CM- Cardio -6- Ischemic Heart Disease CAD
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| what are the manifestations of Ischemic Heart Disease (coronary artery disease) | stable angina
acute coronary syndromes
CHF
sudden cardiac death
silent ischemia
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| Due to fixed coronary lesion leads to mismatch of myocardial metabolic O2 supply and demand increases cardiac work load | stable angina
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| What does Acute Coronary syndrome encompase | includes conditions compatible with MI
unstable angina
STEMI
NSTEMI
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| What happens to atherosclerotic plaque in an acute event | it ruptures and creates a thrombogenic surface within blood vessel that leads to
platelet aggregation/ fibrin formation
limited blood flow distal to lesion
mismatch O2 supply/demand
tissue ischemia (unstable angina)
tissue necrosis (MI)
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| What are the four grades of Acute Coronary Syndrome | class I- angina occurs only with strenous activity
Class II- angina occurs with moderate activity
Class III- angina occurs withe mild activity
Class IV- angina occurs with any activity and may occur at rest
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| What is unstable angina | rapid increase in coronary stenosis but incomplete occlusion
chest pain
at rest
on effort w/ change from previous pattern
previous stable angina becoming severe
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| What are unstable angina patients at definite impending risk of | myocardial necrosis
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| Apart from angina what other conditions lead to supply demand mimatches | aortic stenosis
thyrotoxicosis
profound anemia
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| What do IHD/CAD predispose patient to | heart failure
cardiac arrythmias
sudden cardiac death
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| Name 5 risk factors for IHD/CAD | age >65
Male>Female
Smoking
HTN
Fam Hx
DM
obesity
sedentary life style
elevated cholesterol
inflammation
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| What is the most common cause of IHD/CAD and other causes | atherosclerosis
spasm
Arterial Stenosis
Hypertrophic obstructive cardiomyopathy
metabolic syndrome/ syndrome X
severe HTN
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| when does initial onset of atherosclerosis occur | childhood and adolescence fatty streaks with lipid filled smooth muscle cells and macrophages (foam cells) and intermittent fibrous deposition
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| What happens to the atherosclerosis generally in third decade of life | fibrous plaques appear in the abdominal aorta, coronary and carotid arteries.
they are firm, elevated dome shped lesions on surface that bulge into lumen
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| What are atherosclerotic plaque made of | extracellular lipid with cholesterol crystals and necrotic cell debris
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| What artherosclerotic plaques are usually associated with symptoms | complicated lesions of calcified fibrous plaque containing degrees of necrosis, thrombosis and ulceration
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| What size vessels does atherosclerosis typically effect and how is it characterized | disease of large and medium sized muscular arteries characterized by
endothelial dysfunction
vascular inflammation
buildup of lipids, cholesterol, calcium, and cellular debris withing intima of vessel wall
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| What are the results of plaque formation | vascular remodeling
acute and chronic luminal obstruction
abnormalities of blood flow
diminished oxygen supply to target organs
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| What happens if the enothelium or fibrous cap over a atherosclerotic plaque ruptures | you get exposure of the thrombogenic contents of the core to circulating blood. This is an advanced or complicated lession and inflammatory cells localize to the plaque. T-lmphocytes release inflammatory factors
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| what is the leading mechanism accepted regarding atherogenesis | response to injury where endothelial injury causes vascular inflammation and followed by fibroproliferative response
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| What is the major concern of a plaque rupture | that a thrombus will develop and occlude the blood vessel
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| When is anginal threshold typically lowest | More in the A.M.
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| What type of angina is variable defies any pattern and is prominent at rest. | Prinzmetal Angina (variable angina)
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| What might prinzmetal angina be caused by | myocardial ischemia caused by coronary spasm
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| If you have angina lasting > 20min and it is severe chest discomfort accompanied by profound fatigue what does it often equal | acute myocardial infarction or acute coronary syndrome
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| How long does typical angina pectoris last | 2-10 minutes
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| if angina last for 15-20 minutes what type of angina is it typically representative of | unstable angina
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| If the angina last for hours what might be underlying cause | acute MI
pericarditis
aortic dissection
musculoskeletal disease
herpes zoster
anxiety
cocaine abuse
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| if chest pain is really brief less than 15 seconds is it angina | no pain points to musculoskeletal pain, hiatal hernia or functional pain
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| what can be given to relieve angina pain | nitro
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| If your patient is having chest pain and leaning forward helps relieve the pain more than just quiet standing or sitting what besides angina is likely causing there pain | acute pericarditis
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| in angina what position is best to rest in to relieve pain lying down or standing up | standing up or quietly sitting is best lying down does not relieve angina
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| what are anginal equivalents | discomfort is limited to area of secondary radiation such as
lower jaw
teeth
neck
shoulders
nausea
indigestion
dizziness
diaphoresis
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| What other s/sx accompanying angina should be concerning | profuse sweating- may indicate acute MI or aortic dissection, or Pulmonary Effusion
nausea and vomiting- MI
SOB-MI, pneumothorax or Pulmonary effusion
Palpitations- Acute MI
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| What is important about angina in women, diabetics and elderly | it presents atypically. more vasospastic, microvascular angina
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| When do women often report chest discomfort | at rest
during sleep
during mental stress
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| What is dyspnea | abnormally uncomfortable awareness of breathing
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| if you have sudden development of dyspnea what might that indicate | pulmonary embolism, pneumothorax, acute pulmonary edema, pneumonia, or airway obstruction
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| If dyspnea develops slowly overtime what might that indicate | suggest chronic heart failure
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| if you have exertional dyspnea what might that indicate | left ventricular failure, ischemic heart disease or chronic obstructive lung disease.
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| if you have inspiratory dyspnea what might it be | suggest upper airway obstruction
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| if you have expiratory dyspnea what might it be | lower airway obstruction
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| if you have dyspnea at rest what might it be | pneumothorax, pulmonary embolism, pulmonary edema, anxiety
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| if dyspnea is an anginal equivalent what may it be associated with | sensation of tightness in the chest
present on exertion or emotional stress
relieved by rest
similar to angina in duration
usually responive to or prevented by nitro
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| What is orthopnea | discomfort breathing while lying down patients with left ventricular failure start sleeping with 2 or more pillows to avoid the orthopnea
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| what are the three types of syncope | cardiac syncope
aortic stenosis syncope
neurocardiogenic syncope/ syncope due to postural hypotension
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| What are palpitations | unpleasant awareness of forceful or rapid beating of the heart
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| how are palpitations described | Pounding
Jumping or Skipping a beat
Racing
Irregularity of the heart beat
A "flip flopping"
A "rapid fluttering"
Pounding in the neck
Butterflies in my chest
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| If your patient has claudications ie Peripheral Vascualr disease what else do they likely have | 50% likelihood of having CAD
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| What might you find on PE in angina | could have S3 or S4
xanthomas (cholesterol filled nodules)
signs of CHF
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| what is the most consistent ECG finding during acute ischemia | deviation of ST segment from current of injury mechanism
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| what is the management for angina | risk factor modification
asa daily
NTG prn
long actin nitrates
BB, CCB
PTCA(PCI)
CABG
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| what is the most common cause of MI | atherosclertotic palque ruptures stimulating thrombus formation
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| What is the clinical findings for MI | Severe anginal type pains, usually lasting >30 minutes, NOT relieved by NTG or rest
SOB
Anxiety
Diaphoresis
N/V
Syncope
Atypical & silent presentations
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