CBL 1 Ischemic heart disease Chapter 243

What are the three major determinants of myocardial o2 demand? Heart rate Myocardial contractility Myocardial wall tension (stress)

What are the three major components to coronary blood flow resistance and what is their relative contribution? R1 large epicardial arteries R2 pre-arteriolar vessels R3 Intra-myocardial small vessels

In the absence of significant atherosclerotic obstruction, resistance in R1 is trivial, with R2 & 3 the major determinants

What factors determine the ischemic changes are reversible or permanent? The severity and duration of imbalance between myocardial oxygen supply and demand. <20 min for total occlusion in the absence of collaterals reversible >20 min myocardial necrosis

What does the term ischaemic cardiomyopathy refer to? Patients with IHD who present with cardiomegaly and heart failure secondary to ischaemic damage to the LV myocardium, that may have caused no symptoms prior to the development of heart failure

What does the typical patient with stable angina pectoris present like? Man >50 or woman >60 Complains of episodes of chest discomfort o Described as heaviness, pressure, squeezing, smothering or choking and rarely as flank pain When asked to localise pain, patient often places a clenched fist over the sternum (Levines sign)

How does angina pain present? The pain is usually crescendo-decrescendo in nature Last 2-5 mins

Can radiate to either shoulder and to both arms, especially the ulnar surfaces of forearm and hand Can also arise in or originate in to the back, intra-scapular region, root of neck, teeth and epigastrium Angina is rarely localised below the umbilicus or above the mandible

What important questions need to be asked to assess whether stable angina is progressing to the unstable syndrome? Is the pain occurring with less exertion than in the past? Is the pain occurring at rest? Is the pain or symptoms awakening you?

How what is the positive predictive value of a positive stress test in a male over 55 years with a history or typical angina pectoris like chest pain? 98% likelihood of CAD in this patient Decreased likelihood if atypical or no chest pain by history and/or during the test

In what populations are the rates of false positive stress tests increased? In pts with low probability of IHD, such as assymptomatic men <40 yrs, or premenopausal women with no risk factors of premature atherosclerosis. Also increased in pts taking cardioactive drugs, such as digitalis, and antiarrythmic agents, and those with intraventricular conductance disturbances, resting ST segment and T-wave abnormalities, ventricular hypertrophy or abnormal K+ level

Which patients may be at an increased risk of false negative results? Patients with disease confined to the circumflex artery as the lateral potion of the heart that this vessel supplies is not well represented on a 12 lead ECG

What is the overall sensitivity of stress testing? What is less likely given a negative stress test? Overall sensitivity of 75% Three vessel disease or left main disease is extremely unlikely given a negative stress test

What are the important parameters recorded by the physician at completion of an exercise stress test? Total duration of test The time to onset of ischemic ST-segment change and chest discomfort The external work performed (generally expressed as stage reached) Internal cardiac work performed (product of HR and BP) Depth of ST-segment depression and the time needed for this to recovery on ECG

What are the contraindications to exercise stress testing? How soon after can an exercise stress test be performed in pts following an uncomplicated MI? Rest angina within 48 hrs Unstable rhythm Severe aortic stenosis Acute myocarditis Uncontrolled heart failure Severe pulmonary hypertension Active infective endocarditis

Stress testing can be performed as early as 6 days following an uncomplicated MI using a modified protocol limited via heart rate rather than symptoms

What ECG changes during a stress test are used to define the ischemic ST-segment response? Defined as flat or downsloping depression of the ST-segment >0.1mV below baseline lasting longer than 0.08s

What other factors lead to discontinuation of a exercise stress test? Evidence of chest discomfort Severe shortness of breath Dizziness Severe fatigue ST-segment depression >0.2mV (2mm) A fall in SBP >10mmHg Development of a ventricular tachyarrhythmia

What is the normal HR and BP response during a graded exercise stress test? What does an absence of these characteristic changes indicate? Normal response is a progressive increase in both HR and BP in response to exercise Failure of blood pressure to increase, or a fall in BP with signs of ischaemia during a stress test is an important prognostic sign, as it may reflect ischaemia-induced global left ventricular dysfunction

What atherosclerotic plaques cannot be visualised during coronary arteriography? This method outlines the lumina of the coronary arteries, thus, only plaques that encroach on the coronary lumen can be detect This is of note as many plaques start growth in the intima and media (causing an outward bulging of the artery) before encroaching into the lumen (process referred to as remodelling)

What are the indications for coronary arteriography? Patients with chronic stable angina pectoris who are severely symptomatic despite medical therapy and are being considered for revascularisation (PCI or CABG) Patients with troublesome symptoms that present diagnostic difficulties in whom there is need to confirm or rule out the diagnosis of IHD Patient with known or possible angina pectoris who have survived sudden cadiac arrest Patients with angina or evidence of ischaemia on non-invasive testing with clinical or laboratory evidence of ventricular dysfunction Patients judged to be high risk of sustaining coronary events based on signs of severe ischaemia on noninvasive testing, regardless of the presence or severity of symptoms

What are the main risk factors that can be addressed in a pt with IHD? Obesity impairs the treatment of other risk factors and is accompanied by o Hypertension, hyperlipidemia and hyperglycemia (T2DM) Diet: low in saturated and trans-saturated fatty acids and a reduced caloric intake to achieve optimal body weight Cigarette smoking accelerates coronary artherosclerosis in both sexes and all ages, increased risk of thrombosis, plaque instability, MI and death. In addition, smoking increases myocardial O2 demands and reduces supply exacerbating angina symptoms. Hypertension increased adverse events, LVH etc. Diabetes mellitus Treatment of dyslipidemia HMG CoA reductase inhibitors, lower LDL cholesterol (25-50%), raise HDL cholesterol (5-9%), lower triglycerides (5-30%)