Coronary Artery Disease

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Coronary Artery Disease
Coronary Artery Disease
      • Coronary Artery Disease
      • Differential diagnosis of chest pain ( Commonly asked clinical Vignette in MD Entrance) (MCQ)
      • Costochondritis/musculoskeletal:
        • Sharp, localized pain and reproducible tenderness
        • often exacerbated by exercise
      • Myocardial infarction/angina:
        • Chest heaviness, pressure
        • pain, typically radiating to left arm, shoulder, or jaw
      • Pericarditis:
        • Chest pain radiating to shoulder, neck, or back,
        • worse with deep breathing or cough (pleuritic)
        • relieved by sitting up/leaning forward (MCQ)
      • Aortic dissection:
        • Severe chest pain radiating to the back
        • associated with unequal pulses or unequal blood pressure in right and left arms (MCQ)
      • Abscess/mass:
        • Often sharp, localized pain, pleuritic (MCQ)
      • Pulmonary embolism:
        • Often pleuritic.
        • Frequently associated withtachypnea and tachycardia
      • Pneumonia:
        • Pleuritic, frequently associated with hypoxia (MCQ)
      • GERD/esophageal spasm/tear:
        • Burning pain, dysphagia, may be similarto pain of myocardial infarction (MI)
      • Other causes of chest pain:
        • Peptic ulcer disease, biliary disease, herpes zoster, anxiety, pneumothorax
      • Risk factors for coronary artery disease (MCQ)
      • Modifiable:
        • Smoking , Hypercholesterolemia ,Hypertension
        • Obesity (apple-shaped) ,Diabetes mellitus , Physical inactivity
      • Nonmodifiable:
        • Age ,Male , Family history
      • Criteria for family history of coronary artery disease: (MCQ)
        • MI before age 40 in men
        • MI before age 55 in women
      • Evaluation of CAD
      • Exercise Stress Testing
        • Patients are asked to walk on a treadmill at increasing levels of difficulty to reach a heart rate that is 85% of predicted maximum for age.
        • Alternatively, pharmacologic agents such as dobutamine may be administered IV to stimulate myocardial function in a patient who cannot exercise. (MCQ)
        • ECG monitoring during the procedure detects changes.
        • A test is considered positive for coronary artery disease if the patientdevelops: (MCQ)
          • ST elevation
          • ST depression> 1 mm in multiple leads
          • Decreased BP
          • Failure to exercise more than 2 minutes due to symptoms
        • Failure to complete the test due to reasons other than cardiac symptoms (i.e., arthritis) is not diagnostic.
      • Stress Myocardial Perfusion Imaging
        • Patients are injected with a radioisotope (thallium 201 or technetium 99m sestamibi) and stressed (with exercise or pharmacologic agent). (MCQ)
        • Nuclear imaging is obtained immediately after exercise and in 4 hours.
        • The test can detect:
          • Myocardial perfusion
          • Ventricular volume
          • Ejection fraction
      • Cardiac Catheterization
        • The right heart is accessed by the femoral or internal jugular vein.
        • The left heart is accessed by the femoral or radial artery (from the rightheart).
      • Acute coronary syndromes (ACS)
      • Classified as non-ST-elevation and ST-elevation events.
      • Non-ST-elevation events include non-ST-elevation MI and unstable angina (UA). ACS is due to an imbalance of myocardial oxygen demand and supply.
      • The most common cause of decreased oxygen supply is narrowing of coronary artery by thrombus or plaque that has become unstable.
      • Cardiac enzymes :
        • Myoglobin: (MCQ)
          • Elevated within 1 hour of MI but is nonspecific
          • Creatinine phosphokinase (CPK):
          • Elevated within 4 to 8 hours of MIbut is nonspecific
        • CK MB isoenzyme:(MCQ)
          • Specific marker for myocardial tissue damage
        • Troponin T or I: (MCQ)
          • Very sensitive and specific markers for cardiac muscleinjury.
          • Elevated within 3 hours and can stay elevated for more than a week
          • Renal insufficiency can lead to erroneously high levels depending on the type of troponin and the cutoff value used.
        • “Serial enzymes”:
          • Consists of cardiac biomarkers drawn every 6 to 8hours for a 24-hour period (MCQ)
      • Initial Evaluation of ACS
      • Typical symptoms:
        • Left-sided/substernal chest pressure with radiation to left shoulder, arm, or jaw
        • Shortness of breath
        • Diaphoresis
        • Nausea or vomiting
      • Unstable angina is associated with
        • increasing frequency and/or severity of symptoms
        • symptoms at rest
        • new onset of symptoms.
      • Presentation may be atypical in diabetics and women.
      • Initial test: ECG
      • Determining the Type of ACS and Management protocol
      • ST-elevation MI (STEMI) or new left bundle branch block (LBBB) on ECG:
        • These patients are admitted and managed according to guidelines for STEMI.
      • Unstable angina/non-ST-elevation MI: (MCQ)
        • These two have similar pathogenesis.
        • Non-ST-elevation MI differs from unstable angina in that the lack of oxygen is severe enough to cause myocardial damage and enzyme leakage (unlike unstable angina, where there is no enzyme leakage).
      • Clinical scenario 1: If normal ECG and normal cardiac enzymes and no recurrence ofsymptoms (MCQ)
        • patient can have echocardiogram to assess left ventricular function.
      • Clinical scenario 2: If either test is abnormal (MCQ)
        • patient should be managed as acute ischemia.
      • Clinical scenario 3: If ST depression, inverted T-waves, positive cardiac enzymes, or recurrence of symptoms (but no ST elevation on ECG) (MCQ)
        • patient should be admitted to the hospital and managed as acute ischemia.
      • Risk Stratification
      • TIMI Risk Score (MCQ)
        • Age>65
        • Presence of 3 or more CAD risk factors
        • Prior coronary stenosis 50%
        • Presence of ST segment deviation on admission ECG
        • At least two anginal episodes in last 24 hours
        • Elevated serum cardiac biomarkers
        • Use of ASA in prior 7 days
      • Risk of all cause mortality @ 14 days =
        • 0/1 4.7% ,2 8.3% ,3 13.2 %
        • 4 19.9% , 5 26.2% , 6/7 40.9%
      • Initial Treatment for All ACS
      • Anti-ischemic treatments:
        • Oxygen
        • Nitroglycerin (NTG)
          • for chest pain
          • can be given sublingually
          • Ifpain persists, can be given intravenously.
        • Morphine
          • Given if pain persists despite NTG
        • Beta blockers (MCQ)
          • decrease cardiac oxygen demand
          • have been shownto decrease mortality
          • Aim for a pulse rate of 60.
      • Antiplatelet and anticoagulation:
        • Aspirin (chewable preferred).
        • Clopidogrel is an alternative for those with true aspirin allergy.
        • Both unfractionated heparin and low-molecular-weight heparin can be used.
        • GP IIb/IIa inhibitors have shown to be beneficial for (MCQ)
          • high-risk patients
            • elevated troponin
            • TIMI risk score > 4
            • ongoing ischemia
          • patients undergoing percutaneous intervention.
        • Thrombolytics are not used in unstable angina or non-ST- elevation MI because in 60 to 80% the infarcted artery is not occluded. (MCQ)
      • Treatment for Unstable Angina and Non-ST-Elevation MI
      • General ACS anti-ischemic and antiplatelet treatment
      • Early invasive treatment (cardiac catheterization) if any of the following are present: (MCQ)
        • Elevated troponin
        • Recurrent chest pain despite medical therapy
        • CHF
        • Positive stress test
        • Left ventricular EF < 40%
        • Sustained ventricular tachycardia
        • Cardiac stent within 6 months
      • Early conservative therapy with medical management can be considered in patients who respond to medical managementwithout any of the features mentioned above.
      • Treatment for ST-Elevation MI
      • Patients include those with new left bundle branch block.
      • Requires early revascularization with thrombolytics and/or cardiaccatheterization and stent
      • Cardiac catheterization/percutaneous transluminal coronary angioplasty (PTCA):(MCQ)
        • Coronary angiogram can demonstrate the coronary anatomy as well as the specific diseased vessel causing symptoms.
        • The occlusion of the vessel can be reopened by balloon angioplasty and/or coronary stent placement.
        • Success rate as high as 90% compared to 60% with thrombolytics.
        • Preferred over thrombolytics if: (MCQ)
          • Skilled lab is available in < 12 hours from onset of symptoms and
          • < 30 minutes from entering the ER
          • High risk of ST-elevation MI (i.e., cardiogenic shock)
          • Late presentation (> 3 hours after symptoms)
      • Thrombolytics
        • Thrombolytics are preferred  (MCQ)
          • if patient presents within 12 hours of symptoms, preferably within 3 hours
          • if there will be a delay to PTCA or if cardiac catheterization is not an option.
        • Thrombolytics work to break up clots.
        • Examples include streptokinase, urokinase, anistreplase, alteplase, and reteplase.
        • Absolute contraindications to thrombolytics: (MCQ)
          • Any prior intracranial hemorrhage
          • Stroke within 1 year
          • Intracranial neoplasm
          • Active internal bleeding
          • Suspected aortic dissection
        • Relative contraindications to thrombolytics: (MCQ)
          • Available cath lab within 90 minutes of presentation
          • Systolic blood pressure (sBP) > 180
          • diastolic blood pressure (DBP)> 110
          • Prior stroke or intracranial lesion other than above
          • Bleeding disorder
          • warfarin use with international normalized ratio(INR) > 2
          • Major surgery within 3 weeks
          • Age>75
          • Cardiopulmonary resuscitation (CPR)
          • Peptic ulcer
      • Medications at Discharge for Patients with ACS (MCQ)
      • Aspirin indefinitely
      • Beta blocker indefinitely
      • Angiotensin-converting enzyme (ACE) inhibitor indefinitely
        • initially recommended for patients with ejection fraction (EF) < 40% or anterior wall MI
      • Statin to maintain LDL < 70
      • Clopidogrel for 1 to 12 months depending on stent placement and type
      • Postinfarction Complications
        • Ruptures (usually occur within 4 to 5 days of a large MI):
        • Free wall rupture
        • Acute ventricular septal perforation
        • Acute mitral regurgitation from papillary muscle rupture
        • Arrhythmias:
        • Ventricular tachycardia: (MCQ)
          • If within 48 hours of MI, usually just fromreperfusion of myocardium.
          • If it occurs later than 48 hours, considerimplantable defibrillator.
        • Bradycardia (usually from inferior wall MI)
        • Atrioventricular (AV) block: (MCQ)
          • If inferior wall MI, this will usually reverse
          • if anterior wall MI, usually will require pacemaker
        • Dressler’s syndrome: (MCQ)
          • Usually occurs 1 or 2 weeks after cardiac injury (MI or cardiac surgery).
          • It is associated with fever, pericarditis, and sometimes pericardial or pleural effusions; likely a hypersensitivityprocess.
          • Treat with NSAIDs.
      • Secondary Prevention of unstable angina/non-ST-elevation MI and ST- elevation MI:
        • Smoking cessation
        • Aggressive diabetes management
        • Aggressive control of hypertension (maintain < 140/90)
        • Lipid control with statins as above and dietary modification
      • ANGINA
      • Unstable angina
        • An acute coronary syndrome diagnosed by the following history:
          • New-onset angina
          • Angina that changes or accelerates in pattern, location, or severity
          • Angina at rest
      • Stable angina:
        • A chronic, episodic pain syndrome due to temporary myocardial ischemia.
        • Pattern of pain is similar to that of acute MI, but resolves with rest or medication.
      • Prinzmetal’s angina:
        • Angina due to coronaryvasospasm, not linked to exertion.
        • Distinguished from unstable angina by chronic, intermittent nature.
        • Pain usually occurs at a specific hour in the early morning
        • Coronary vessels are angiographically normal.
        • Etiology : Temporary myocardial ischemia
        • Diagnosis
          • ECG
            • ST segment depression or elevation
            • T wave inversion
            • May be normal
        • Treatment
          • For Stable Angina (MCQ)
            • Beta blockade: Reduces myocardial oxygen demand
            • Aspirin: Reduces risk of MI in asymptomatic patients
            • Morphine: For analgesia, but does not affect outcome
            • Modify risk factors for coronary artery disease.
            • Sublingual NTG for episodic pain
            • Echocardiogram to assess left ventricular function
            • Exercise stress test
            • Consider coronary revascularization after aforementioned tests: PTCAor coronary artery bypass graft (CABG).
          • For Prinzmetal’s Angina
            • Calcium channel blockers and nitrates to reduce vasospasm
            • Clinical Pearls :
            • The maximum heart rate is estimated as: [220 −patient’s age]. (MCQ)
            • ECG Changes (MCQ)
        • Inferior wall MI:
          • ST elevation in II, III, aVF
        • Cor pulmonale:
          • ST depression in II, III, aVF
        • Anteroseptal MI:
          • ST elevation in V1, V2,
        • Lateral wall MI:
          • ST elevation in V4, V5, V6
        • Posterior wall MI:
          • ST depression in V1, V2
            • Low-molecular-weight heparin
        • given sub-Q every 12 hours.
        • PT/PTT does not need to be checked.
            • The thrombolytic streptokinase
        • highly immunogenic
        • cannot be used in the same patient twice within a 6-month period.
            • Clinical Vignette in MD Entrance : (MCQ)
        • A 64-year-old man who was discharged from the hospital after MI 2 weeks ago presents with fever, chest pain, and generalized malaise. ECG shows diffuse ST-T wave changes
          • Diagnosis: Dressler’s syndrome.
          • Treat with nonsteroidal anti-inflammatory drugs (NSAIDs).
            • Clinical Vignette in MD Entrance : (MCQ)
        • A 72-year-old smoker presents complaining of three episodes of severe heavy chest pain this morning. Each episode lasted 3 to 5 minutes, but he has no pain now. He has never had this type of pain before.
        • Diagnosis:  Unstable angina.

 

            • Clinical Vignette in MD Entrance : (MCQ)
          • A 70-year-old man presents with frequent episodes of dull chest pain on and off for 8 months. He says the pain wakes him from sleep.
          • Diagnosis:  Prinzmetal’s angina.
Serum Markers
Serum Markers

 

Atherosclerosis-plaque-coro
Atherosclerosis-plaque-coro

Micrograph of a coronary artery with the most common form of coronary artery disease (atherosclerosis) and marked luminal narrowing

 

Myocardial Infarction
Myocardial Infarction

Coronary heart disease: Plaque builds up in blood vessels in the heart making them narrow,

Heart attack: here, a blood clot suddenly gets stuck in one of the narrow blood vessels.

 

Angiography_coronary_stenosis
Angiography_coronary_stenosis

 

Coronary angiogram showing stenosis

 

Stress ECG_ST Depression
Stress ECG_ST Depression

Coronary artery disease Stress test

 

Stress-ECG of a patient with coronary heart disease: ST-segment depression (arrow) at 100 watts of exercise. A: at rest, B: at 75 watts, C: at 100 watts, D: at 125 watts.

 

 

Coronary artery disease : Exercise stress test
Coronary artery disease : Exercise stress test

(Coronary artery disease : Exercise stress test)

A male patient walks on a stress test treadmill to have his heart’s function checked

 


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