Internal Medicine: Cardiology
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What are MAJOR risk factors for myocardial ischemia?
- Hyperlipidemia (elevated LDL)
- Cigarette smoking
- Age (Men >45; women >55)
- Family history
- Low HDL
What are minor risk factors for MI?
- sedentary lifestyle
- excess alcohol
Symptoms of angina due to myocardial ischemia
- Heaviness, pressure, squeezing, tightness.
- RARELY described as sharp or stabbing pain.
- Usually gradual in onset.
- Relieved with rest or nitroglycerin.
- ischemic pain does NOT change with breathing or with body position. Also, there is no associated chest tenderness. If these symptoms are present, consider other diagnoses.
What is syndrome X?
- Exertional angina with normal coronary arteriogram (no coronary stenosis seen with cardiac catheterization). But you do see positive exercise testing and nuclear imaging show evidence of MI.
- Prognosis is excellent.
- Different from Prinzmetal's angina.
- Do not confuse the name with metabolic syndrome X.
What is the worst risk factor for myocardial ischemia?
What is the most common risk factor for myocardial ischemia?
What are the indications for a stress test?
- To confirm diagnosis of angina.
- To evaluate response of therapy in patients with documented CAD.
- To identify patients with CAD who may have a high risk of acute coronary events.
What are you looking for in a Stress ECG test?
- ST segment depression;indications for an ECG test is INTERMEDIATE risk for myocardial ischemia in patients with STABLE angina. Thus, most stress tests are ordered to induce an SUBendocardial ischemia, which is appreciated as a ST segment depression on an ECG.
- Other positive findings include onset of heart failure, chest pain, ventricular arrhythmia, or hypotension.
What is the next step for a POSITIVE stress test? (any type of stress test)
What is a positive sign in Stress Echocardiography?
Wall motion abnormalities (Akinesis or dyskinesis) that is not present at rest. Also, chest pain, hypotension, or arrhythmia.
What are some benefits that stress echo has over stress ECG?
sECHO is more sensitive than sECG in detecting ischemia (according to some cardiologists). Also, you can assess LV size and function, diagnose valvular disease, and can identify CAD in the presence of preexisting ECG abnormalities
How do you get a direct image of the lack of myocardial perfusion during a stress test?
IV thallium 201 or sestamibi (Technetium-99m) scintigraphy during stress test.
How do you determine if an MI is reversible or irreversible?
During stress myocardial perfusion imaging, reversible MI is shown by areas of hypoperfusion that is perfused over time. If blood flow is not restored, the damage is irreversible.
How do you rescue reversible myocardial ischemia?
- Percutaneous coronary intervention, or
- Coronary artery bypass graft
What are the agents used for chemical stress test?
- IV adenosine, dipyridamole, or dobutamine.
- These substances can induce cardiac stress without the need for physical exercise and thus be combined with ECG, echo, or nuclear perfusion imagining to produce results similar to exercise stress tests.
What are the specific effects of IV adenosine, dipyridamole, or dobutamine?
- IV adenosine and dipyridamole causes generalized coronary vasodilation. Note that diseased coronary arteries will already be maximally dilated, thus you will see hypoperfusion via "steal effect"
- In contrast, dobutamine increases myocardial oxygen demand by increasing HR, BP, and cardiac contractility.
What is "Holtering monitoring" and when is it used?
- Holtering monitoring is an ambulatory ECG that is useful for detecing silent ischemia (asymptomatic ECG changes). This monitor can also be used to evaluate arrhythmias, HR variability, and to assess pacemaker and implantable cardioverter-defibrillator (ICD) functions.
- It can also be useful for evaluation of unexplained syncope and dizziness.
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