Medical Archive

Introduction

Epidemiology and global trends

Pathophysiology

Coronary atherosclerosis

Coronary anatomy

Stable angina pectoralis

History 

??? pain, 2-5?, Lt. soulder, both arm? ??

Classic	Typical location (eg, substernal), quality & duration Provoked by exercise or emotional stress Relieved by rest or nitroglycerin
Atypical	2 of the 3 characteristics of classic angina
Nonanginal	<2 of the 3 characteristics of classic angina

Physical examination

	S3	S4
Features	Ventricular gallop sound (after S2) Heard during rapid filling of ventricles in diastole Turbulent blood flow to the ventricles d/t increased volume	Atrial gallop sound (before S1) Heard immediately after atrial contraction phase as blood is forced into a stiff ventricle.
Normal	Children Young adults Pregnancy	Healthy older adults
Abnormal/ associated conditions	Age >40 Heart failure RCMP High-output states	Younger adults, children Ventricular hypertrophy Acute myocardial infarction

Laboratory examination

Electrocardiogram

75%, Confounding Resting EKG??? imaging ??

Stress test

Exercise EKG test

• ??? ??? ????? ???? ???? ??
• Ischemic ST-segment response, positive test
  • ??? ??? ??
  • Baseline (PR segment)?? 0.1mV ?? ??? ??? 0.08? ?? ??
  • ??? ??? ?? + 1mm ??? ?? ?? ??? ??? ST depression
• ?? ???? ?? ???
  • ?? ????, ???, ??
  • Stage II ??? ? ST-segment depression >2mm (0.2mV)
  • ST depression? ?? ?? ? 5? ?? ??
  • Stage ??? ?? BP? ???? ???? ??. SBP 10mmHg???
  • Ventricular arrhythmia

??: ??? ??, ??? ?? (within 48hr), EKG?? old infarc ??
?+: ?? ???, digitalis/quinidine, R/LBBB, WPW, LVH, hypokalemia
?-: LCX ischemia

Stress myocardial perfusion scintigraphy

• ?? ??: ??, ?? (dobutamine?? adenosine)
• Stress ?? 99mTc, 201TI? ???? SPECT

Stress echocardiography

• ?????? ??? ??? ?? ?? ??? ??? LV ?? ??
• Exercise EKG?? ? ??, ??, ???? ???? ? ????

Cardiac imaging

MIBI (90%)	Ix: HR85% ??x, ischemia ?? ???
ECHO	Ix: chronic angina or MI Hx, HF ?? ? LVfx ???
CMR	Dobutamine ? complete ventricular eval.

?? ????? LV function??? ?? exercise EKG?? ????? ??? r/o ??

Coronary arteriography

Prognosis

Treatment

Agents That Have a Physiological Effect

• Nitrate
  • Long-acting added for persistent angina
  • NTG: drug-free intervals of 8-10 hours should be maintained to prevent tachyphylaxis
  • Predominantly affect the large veins ? venodilation ? ?capacitance ? ?preload
• Beta blocker
  • First-line therapy for stable angina
  • ?Myocardial contractility & heart rate
• Calcium channel blocker
  • Heart-rate lowering agents (non-DHP)
    • Alternative to beta blocker
    • ?Myocardial contractility & heart rate
  • Dihydropyridine (DHP)
    • Added to beta blocker when needed
    • Coronary artery vasodilation
    • ?Afterload by systemic vasodilation

Agents That Affect Myocardial Metabolism

• Ranolazine
  • Alternative therapy for refractory angina
  • Late Na+ current blockade ? ?Ca2+ efflux via exchanger ? ?diastolic wall tension and O2 consumption.
  • S/E: Dizziness, constipation, nausea, QT-interval prolongation (d/t blockade of K+ ch as well)
  • CIx: Liver cirrhosis
  • Intractions: CYP3A4 substrates, drugs that prolong the corrected QT interval

Acute angina

A	Aspirin (ACEi)	SA? ??? ?? ?? anti-platelet Tx (anti-thrombotic X) SA?? routine X. LV dysfunction, HTN, DM ??? ?? ??
B	BB	R.CIx: Unstable HF, BP<90, HR<60, Asthma, ??????
(C)	CCB	BB ?? ?. Conduction disturbance ??? BB ??  BB? ??: nonDHP?? verapamil ? ?? ??!
N	Nitrate	Oxygen demand? supply ?? ??. ??? m/c Cx

Variant angina

??? ???? ??. Epicardial coronary spasm

??
Resting angina, ?? ?? ?? transient ST elevation
CAG?? ??? ??? ??? ergosterol challenge? ???.

??
Nitrate, CCB (spasm ??)

??: BB(?? ??, spasm ??), High-dose aspirin (ischemia ??), ergot alkaloid(partial ?-agonist, serotonergic), cigarette smoking, cocaine/amphetamines, triptans

Coronary revascularization

Revascularization Indication

????? ?? ?? ?? ?
?? ??? ? r/o ??
???? ? angina
Ventricular dysfunction ?? ?? ?
High risk (??? ??)
Pilot, ??, ???

Asymptomatic (silent) ischemia

Treatment