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lecture 10 rutherford

3 determinants of myocardial oxygen consumption most important is HR, ventricular wall tension and contractility
coronary blood flow occurs during diastole, not systole b/c myocardium is contracting and disallows flow through those vessels
factors in the HPI that make pt with chronic ischemia most at risk for typical angina dx, must be yes to all 3?s: Is chest discomfort substernal? Sx precipitated by exertion? Relief within 5-10 min after rest or NTG?. If 2 = atypical angina
factors in the PMHx that make pt with chronic ischemia most at risk smoker, DM, HTN, hypercholesterolemia, PVD, prior hx of MI. males over 40, females over 50 y/o
factors in the FMHx that make pt with chronic ischemia most at risk prior h/o MI or sudden death in male relative before 55 y/o or in female before 65 y/o
factors in the PEx that make pt with chronic ischemia most at risk arcus senilis, xanthomas, elevated BP, diminished or absent pulses, venous insufficiency, apical heave or displacement of apex, S4
changes on EKG seen in chronic ischemic/angina pt non-specific ST-T changes with or without Q waves indication prior transmural infarct
PEx suggestive of myocardial ischemia or infarction dec systolic function (rales from pulmonary congestion, dyskinetic apical impulse), dec diastolic compliance (S4), mitral regurgitation, diaphoresis, inc HR & BP
exercise Echo may demonstrate regions of abnl myocardial contraction aka hypo-, a-, dyskinesia during transient ischemia precipitated by either exercise or IV dobutamine infusion
thallium scintigraphy allows visualization of myocardial perfusion at rest and during exercise. thallium-201 normally readily taken up by healthy myocardial cells. looking for "cold spots"
dx of angina best made by taking pt history!
sensitivity of test probability that someone with dz will test positively
specificity of test probability that someone without dz will test negatively
positive predictive value probability that someone will actually have dz given a positive outcome on test; remember that dz prevalence within a specific population is always important factor
diagnostic indicators during exercise Echo ST changes on EKG with or without induced angina, angina alone induced with exercise, fall in SBP, decreased exercise capacity
the most important prognostic factor in pts with chronic stable angina pectoris LV function; if on exam there is S4, evidence of heart failure, EKG shows prior MI or CXR shows CM or pulmonary congestion, prognosis is worse than a person with just nl CAD, although this is also a big factor
cutoff in terms of stress test units for good prognosis if pt gets to 10 mets (metabolic equivalent of oxygen uptake at rest) even with angina, he/she passes. those who can't get past 5 b/c of angina FAIL
medical therapy that is shown to reduce mortality and prevent AMIs in pts with chronic ischemic dz ASA and effective LDL lowering
for any pt with ACS, mortality depends on cumulative myocardial injury to that point measure using EF or LV function, which is more important than the extent of dz
medical therapy that is helpful in reducing sx and improving exercise tolerance but not necessarily mortality beta blockers, nitrates, Ca+ channel blockers
3 big factors incorporated into the tx algorithm for chronic stable angina pts CV reserve, exercise capacity, LV function
general recommendations for anyone with angina, whether unstable or not weight control, good glycemic and HTN control, brisk exercise of 30-40 min 4x/week
indication for coronary revascularization pts with main LAD stenosis of @ least 50%, multivessel dz involving proximal LAD or LV dysfunction. to improve sx in those with severe and debilitating angina unresponsive to medical tx
Created by: sirprakes