CCS Angina Classification and Diagnostics

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Questions and Answers

What percentage of penetrating cardiac injuries is due to stab wounds?

40-50%

60-70% (correct)

75-80%

30-40%

Which chamber of the heart is least frequently injured in penetrating cardiac trauma?

Right Atrium

Left Ventricle

Left Atrium (correct)

Right Ventricle

Beck's triad is characterized by which combination of findings?

Shock, bradycardia, pericardial fluid

Hypotension, venous pressure, muffled heart sounds (correct)

Muffled heart sounds, elevated blood pressure, tachycardia

Increased heart rate, chest pain, cyanosis

In the context of cardiac output, how is stroke volume (SV) calculated?

SV = LVEDV - LVESV Signup and view all the answers

What is the normal range for Mean Arterial Pressure (MAP)?

70-100 mmHg Signup and view all the answers

What is the primary characteristic of Class I in the CCS Angina Classification?

Angina is triggered by strenuous or prolonged exertion. Signup and view all the answers

In the CCS Angina Classification, which class describes a situation where angina occurs after walking >=1 block on the level?

Class III Signup and view all the answers

What diagnostic tool is primarily used to assess cardiac silhouette and pulmonary congestion?

Chest X-ray (CXR) Signup and view all the answers

Which of the following is NOT a feature assessed by 12-Lead Electrocardiogram (12-L ECG)?

Wall motion Signup and view all the answers

Which type of imaging is used to identify transmural infarct and ventricular scar?

Magnetic Resonance Imaging (MRI) Signup and view all the answers

What does Cardiac Catheterization primarily provide information about?

Cardiac output and wall motion Signup and view all the answers

In the context of coronary anatomy, what is the Left Main Coronary artery responsible for?

Branching into major coronary arteries. Signup and view all the answers

What is a common characteristic of Class IV angina according to the CCS classification?

Angina is present at rest. Signup and view all the answers

What does a normal Ankle-Brachial Index (ABI) range from?

0.9-1.0 Signup and view all the answers

Which is NOT a complication of revascularization?

Chronic venous insufficiency Signup and view all the answers

What ABI value is considered severe?

0-0.49 Signup and view all the answers

What condition is characterized by profound paralysis and major tissue loss?

Irreversible Signup and view all the answers

Which of the following is a major sign of reperfusion syndrome?

Hypotension Signup and view all the answers

Which drug is known for its strong positive inotropic effect with minimal α1 action?

Dobutamine Signup and view all the answers

What characterizes a pseudoaneurysm in contrast to a true aneurysm?

A pseudoaneurysm lacks a complete arterial wall structure. Signup and view all the answers

Which factor is NOT considered a risk factor for Abdominal Aortic Aneurysm (AAA)?

Female gender Signup and view all the answers

What is the average growth rate of an Abdominal Aortic Aneurysm (AAA)?

0.4 cm/year Signup and view all the answers

Which of the following agents is classified as a pure α agonist with no direct cardiac effects?

Phenylephrine Signup and view all the answers

What imaging techniques are used to diagnose an Abdominal Aortic Aneurysm (AAA)?

CT scan with contrast, MRI, MRA, angiography Signup and view all the answers

In the context of vascular surgery, what is the most common site for aneurysmal disease?

Abdominal aorta Signup and view all the answers

Which of the following is true regarding Nitroglycerin (NTG) in the context of anti-hypertensives?

NTG improves coronary blood flow to ischemic zones. Signup and view all the answers

What is the most common source of distal emboli leading to Acute Limb Ischemia?

Atrial thrombus from atrial fibrillation Signup and view all the answers

Which clinical finding is NOT part of the 6P's associated with acute limb ischemia?

Phlebitis Signup and view all the answers

What is the operative mortality rate associated with endovascular treatment?

9% Signup and view all the answers

Which of the following is a common complication associated with endovascular treatment?

Endoleak Signup and view all the answers

Which therapy is categorized under surgical options for treating acute limb ischemia?

Thrombectomy Signup and view all the answers

In which artery is the most common location for an embolus to lodge?

Common femoral artery Signup and view all the answers

What percentage represents the stroke rate for endovascular treatments?

7% Signup and view all the answers

Which clinical category indicates a limb that is viable but not immediately threatened?

Category I Signup and view all the answers

Study Notes

Canadian Cardiovascular Society (CCS) Angina Classification

Class I: Ordinary physical activity doesn't cause angina, but it may occur with strenuous or prolonged exertion.
Class II: There's a slight limitation of ordinary activity, with angina potentially occurring with rapid walking or stair climbing.
Class III: Marked limitation of physical activity, with angina occurring after walking a short distance (≥1 block) or climbing one flight of stairs.
Class IV: Inability to engage in physical activity without discomfort, with angina potentially present at rest.

Diagnostic Tools

Chest X-ray (CXR): Evaluates cardiac silhouette, pulmonary congestion, and related pulmonary pathology.
12-Lead Electrocardiogram (12-L ECG): Assesses heart rate, rhythm, ventricular hypertrophy, blocks, and ischemia.
2-Dimensional Echocardiography with Doppler (2DED): Measures chamber size, wall motion, shunts, valve pathology, left ventricular function, and effusions.
Viability Studies:
- Radionuclide Studies:
  - Thallium scan
  - Positron Emission Tomography (PET) scan
- Magnetic Resonance Imaging (MRI): Detects transmural infarct, ventricular scar, and aneurysm.
Cardiac Catheterization/Coronary Angiography: Measures chamber pressures, cardiac output, quantifies shunts, assesses wall motion, and visualizes coronary anatomy.
Computed Tomography (CT) Coronary Angiography: Identifies intraluminal calcium.

Penetrating Cardiac Trauma

Prevalence: 60-70% of penetrating chest injuries, primarily due to stab wounds.
Commonly Affected Chambers: Right ventricle (40-45%), left ventricle, right atrium, and left atrium (least injured: 5%).
Simultaneous Chamber Injuries: Occur in 30% of cases.
Beck's Triad: Hypotension, raised venous pressure, and muffled heart sounds, primarily seen in cases of pericardial tamponade.
Ventricular Septal Rupture: Occurs in the muscular portion near the apex.
Pericardial Tear: More common on the left side, leading to potential herniation.
Diagnosis: ECG, CXR, cardiac enzymes.
Treatment: ICU management, treated as a myocardial infarction (MI).

Normal Values & Formulas

Cardiac Output (CO): 4-8 L/min; CO = Stroke Volume (SV) x Heart Rate (HR)
Cardiac Index (CI): 2.5-4 L/min
Stroke Volume (SV): 1 mg/kg/beat; SV = Left Ventricular End-Diastolic Volume (LVEDV) - Left Ventricular End-Systolic Volume (LVESV)
Stroke Volume Index (SVI): 33-47 mL/beat/m2
Mean Arterial Pressure (MAP): 70-100 mmHg; MAP = Diastolic Blood Pressure (DBP) + ½ of Pulse Pressure
Pulmonary Artery Wedge Pressure (PAWP): 10-15 mmHg; PAWP = Left Atrial Pressure (LAP) = Left Ventricular End-Diastolic Pressure (LVEDP)
Central Venous Pressure (CVP): = Right Atrial Pressure (RAP) = Right Ventricular End-Diastolic Pressure (RVEDP)
Pulse Pressure: Systolic Blood Pressure (SBP) - DBP
Systemic Vascular Resistance (SVR): 800-1200 dynes sec/cm5; SVR = [(MAP-RAP)x 80]/CI
Systemic Vascular Resistance Index (SVRI): 1600-2400 dynes sec m2/cm5
Peripheral Vascular Score (PVS): 50-250
Left Ventricular Stroke Work Index (LVSWI): 45-75 mg/m/beat m2

Determinants of Stroke Volume (SV)

Preload: Left Ventricular End-Diastolic Pressure (LVEDP) or LVED fiber length.
Afterload: Left Ventricular systolic wall tension, determined by preload and SVR.
Filling Pressure: May be affected by atrial conditions like atrial fibrillation or flutter.

Inotropic Medications

Dobutamine: Positive inotrope, strong β1 effect (increases contractility and heart rate), mild β2 effect (decreases vascular resistance), minimal α1 effect (decreases preload and afterload).
Epinephrine: Strong β1 effect (increases contractility and heart rate, cardiac output), alpha-agonist effect at higher doses (increases SVR).
Norepinephrine (Levo): Increases SVR, contractility, heart rate, strong α and β adrenergic effects.
Milrinone: Phosphodiesterase inhibitor, decreases SVR, modest inotropic effect.
Phenylephrine: Pure α agonist, increases SVR, no direct cardiac effect.

Anti-Hypertensive Medications

Nitroglycerin: Vasodilator, decreases preload, filling pressure, SV, and CO. Dilates coronary conductance vessels and improves blood flow to ischemic zones. At higher doses, it acts as an arterial vasodilator.

Aortic Diseases

Aneurysmal Disease: Dilation of an artery >1.5x its normal diameter. Most common in the abdominal aorta, thoracic aorta, cerebral vessels, iliac, popliteal, and femoral arteries.
Law of Laplace: Tension (T) = Pressure (P) x Radius (r).
Classification of Aneurysms:
- Shape: Fusiform, saccular.
- Wall Constituents: True aneurysm, pseudoaneurysm.
- Etiology: Dissecting aneurysm, mycotic, traumatic.

Abdominal Aortic Aneurysm (AAA)

Etiology: Degenerative, atherosclerosis, progressive loss of elastin, metalloprotease activity.
Incidence: Higher in individuals over 50 years old, males are more affected than females (5:1).
Risk Factors: Advanced age, male sex, white ethnicity, family history, smoking, hypertension, hypercholesterolemia, peripheral vascular occlusive disease (PVOD), coronary artery disease (CAD).
Signs and Symptoms: Often asymptomatic. Nausea and vomiting, pulsatile abdominal mass, abdominal/low-back pain, hypotension.
Growth Rate: Average of 0.4 cm/year.
Diagnosis: Ultrasound (UTZ), CT scan with contrast, MRI, magnetic resonance angiography (MRA), angiography.
Endovascular Treatment:
- Operative mortality rate of 9%.
- Stroke rate of 7%.
- Paraplegia/paraparesis rate of 3%.
- Endoleak rate of 20-25%.
- Other complications: Stent-graft misdeployment, device migration, endograft kinking.

Peripheral Arterial Occlusive Disease

Lower Extremity Acute Ischemia/Acute Limb Ischemia (ALI): The heart is the most common source of distal emboli (70%).
Atrial Thrombus from Atrial Fibrillation (AF): Most common cause of emboli.
Mural Thrombus from Left Ventricular (LV) Aneurysm: Most common cause of saddle embolus.
Clinical Manifestations (6 Ps): Pain, pallor, paresthesia, paralysis, pulselessness, poikilothermia (perishing cold).
Location of Embolus Lodgment: Common femoral artery is the most frequent site.
Treatment:
- Medical: Anticoagulation with heparin.
- Lysis: Urokinase, recombinant tissue plasminogen activator (rtPA).
- Surgery: Embolism removal (embolectomy), thrombectomy.

TransAtlantic Inter-Society Consensus (TASC) Classification

Category I: Viable, not immediately threatened.
Category II: Threatened.
- Marginally Threatened: Salvageable with prompt treatment.
- Immediately Threatened: Salvageable with immediate revascularization.
Category III: Irreversible, major tissue loss or permanent nerve damage.

Complications of Revascularization

Reperfusion Syndrome: Hypotension, hyperkalemia, myoglobinuria, renal failure.
Compartment Syndrome
Ischemic Neuropathy
Muscle Necrosis
Recurrent Thrombosis:
- Recurrent embolization
- Inadequate thrombus removal
- Arterial injury from thrombectomy catheter
- Failure to treat critical lesion-causing thrombosis
- Extensive muscle edema preventing distal flow
- Underlying hypercoagulable state
- Technical problem with bypass graft or arteriotomy closure.

Fontaine/Rutherford Classification

A classification system used to evaluate the severity of peripheral arterial disease.

Ankle-Brachial Index (ABI)

Sensitivity: 95%
Specificity: 99%
Normal ABI: 0.9-1.0
Mild: 0.8-0.89
Moderate: 0.5-0.79
Severe: 0-0.49
Pressure Drop: A 30 mmHg drop between two adjacent levels identifies the site of the most proximal occlusion.
Rest Pain: Associated with toe pressure of 30 mmHg.

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Description

This quiz covers the Canadian Cardiovascular Society (CCS) classification of angina, detailing the four classes and their implications for physical activity. Additionally, it includes important diagnostic tools such as chest X-ray, ECG, and echocardiography used in evaluating heart health. Test your knowledge and understanding of these critical cardiovascular concepts.