Questions and Answers
What characterizes ischemic heart disease?
Which arteries are primarily responsible for regulating blood flow in the coronary circulation?
What is the main factor stimulating vasomotion in epicardial arteries?
What is the primary function of capillaries in the coronary circulation?
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Which of the following correctly describes a component of the supply side in the context of coronary circulation?
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What stage of atherosclerosis is characterized by the presence of lipids and foam cells?
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Which of the following features is associated with calcified plaques in atherosclerosis?
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What is a primary characteristic of the healthy stage in the process of atherosclerosis?
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In the context of atherosclerosis progression, what does the fibrofatty plaque stage involve?
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Which part of the heart is the least perfused and has a greater tendency for ischemia?
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What type of myocardial condition is often caused by repeated ischemic attacks?
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Which leads represent the inferior wall of the heart?
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Which artery supplies the anterior wall of the heart?
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Which leads are associated with the lateral wall of the heart?
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What is the typical duration of an angina episode?
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Which Canadian Cardiovascular Society functional class allows for ordinary physical activity without causing angina?
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In which Canadian Cardiovascular Society functional class is there marked limitation of ordinary physical activity?
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What feeling do patients typically describe during an angina episode?
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What is the typical age of a woman experiencing stable angina?
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Which of the following statements is true regarding angina episodes?
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What is the typical duration of unstable angina?
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Which sign is commonly associated with unstable angina?
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How does myocardial ischemic discomfort typically present in terms of radiation?
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Which of the following is a known risk factor for premature ischemic heart disease?
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Identifying lifestyle factors, which is a contributor to premature ischemic heart disease?
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Which condition is associated with increased risk of premature ischemic heart disease?
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What demographic factor may contribute to the risk of premature ischemic heart disease?
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Which laboratory test is performed to assess microalbuminuria?
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What is the purpose of a stress test in diagnostics for ischemic heart disease?
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Which class of medications is primarily used for treating angina?
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What is the primary monitoring method during a stress test for ischemic heart disease?
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Which of the following is NOT a common component of the lipid profile test?
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How is chest pain characterized according to its onset?
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What types of pain qualities might indicate a serious condition?
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Which areas can the radiation of chest pain typically affect?
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What is the significance of timing for chest pain in a clinical assessment?
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What does the term 'precipitating factors' refer to in a clinical context?
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What is the relationship between estrogen hormone and cardiac disease risks in women?
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Which symptom is NOT typically associated with the Review of Systems in this context?
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When does the incidence of ischemic heart disease equalize between genders?
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What condition is characterized by a murmur of Mitral Regurgitation?
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Which feature indicates a high risk for ischemic heart disease?
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What does low exercise capacity at low workload suggest?
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How is ejection fraction (EF) related to ischemic heart disease risk?
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Which of the following is a high-risk feature of ischemic heart disease?
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What high-risk feature is associated with ischemic heart disease apart from low exercise capacity?
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Study Notes
Overview of Ischemic Heart Disease (IHD)
- IHD is characterized by insufficient blood and oxygen supply to a segment of the myocardium.
- The condition arises from a mismatch between myocardial oxygen supply and demand.
Coronary Arteries Classification
-
Epicardial Arteries
- Primary site of blood flow regulation; flow serves as the main stimulus for vasomotion.
- Exhibits minimal resistance in the absence of atherosclerosis.
-
Small Arteries & Arterioles
- Major site of pressure and resistance within coronary arteries.
- Accounts for significant resistance affecting blood flow to the heart.
-
Arterioles
- Responsible for fine-tuning blood flow through metabolic autoregulation.
- Influences of humoral factors and neural control play critical roles in flow regulation.
-
Capillaries
- Sites for the exchange of essential nutrients, oxygen, and carbon dioxide between blood and myocardial tissue.
Ischemic Heart Disease (IHD)
- Characterized by inadequate blood and oxygen supply to myocardium.
- Results from an imbalance between myocardial oxygen supply and demand.
Coronary Arteries Classification
-
Epicardial Arteries
- Primary flow determinant for vasomotion is blood flow.
- Typically exhibit the least resistance in the absence of atherosclerosis.
-
Small Arteries & Arterioles
- Sites of greatest vascular resistance and pressure within coronary circulation.
- Blood flow regulation achieved through metabolic autoregulation, humoral factors, and neural control.
-
Capillaries
- Function: Exchange of nutrients, carbon dioxide, and oxygen between blood and myocardium.
Demand Factors for Cardiac Function
- Heart Rate: Increases in heart rate elevate myocardial oxygen demand due to enhanced cardiac output.
- Contractility: The strength of cardiac muscle contractions directly affects the amount of oxygen the heart requires to function efficiently.
- Systolic Wall Tension: Influenced by ventricular pressure and chamber radius, thicker heart walls increase tension and subsequently raise demand for oxygen.
Supply Factors for Cardiac Function
- Oxygen Carrying Capacity of the Blood: Hemoglobin levels determine the blood's ability to transport oxygen to tissues, influencing overall oxygen supply to the heart.
- Coronary Blood Flow: Blood flow through the coronary arteries is crucial for delivering necessary oxygen and nutrients to myocardial tissues.
- Vascular Resistance: Resistance in the vascular system can limit blood flow; lower resistance improves oxygen delivery to cardiac tissues.
Stages of Atherosclerosis
- Healthy Stage: Characterized by a patent lumen (clear and unobstructed), allowing for unrestricted blood flow.
- Fatty Streak Stage: Develops with the accumulation of lipids and foam cells, signaling the early formation of atherosclerotic changes.
- Fibrofatty Plaque Stage: Involves the formation of a fibrous cap, containing a core of lipids and proliferated smooth muscle cells, contributing to vessel narrowing.
- Calcified Plaques Stage: Advanced atherosclerosis where thrombus formation and calcification occur, further obstructing blood vessels and increasing the risk of cardiovascular events.
Prolonged Ischemia
- Leads to decreased perfusion in the subendocardial region of the heart.
- Subendocardium is the least perfused area, making it more susceptible to ischemia compared to the subepicardial layer.
Effects of Repeated Ischemic Attacks
- Micro infarction or myocardial fibrosis can occur due to recurring ischemic events.
- These conditions are indicative of underlying heart damage.
Wall Representations in ECG
-
Inferior Wall:
- Manifested through leads II, III, and aVF.
- Supplied by the right coronary artery.
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Anterior Wall:
- Represented by precordial leads V1 to V4.
- Supplied by the left anterior descending (LAD) artery.
-
Lateral Wall:
- Shown in leads I, aVL, V5, and V6.
- Supplied by the left circumflex artery.
Chronic Coronary Syndrome (Stable Angina)
- Manifestation of Ischemic Heart Disease (IHD).
- Commonly affects men over 50 years and women over 60 years.
- Patients typically report episodes of chest discomfort characterized as heaviness, pressure, squeezing, smothering, or choking, but rarely as acute pain.
- Anginal episodes usually follow a crescendodecrescendo pattern, lasting between 2 to 5 minutes.
Canadian Cardiovascular Society Functional Classification
-
CCS I:
- No angina with ordinary physical activity.
-
CCS II:
- Slight limitation during ordinary activities.
- Angina may occur with rapid walking, walking uphill, after meals, in cold weather, during emotional stress, or shortly after awakening.
- More than two blocks on level ground or climbing over one flight of stairs causes angina under normal conditions.
-
CCS III:
- Marked limitations in ordinary physical activity.
- Angina occurs when walking one to two blocks on level ground or climbing more than one flight of stairs under normal conditions.
-
CCS IV:
- Inability to engage in any physical activity without discomfort.
- Anginal symptoms may be present even at rest.
Acute Coronary Syndrome
- Unstable angina lasts approximately 15-20 minutes.
- Characterized by intermittent chest pain due to insufficient blood flow to the heart.
Levine’s Sign
- A clenched fist is used to indicate central substernal discomfort, related to angina pectoris.
- This sign helps patients communicate the nature of their chest pain effectively.
Myocardial Ischemic Discomfort
- Discomfort associated with myocardial ischemia does not radiate to the trapezius muscles.
- Radiating pain to the trapezius is often more indicative of pericarditis, distinguishing it from angina.
Risk Factors for Premature Ischemic Heart Disease (IHD)
- Understanding risk factors is crucial for prevention strategies.
- Common risk factors include hypertension, high cholesterol, smoking, diabetes, sedentary lifestyle, and obesity.
- Family history and age also play significant roles in susceptibility to IHD.
Ischemic Heart Disease (IHD)
- Characterized by inadequate blood and oxygen supply to the myocardium, often due to supply-demand imbalance.
- Coronary arteries are classified into different types based on their function and location:
- Epicardial Arteries: Main stimulus for vasomotion is blood flow; least resistance in the absence of atherosclerosis.
- Small Arteries & Arterioles: High resistance, plays a key role in regulating blood flow via metabolic autoregulation, humoral factors, and neural control.
- Capillaries: Site of nutrient, carbon dioxide, and oxygen exchange.
- Myocardial oxygen demand factors:
- Heart rate
- Contractility of the heart
- Systolic wall tension (thickness)
- Myocardial oxygen supply factors:
- Oxygen-carrying capacity of the blood
- Coronary blood flow
- Vascular resistance
Stages of Atherosclerosis
- Healthy Stage: Patent lumen of arteries.
- Fatty Streak: Presence of lipids and foam cells in arterial walls.
- Fibrofatty Plaque: Characterized by a lipid core and smooth muscle cells.
- Calcified Plaques: Development of thrombus and calcification.
- Prolonged Ischemia: Results in decreased perfusion in the subendocardial region, which is the least perfused part of the heart and more susceptible to ischemia compared to the subepicardial layer.
- Micro Infarction/Myocardial Fibrosis: Caused by repeated ischemic attacks.
Wall Supply in Ischemic Events
- Inferior Wall: Leads II, III, aVF; supplied by right coronary artery.
- Anterior Wall: Precordial leads V1 to V4; supplied by left anterior descending (LAD) artery.
- Lateral Wall: Represented by I, aVL, V5, and V6; supplied by left circumflex artery.
Chronic Coronary Syndrome (Stable Angina)
- Manifests as episodes of chest discomfort, desribed as heaviness, pressure, or squeezing, typically lasting 2-5 minutes.
- Commonly affects men over 50 and women over 60 years old.
- Angina often has a crescendo-decrescendo pattern.
Canadian Cardiovascular Society Functional Classification
- CCS I: No angina with ordinary activities.
- CCS II: Slight limitation during vigorous activities; may induce angina under stress or temperature changes.
- CCS III: Marked limitation; angina occurs with light activities, like walking short distances.
- CCS IV: Angina may be present at rest; inability to perform physical activities without discomfort.
Acute Coronary Syndrome
- Includes unstable angina, which lasts 15-20 minutes.
- Levine’s Sign: Clenched fist indicates central substernal discomfort.
- Myocardial ischemic discomfort generally does not radiate to the trapezius, distinguishing it from pericarditis.
Risk Factors for Premature IHD
- Various risk factors lead to the early onset of ischemic heart disease, highlighting the importance of early detection and management.
Physical Examination
- Typically normal in Ischemic Heart Disease (IHD).
- Important to search for atherosclerotic disease indicators at other locations, such as:
- Xanthelasmas: yellowish cholesterol deposits around the eyelids.
- Xanthomas: fatty growths that can develop under the skin.
Laboratory Tests
-
Urine Tests:
- Evaluate for Diabetes Mellitus (DM) and renal disease via microalbuminuria.
-
Blood Tests:
- Lipid Profile: measures LDL (bad cholesterol), HDL (good cholesterol), and triglycerides.
- Glucose levels to assess blood sugar.
- HbA1c: indicates average blood glucose over the past 2-3 months.
- Creatinine (CREA) for kidney function assessment.
- Hematocrit (Hct) levels to check blood volume.
- Thyroid function tests to rule out thyroid issues.
- C-reactive protein (CRP) to assess inflammation.
- Chest X-ray for imaging of the heart and lungs.
Diagnostics
-
Stress Test:
- Conducted before a Coronary Angiogram to evaluate heart function under stress.
- Patient undergoes monitoring for blood pressure and ECG changes during the test.
- Test involves walking rapidly with increasing speed and incline.
-
Bruce Protocol:
- Commonly used protocol for conducting the stress test to evaluate exercise capacity and cardiovascular response.
Drug Therapy for Angina
- Medications include:
- Nitrates: to relieve angina and dilate blood vessels.
- Beta-blockers: to reduce heart rate and workload on the heart.
- Calcium Channel Blockers: to relax blood vessels and decrease heart workload.
- Ivabradine: targets specific ion channels to lower heart rate.
- Renolazin: improves blood flow to the heart muscles by reducing metabolic demands.
Clinical Case Overview
- Symptoms onset classified as acute if recent or chronic if present for 3-6 months or longer.
- Identify precipitating factors; assess activities at the onset of chest pain for context.
Chest Pain Classification
- Utilize CCS (Canadian Cardiovascular Society) Classification to categorize chest pain severity.
- Pain quality can vary; examples include sharp, stabbing, squeezing, or substernal pain.
Pain Characteristics
- Radiation of pain typically includes:
- Shoulders and arms (one or both)
- Mandible
- Not associated with trapezius or below the umbilicus.
Severity and Timing
- Severity of chest pain may align with the CCS classification level.
- Timing of pain can be critical for diagnosis:
- Determine if pain occurs at rest or during physical activity.
Clinical Case Overview
- Importance of social and environmental history in clinical assessment, including occupation and lifestyle factors such as diet and exercise.
- Estrogen hormone plays a protective role against cardiac disease in females, reducing the incidence of ischemic heart disease (IHD) prior to menopause.
- Risk of IHD in females and males equalizes after menopause, highlighting the hormonal influence on cardiovascular health.
Physical Examination Findings
- Generally normal physical examination results unless there are signs of target organ damage.
- Potential signs of damage include:
- Cardiomegaly: enlargement of the heart.
- Murmur of Mitral Regurgitation: indicative of heart valve issues.
Review of Systems
- Visual Symptoms: Possible reports of blurry vision, warranting further investigation.
- Thyroid Function: Inquiry into symptoms of hypo- or hyperthyroidism, affecting metabolic processes.
- Respiratory Symptoms: Difficulty breathing may indicate underlying pulmonary issues or heart failure.
- Urinary Function: Decreased urine output can signal renal impairment or fluid balance problems.
-
Vascular Health:
- Peripheral Arterial Disease (PAD) may present with symptoms affecting circulation.
- Aneurysm presence requires urgent assessment for possible vascular rupture.
- Gastrointestinal Symptoms: Abdominal pain necessitates exploration of digestive or organ-related issues.
- Claudication Symptoms: Intermittent claudication indicates compromised blood flow, particularly during exertion.
Clinical Case Overview
- Social and environmental history includes occupation and lifestyle factors like diet and exercise.
- In females, estrogen provides cardiovascular protection; risk of ischemic heart disease (IHD) increases post-menopause.
- Physical examination can be normal or reveal target organ damage such as cardiomegaly or mitral regurgitation.
Review of Systems
- Symptoms may include blurry vision, thyroid dysfunction, breathing difficulties, decreased urine output, peripheral arterial disease, aneurysms, abdominal pain, and intermittent claudication.
- Important high-risk features for IHD are low exercise capacity or ischemia at low workload and large ischemic myocardium.
Ischemic Heart Disease (IHD)
- IHD is characterized by inadequate blood supply and oxygen to the myocardium due to supply-demand imbalance.
- Coronary arteries categorized as:
- Epicardial Arteries: Minimal resistance in absence of atherosclerosis.
- Small Arteries & Arterioles: High pressure and resistance regions.
- Arterioles: Regulate blood flow via metabolic autoregulation and neural control.
- Capillaries: Responsible for nutrient and gas exchange.
Demand and Supply Factors
- Demand for myocardial oxygen increases with heart rate, contractility, and wall tension.
- Supply is influenced by blood oxygen capacity, coronary blood flow, and vascular resistance.
Stages of Atherosclerosis
- Healthy: Patent lumen of arteries.
- Fatty Streak: Accumulation of lipids and foam cells.
- Fibrofatty Plaque: Development of a core surrounded by smooth muscle cells.
- Calcified Plaques: Formation includes thrombus and calcification.
- Prolonged ischemia leads to decreased perfusion of the subendocardium, susceptible to ischemia.
Ischemic Manifestations
- Micro infarctions and myocardial fibrosis occur from repeated ischemic episodes.
- Inferior wall ischemia typically seen in leads II, III, and aVF, supplied by the right coronary artery.
- Anterior wall ischemia reflected in leads V1 to V4, supplied by the LAD artery.
- Lateral wall ischemia indicated by leads I, aVL, and V5 to V6, supplied by the left circumflex artery.
Chronic Coronary Syndrome
- Known as stable angina, typical presentation involves chest discomfort, often described as heaviness or pressure.
- Anginal episodes tend to behave in a crescendodecrescendo pattern, lasting 2-5 minutes.
Canadian Cardiovascular Society Functional Classification
- CCS I: No angina with normal activity.
- CCS II: Slight limitation; angina with vigorous activities or emotional stress.
- CCS III: Marked limitation; angina with standard activities.
- CCS IV: Angina at rest or inability to perform any physical activity without discomfort.
Acute Coronary Syndrome
- Unstable angina characterized by prolonged discomfort lasting 15-20 minutes.
- Levine’s sign is a clenched fist indicating central chest discomfort.
- Myocardial ischemic discomfort typically does not radiate to trapezius muscles, unlike pericarditis.
Risk Factors for Premature IHD
- Physical examination may appear normal; look for atherosclerotic disease signs elsewhere (e.g., xanthelasmas).
- Laboratory tests include urine assessments for diabetes and renal disease, and a lipid profile comprising LDL, HDL, triglycerides, glucose levels, and other relevant biomarkers.
- Chest X-ray and diagnostic tests include stress tests and electrocardiograms before coronary angiogram, often using the Bruce protocol.
Drug Therapy for Angina
- Common treatments include nitrates, beta-blockers, calcium channel blockers, ivabradine, and ranolazine.
Clinical Case Details
- Symptom onset can be classified as acute or chronic based on duration.
- Factors precipitating symptoms should be assessed (e.g., activities during onset).
- Quality of pain may vary; common characteristics include sharp, squeezing, or substernal locations.
- Pain radiation typically occurs to shoulders, arms, or jaw, but not trapezius or below the umbilicus.
- Severity and timing of pain (at rest or during activity) are critical in assessment.
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Description
This quiz explores the key concepts of Ischemic Heart Disease (IHD), including its definition, causes, and the classification of coronary arteries. Understand the physiological balance between myocardial oxygen supply and demand and the implications of atherosclerosis on blood flow.
