lecture 10 rutherford
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3 determinants of myocardial oxygen consumption | most important is HR, ventricular wall tension and contractility
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coronary blood flow occurs during | diastole, not systole b/c myocardium is contracting and disallows flow through those vessels
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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
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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
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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
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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
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changes on EKG seen in chronic ischemic/angina pt | non-specific ST-T changes with or without Q waves indication prior transmural infarct
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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
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exercise Echo | may demonstrate regions of abnl myocardial contraction aka hypo-, a-, dyskinesia during transient ischemia precipitated by either exercise or IV dobutamine infusion
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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"
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dx of angina best made by | taking pt history!
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sensitivity of test | probability that someone with dz will test positively
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specificity of test | probability that someone without dz will test negatively
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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
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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
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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
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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
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medical therapy that is shown to reduce mortality and prevent AMIs in pts with chronic ischemic dz | ASA and effective LDL lowering
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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
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medical therapy that is helpful in reducing sx and improving exercise tolerance but not necessarily mortality | beta blockers, nitrates, Ca+ channel blockers
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3 big factors incorporated into the tx algorithm for chronic stable angina pts | CV reserve, exercise capacity, LV function
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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
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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
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