When this happens, platelets aggregate on the disrupted plaque causing subtotal or total occlusion of the coronary artery. Subtotal occlusion of a coronary artery results in _________; this term includ: Atherosclerotic plaques may destabilize and rupture. When this happens, platelets aggregate on the disrupted plaque causing subtotal or total occlusion of the coronary artery. Subtotal occlusion of a coronary artery results in UNSTABLE ANGINA; this term includes new onset angina, increasing angina, and rest angina.
Plaque rupture with thrombus that totally occludes the coronary artery results in _________ .: Plaque rupture with thrombus that totally occludes the coronary artery results in MYOCARDIAL INFARCTION.
The history and physical exam are the most importan components of the initial evaluation of patients with chest pain. The history should focus on a thorough description of the chest pain and a review of the patient's CAD risk factors. What are the CAD ri: What are the CAD risk factors?
1. Smoking
2. Hypertension
3. Hyperlipidemia
4. Diabetes mellitus
5. Family history of early CAD: 1st degree male relative with MI at less than 55 years of 1st degree female relative with MI at less than 65 years.
How do I diagnose stable angina?: The H&P are the most important components of the initial evaluation of patients with chest pain.

The history should focus on a thorough description of the chest pain and a review of the patients CAD risk factors.

The physical exam should be directed at detecting the presence of the exacerbating factors.
Chest Pain Characteristics Predictive of Cardiac Ischemia: QUALITY oF PAIN: Ischemia more likely vs. Ischemia less likely: Ischemia MORE likely: squeezing/vise-like, pressure, heaviness, suffocating

Ischemia LESS likely: sharp, stabbing, knifelike
Chest Pain Characteristics Predictive of Cardiac Ischemia: LOCATION OF PAIN: Ischemia more likely vs. Ischemia less likely: Ischemia MORE likely:
Poorly localized, substernal, radiates to neck, jaw, teeth, shoulders, arms
Ischemia LESS likely:
Sharply demarcated
Chest Pain Characteristics Predictive of Cardiac Ischemia: DURATION OF PAIN: Ischemia more likely vs. Ischemia less likely: Ischemia MORE likely:
Minutes

Ischemia LESS likely:
Seconds only
Hours to days
Chest Pain Characteristics Predictive of Cardiac Ischemia: PROVOCATION OF PAIN: Ischemia more likely vs. Ischemia less likely: Ischemia MORE likely:
Exertion
Ischemia LESS likely:
Position
Chest Pain Characteristics Predictive of Cardiac Ischemia: RELIEF OF PAIN: Ischemia more likely vs. Ischemia less likely: Ischemia MORE likely:
Rest, nitroglycerin
vs.
Ischemia LESS likely
Change in position
The likelihood of ischemia correlates with increasing patient age, number of typical chest pain characteristics and number of __________ .: The likelihood of ischemia correlates with increasing patient age, number of typical chest pain characteristics and number of CAD RISK FACTORS.
Upon completing your H&P, you should be able to make a rought estimate of the likelihood that your patient's symptoms are caused by CAD. For example, a 60 yo man with a history of HTN, hyperlipidemia, who complains of aching substernal di: For example, a 60 yo man with a history of HTN, hyperlipidemia, who complains of aching substernal discomfort that reliably begins about 20 minutes into his daily jog and clears within 5 minutes if he stops exercising has a HIGH likelihood of CAD.

A 50 yo man with a history of tobacco who experiences sharp, substernal chest pain primary when he uses his upper extremities has an INTERMEDIATE likelihood of CAD as the cause of his symptoms.
When is a stress test indicated? In patients with an ___________ likelihood of CAD, an exercise tolerance test (ETT) may aid diagnosis, which a positive test increasing the likelihood of CAD and a negative test decreasing its likelihood.: In patients with an INTERMEDIATE likelihood of CAD, an exercise tolerance test (ETT) may aid diagnosis, wich a positive test increasing the likelihood of CAD and a negative test decreasing its likelihood.
How useful is the ETT is patients with a high pre-test likelihood of CAD (based on history)?: The ETT has little impact on your diagnostic certainty in patients with a high pretest likelihood of CAD. In these patients, the ETT is still useful because it helps separate those who have a good prognosis from those at higher risk for progressing from stable angina to unstable angina or acute MI.
How do I diagnose unstable angina? Unstable angina is characterized as ischemic chest pain that: (1) is of new onset (2) is of increasing severity (3) occurs at rest or (4) occurs post-MI or post-revascularization: The physical exam, EKG and cardiac enzyme levels may be NORMAL in this setting and do NOT rule out unstable angina.
UNSTABLE ANGINA When the physical exam, EKG and cardiac enzyme levels are ________ , they may alert you to patients who are at higher risk for progressing to myocardial infarction or sudden cardiac death.: When the physical exam, EKG and cardiac enzyme levels are ABNORMAL, they may alert you to patients who are at higher risk for progressing to myocardial infarction or sudden cardiac death.
Risk stratification of patients with unstable angina: HISTORY: Low risk vs. Intermediate risk vs. High risk: LOW RISK:
INTERMEDIATE RISK:
HIGH RISK:
Risk stratification of patients with unstable angina: EXAM: Low risk vs. Intermediate risk vs. High risk: LOW RISK:
Normal

INTERMEDIATE RISK:
Hemodynamically stable

HIGH RISK:
Hemodynamic instability, CHF
Risk stratification of patients with unstable angina: EKG: Low risk vs. Intermediate risk vs. High risk: LOW RISK:
Normal

INTERMEDIATE RISK:
T-wave changes, but no ST segment deviation

HIGH RISK:
ST segment deviation, new bundle branch block
Risk stratification of patients with unstable angina: LAB: Low risk vs. Intermediate risk vs. High risk: LOW RISK:
normal cardiac enzymes

INTERMEDIATE RISK:
normal or minimally elevated cardiac enzymes

HIGH RISK:
elevated cardiac enzymes
Risk stratification of patients with unstable angina: AGE: Low risk vs. Intermediate risk vs. High risk: LOW RISK:
Younger

INTERMEDIATE RISK:
Older

HIGH RISK:
Even older
Risk stratification of patients with unstable angina: MI RISK: Low risk vs. Intermediate risk vs. High risk: LOW RISK:
3%-6%

INTERMEDIATE RISK:
9%

HIGH RISK:
18%
Risk stratification of patients with unstable angina: DEATH RISK: Low risk vs. Intermediate risk vs. High risk: LOW RISK:
0%

INTERMEDIATE RISK:
1.5%

HIGH RISK:
6%
Acute MI needs to be diagnosed rapidly in order to optimze patient outcome. Early treatment decisions hinge on the ________; so this should be obtained without delay in any patient with suspected MI.: Early treatment decisions hinge on the EKG; so this should be obtained without delay in any patient with suspected MI.
Most patients with acute MI present with chest pain. When chest pain radiates to arms or shoulders and is associated with diaphoresis, MI is more likely. As many as ____ of patients with acute MI do not have chest pain at the time of presenta: As many as 30% of patients with acute MI do not have chest pain at the time of presentation. These patients are more likely to be:
1. female
2. older
3. diabetic

**These patients may instead present with fewer classic symptoms such as nausea, dyspnea or palpitations.
The EKG is less sensitive than cardiac enzymes for the detection of myocardial injury. Because of its virtually immediate availability, however, early treatment decision depend on the EKG findings. Patients with _______, _______, o: Patients with NEW ST-SEGMENT ELEVATIONS, NEW Q WAVES, or NEW CONDUCTION DEFECT (e.g. left bundle branch block) in the setting of acute ischemic symptoms are assumed to have acute MI.
When the initial EKG has normal or nonspecific findings and the patients has ongoing symptoms, repeat the EKG at ________ minute intervals. This may reveal evolving abnormalities that will allow the diagnosis of MI before cardiac enzyme levels become ava: When the initial EKG has normal or nonspecific findings and the patients has ongoing symptoms, repeat the EKG at 10-15 minute intervals. This may reveal evolving abnormalities that will allow the diagnosis of MI before cardiac enzyme levels become available.
While cardiac enzyme levels should be measured in all patients when acute coronary syndromes, they become critically important for diagnosing MI in patients whose symptoms and EKG findings are nonspecific. _____ and _____ are the enzymes most: CREATINE KINASE (CK) and TROPONIN-I are the enzymes most frequently measured. Their serum levels being to rise 4-6 hours after the onset of symptoms and thus initially may be normal in patients who seek care promptly.
Serial measurements allow the detection of the rise and fall of cardiac enzymes, which follow a typcial time course when they are released from damaged ___________ .: Serial measurements allow the detection of the rise and fall of cardiac enzymes, which follow a typcial time course when they are released from damaged MYOCARDIAL CELLS.
Time course for cardiac enzymes elevations in acute MI: Troponin: onset, peak, duration Creatine Kinase : onset, peak, duration: TROPONIN
Onset: 4-6 hours
Peak: 18-24 hours
Duration: up to 10 days

CREATINE KINASE
Onset: 4-6 hours
Peak: 18-24 hours
Duration: 36-48 hours
What are the goals of therapy for patients with stable angina?: The goals of therapy are to reduce symptoms, improve functional status, and prevent future myocardial infarction.

Patients who achieve high levels of exercise without evidence of ischemia during exercise tolerance testing have a good prognosis. Less than 1% will die of their CAD within the next year.
Patients with stable angina and good exercise tolerance can be managed with medications. First line therapies are ________ to prevent platelet aggreation and _________ to decrease myocardial oxygen demand.: First line therapies are ASPIRIN to prevent platelet aggregation and a BETA-BLOCKER to decrease myocardial oxygen demand.
Rapid acting __________ is used for episodes of angina that occur despite first-line therapy.: Rapid acting NITROGLYCERIN is used for episodes of angina that occur despite first-line therapy.
____________ and _____________ can be added to or substituted for B-blockers in those patients who do not completely respond, who are intolerant, or who have contraindications to B-blocker therapy.: CCBs and long-acting nitroglyercin can be added to or substituted for B-blockers in those patients who do not completely respond, who are intolerant, or who have contraindications to B-blocker therapy.
It is important to address each patient's CAD risk factors. Smoking cessation and treatment of _______ and ______ reduce the patient's risk for progressing to unstable angina or myocardial infarction.: It is important to address each patient's CAD risk factors. Smoking cessation and treatment of HTN and HYPERLIPIDEMIA reduce the patient's risk for progressing to unstable angina or myocardial infarction.
Which patients with stable angina need referral to cardiology and what will happen to them?: Patients with chest pain or EKG findings at low exercise intensity on ETT have a poorer prognosis in that 5% or more of these patients will die of their CAD in the next year.

This group of patients should be referred to a cardiologist for further evaluation, which may include coronary catheterization and possibly revascularization, either by angioplasty, stenting, or coronary artery bypass surgery.
How do I treat patients with UNSTABLE ANGINA? The goals of initial management are: 1. rapidly relieve chest pain 2. assess and reduce risk for acute MI and cardiac death 3. maintain stable hemodynamics. Initiate treat: Initiate treatment with ASPIRIN and IV HEPARIN, which reduce mortality and risk for progression to MI, possibly by preventing further clot development at the site of plaque rupture.
Treatment of Unstable Angina: If the patient is intolerant or hypersensitive to aspirin, _______ or ________ should be used.: If the patient is intolerant or hypersensitive to aspirin, CLOPIDOGREL or TICLOPIDINE should be used.
Treatment of Unstable Angina: _____ and ______ reduce myocardial oxygen demand, may improve coronary blood flow, and are given to relieve chest pain or if ____________ are elevated.: NITRATES and BETA-BLOCKERS reduce myocardial oxygen demand, may improve coronary blood flow, and are given to relieve chest pain or if CARDIAC ENZYMES are elevated.
Treatment of Unstable Angina: For ongoing ischemia despite treating with aspirin, heparin, nitrates, beta-blockers OR for planned angiography with stent/plasty, recent recommendations are to add a _______________ .: For ongoing ischemia despite treating with aspirin, heparin, nitrates, beta-blockers OR for planned angiography with stent/plasty, recent recommendations are to add a PLATElET GPIIb/IIIa RECEPTOR ANTAGONIST AGENT (eptifibatide or tirofiban).
Treatment of Unstable Angina: Once the patient is pain free and hemodynamically stable, the patients' risk of dying or of having a nonfatal MI is formally assessed. Patients at high risk for progression to MI are referred to ______: Once the patient is pain free and hemodynamically stable, the patients' risk of dying or of having a nonfatal MI is formally assessed.

Patients at high risk for progression to MI are referred to CORONARY CATHETERIZATION, while those at low risk may be managed with medications.
Treatment of Unstable Angina: Exercise treadmill testing is used to guide therapy in patients at _________ risk. In general, those who do well on ETT testing may be managed medically while those who do poorly are referred for coronary catheter: Exercise treadmill testing is used to guide therapy in patients at INTERMEDIATE risk. In general, those who do well on ETT testing may be managed medically while those who do poorly are referred for coronary catheterization.
How do I treat patients with acute MI? The Goals for Management of Acute MI: Immediate Goals Subacute Goals Long-term Goals: IMMEDIATE Goals

1. Relieve pain
2. Restore hemodynamic stability
3. Initiate reperfusion within 30 minutes
4. Prevent recurrent thrombosis
5. Detect and treat arrhythmia

SUBACUTE Goals
1. Identify patients with recurrent ongoing ischemia
2. Monitor for complications

LONG-TERM Goals
1. Stop smoking
2. Control BP
3. Lower lipids
Treating Acute MI: As for patients with unstable angina: aspirin, nitrates and beta-blockers are the mainstays of early treatment. Attempts to reopen occluded artery should begin as soon as possible. __________ and __________ are b: THROMOLYTICS and ANGIOPLASTY are both effective and the decision about which approach to employ depends on individual patient characteristics and the availability of cardiac catherization facility.
Depending on the technique used to re-establish perfusion in the affected artery, ________ or ___________ may be helpful in maintaining vessel patency.: Depending on the technique used to re-establish perfusion in the affected artery, HEPARIN or ANTIPLATELET AGENTS may be helpful in maintaining vessel patency.
ACEIs improve survival after acute MI, but may cause ________ and thus should be used with caution.: ACEIs improve survival after acute MI, but may cause HYPOTENSION and thus should be used with caution.
What are complications of acute MI?: Patients should be monitored for complications of acute MI:

1. Atrial and ventricular arrhythmias
2. CHF
3. Papillary muscle rupture (leading to acute mitral regurgitation)
4. Ventricular rupture

Patients with large anterior wall MI may develop clot in their left ventricle.
When is the patient ready for discharge?: Patients who have an uncomplicated post-MI course with no evidence of recurrent ischemia can undergo a low-level ETT within a few days of their MI. If the ETT is negative, they can be safely discharged from the hospital on medical management.
What medications should I prescribe when the patient is ready to leave the hospital? First line therapies for patients following MI are similar to those for patients with stable angina. Unless there are specific contraindications t: Unless there are specific contraindications to their use, ASPIRIN and BETA-BLOCKERS should be prescribed for all patients.

Patients with reduced left ventricular function (EF less than 40%) benefit from the addition of ACEI.
What medications should I prescribe when the patient is ready to leave the hospital? Lipid-lowering therapy reduces the risk for recurrent MI; the target goal for LDL for patients with coronary artery disease is less than ____ , so medication: Lipid-lowering therapy reduces the risk for recurrent MI; the target goal for LDL for patients with coronary artery disease is less than 100, so medication is recommended when LDL levels exceed 125 mg/dL.

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