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Questions and Answers
What does afterload refer to in relation to heart function?
What does afterload refer to in relation to heart function?
Which of the following is NOT a general measure for treating unstable angina?
Which of the following is NOT a general measure for treating unstable angina?
What is one benefit of a regular exercise program for individuals with unstable angina?
What is one benefit of a regular exercise program for individuals with unstable angina?
Which medication is commonly used in the medical treatment of unstable angina?
Which medication is commonly used in the medical treatment of unstable angina?
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When is coronary revascularization indicated?
When is coronary revascularization indicated?
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Which of the following anti-angina drugs is a potassium channel activator?
Which of the following anti-angina drugs is a potassium channel activator?
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What is the recommended maximum heart rate during an exercise program for individuals with unstable angina?
What is the recommended maximum heart rate during an exercise program for individuals with unstable angina?
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What should be done if angina pain is not relieved after taking 2-3 nitroglycerine tablets?
What should be done if angina pain is not relieved after taking 2-3 nitroglycerine tablets?
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Which condition typically indicates the need for coronary arteriography?
Which condition typically indicates the need for coronary arteriography?
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What is one of the key benefits of an exercise ECG?
What is one of the key benefits of an exercise ECG?
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Which principle of treatment focuses on improving coronary blood flow?
Which principle of treatment focuses on improving coronary blood flow?
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What does ST segment depression on an exercise ECG indicate?
What does ST segment depression on an exercise ECG indicate?
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Which term describes the volume of blood returning to the heart and stretching the ventricles?
Which term describes the volume of blood returning to the heart and stretching the ventricles?
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What condition is diagnosed using ambulatory ECG?
What condition is diagnosed using ambulatory ECG?
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Afterload can be defined as:
Afterload can be defined as:
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Which type of arrhythmia may be revealed during an exercise ECG?
Which type of arrhythmia may be revealed during an exercise ECG?
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What should be the primary approach to treat unusually high oxygen demand from the myocardium?
What should be the primary approach to treat unusually high oxygen demand from the myocardium?
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What does a cold spot or filling defect in a radionuclide study primarily indicate?
What does a cold spot or filling defect in a radionuclide study primarily indicate?
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Which of the following best describes unstable angina?
Which of the following best describes unstable angina?
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What is a common characteristic of variant angina?
What is a common characteristic of variant angina?
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Which symptom is commonly associated with stable angina?
Which symptom is commonly associated with stable angina?
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What characterizes unstable angina compared to stable angina?
What characterizes unstable angina compared to stable angina?
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Which benefit is most associated with a structured exercise program for patients with coronary microvascular disease?
Which benefit is most associated with a structured exercise program for patients with coronary microvascular disease?
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What is one key benefit of a well-planned exercise program for individuals with stable angina?
What is one key benefit of a well-planned exercise program for individuals with stable angina?
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What is a primary treatment principle for managing unstable angina?
What is a primary treatment principle for managing unstable angina?
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Which of the following is NOT typically a treatment principle for managing unstable angina?
Which of the following is NOT typically a treatment principle for managing unstable angina?
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Which of the following is a commonly recommended medical treatment option for controlling angina symptoms?
Which of the following is a commonly recommended medical treatment option for controlling angina symptoms?
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In patients with silent ischemia, which factor is most often related to the condition?
In patients with silent ischemia, which factor is most often related to the condition?
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Which symptom is NOT typically associated with refractory angina?
Which symptom is NOT typically associated with refractory angina?
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What is the main physiological change that occurs during myocardial ischemia leading to angina?
What is the main physiological change that occurs during myocardial ischemia leading to angina?
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Which type of angina is characterized by pain due to coronary artery spasm rather than blockage?
Which type of angina is characterized by pain due to coronary artery spasm rather than blockage?
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How does angina pectoris typically present in patients?
How does angina pectoris typically present in patients?
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Which of the following is NOT a recognized clinical type of angina?
Which of the following is NOT a recognized clinical type of angina?
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Which of the following is NOT a modifiable risk factor for ischemic heart disease?
Which of the following is NOT a modifiable risk factor for ischemic heart disease?
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What characterizes obstructive coronary artery disease?
What characterizes obstructive coronary artery disease?
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Which type of ischemic heart disease is identified when the large arteries are not blocked more than 50 percent?
Which type of ischemic heart disease is identified when the large arteries are not blocked more than 50 percent?
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What is a potential effect of psychological tension in relation to heart disease?
What is a potential effect of psychological tension in relation to heart disease?
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Which of the following is a feature of coronary microvascular disease?
Which of the following is a feature of coronary microvascular disease?
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What is a benefit of an exercise program for individuals with ischemic heart disease?
What is a benefit of an exercise program for individuals with ischemic heart disease?
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Which option is a principle treatment method for managing unstable angina?
Which option is a principle treatment method for managing unstable angina?
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What is a common side effect associated with lifestyle modifications for heart disease management?
What is a common side effect associated with lifestyle modifications for heart disease management?
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Which of the following medications is typically used in the management of ischemic heart disease?
Which of the following medications is typically used in the management of ischemic heart disease?
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Study Notes
Afterload
- The resistance the heart must overcome to open the aortic valve and push blood into circulation
- Is represented by the knot at the end of a balloon analogy: the balloon must work against the knot to get the air out
Treatments for Ischemic Heart Disease
- General measures (risk factor modification):
- Avoid conditions that cause angina: severe exertion & emotional stress
- Control risk factors of atherosclerosis: smoking, obesity, hypertension, hyperlipidemia
- Control aggravating factors of myocardial ischemia: anemia, hypoxia, thyrotoxicosis
- Exercise Program
- Benefits: reduces heart rate and blood pressure especially with stress, improves skeletal muscle action leading to increased effort tolerance, may increase collateral coronary blood flow, decreases platelet aggregation, and increases fibrinolytic activity
- Precautions: exercise should be regular, gradual, and dynamic (e.g. walking 30 minutes, 3 days a week), stopped before producing pain or tachycardia more than 110-120/min
- Medical Treatment (Anti-angina drugs)
- Nitrates
- Beta-blockers
- Calcium Channel Blockers
- Anticoagulants: anti-platelets, heparin
- Potassium channel activators
- Coronary Revascularization
- Indications: improvement of survival in patients with disease of the left main coronary, left anterior descending, or three-vessel disease (post-infarction ischemia), intractable angina not responding to medical treatment
- Procedures: Percutaneous Coronary intervention (PCI) which includes Percutaneous Transmural Coronary Angioplasty (PTCA), Coronary stenting; surgery: Coronary Artery Bypass Graft (CABG) using internal mammary artery or saphenous vein graft
- Treatment of Angina Attack
- Complete rest
- Nitroglycerine 0.5 mg or isosorbide dinitrate 5 mg sublingually
- If pain is not relieved after 2-3 tablets, the patient should be immediately transferred to the hospital and evaluated for the possibility of myocardial infarction
Investigations for Ischemic Heart Disease
- Electrocardiogram (ECG):
- Resting ECG: usually normal between attacks, may show evidence of ischemia during pain (ST segment changes: depression [horizontal or downsloping] or elevation in variant angina, T wave changes: inverted, flat, or peaked, different types of arrhythmias)
- Exercise ECG: may show evidence of ischemia during exercise (ST segment depression [horizontal or downsloping], ventricular arrhythmias, typical angina chest pain during test)
- Ambulatory ECG: for the diagnosis of variant angina
- Echocardiography: may show regional wall motion abnormalities dyskinesia or akinesia during rest or induced by exercise
- Radionuclide Study: usingThallium 201 or Technitium 99m. Ischemia appears as a filling defect (cold spot) induced by exercise or dobutamine & test disappear after rest
- Coronary Arteriography:
- Indications: intractable angina not responding to medical treatment, indicated when non-invasive tests have failed to establish the cause of atypical chest pain, unstable angina, post-infarction angina, recurrent chest pain of unknown origin in which all other investigations are normal, now it is performed in all patients who are candidates for coronary revascularization
- Benefits: provides detailed information about the number, site, and severity of obstructive lesions
Principles of Treatment for Ischemic Heart Disease
- Increase oxygen supply or reduce oxygen demand of the myocardium
- Reduce heart rate
- Reduce preload
- Reduce afterload
- Improve coronary blood flow
Cardiac Output (COP)
- The amount of blood pumped by the ventricle with each beat
- COP = Heart Rate x Stroke Volume
Stroke Volume
- The amount of blood pumped by the ventricle with each beat
- Affected by:
- Contractility strength of cardiac muscle
- Preload
- Afterload
Preload
- Volume of blood received by the heart
- Basically, preload is stretch. The amount of the volume being returned to the heart
- Preload is the end diastolic volume that stretches the right or left ventricle of the heart to its greatest dimensions under variable physiologic demand (the amount of ventricular stretch at the end of diastole)
- Analogy: a balloon stretches when you blow air into it (the more air you blow in, the greater the stretch)
- Factors that increase preload:
- Increased venous return
- Hypervolemia
- Decreased heart rate
- Increased ventricular compliance
- Factors that decrease preload:
- Decreased venous return
- Hypovolemia
- Increased heart rate
- Decreased ventricular compliance
Afterload
- Pressure/resistance the heart has to overcome to eject blood
- Basically, afterload is squeeze. The amount of resistance that the heart has to overcome in order to eject blood
- The pressure the heart must work against to eject blood during systole (ventricular contraction)
- Systemic vascular resistance
- Factors that increase afterload:
- Hypertension
- Aortic stenosis
- Increased systemic vascular resistance
- Factors that decrease afterload:
- Vasodilation
- Decreased systemic vascular resistance
Coronary Microvascular Disease
- Affects the heart's smallest arteries
- Can happen alone, with obstructive or non-obstructive coronary artery disease, or other heart diseases
- Occurs when molecular changes in the microvascular system of the heart prevent normal blood flow through the small arteries
Clinical Types of Ischemic Heart Disease
-
Angina:
- Stable angina (angina pectoris)
- Unstable angina
- Variant angina (Prinzmetal angina)
- Intractable angina (refractory angina) - severe
- Silent ischemia - in diabetes mellitus
- Myocardial infarction (MI)
Presentation of Ischemic Heart Disease
-
Asymptomatic:
- Silent myocardial ischemia
-
Symptomatic:
- Chest pain:
-
Other presentations (with or without chest pain):
- Heart failure
- Arrhythmias
- Syncope
- Sudden death
What is Angina?
- Chest pain that occurs due to transient inadequacy of blood and oxygen supply to the myocardium (myocardial ischemia) that leads to an imbalance between oxygen demand and oxygen supply
- Angina pectoris is chest pain or discomfort that occurs when the heart muscle does not get enough blood
- Angina pectoris is chest pain resulting from myocardial ischemia (inadequate blood supply) to the myocardium
Pathogenesis of Angina Pain
- Myocardial ischemia develops when coronary blood flow becomes inadequate to meet myocardial oxygen demand
How?
- Deprives myocardial tissues of oxygen and nutrients for aerobic metabolism
- Results in inclusion of anaerobic metabolism which leads to accumulation of metabolites (e.g. lactate, pyruvate) in cardiac muscle
- Metabolites stimulate myocardial nerve endings (nerve fibers) which discharge impulses along sympathetic fibers to upper thoracic segments of the spinal cord resulting in pain
- Leads to cardiac chest pain of angina pectoris
Clinical Types of Angina
-
Stable Angina (Angina Pectoris = Classic Angina)
- Characterized by classic anginal chest pain (mentioned before):
- Retrosternal constricting discomfort radiating to left arm, neck, jaw
- Provoked by physical exertion, especially after meals and in cold, windy weather or by anger or excitement
- Relieved (usually within minutes) with rest or sublingual nitroglycerin
- Typical Angina: all three features
- Atypical Angina: two out of the three
- Non Anginal Chest Pain: one or less of these features
- Characterized by classic anginal chest pain (mentioned before):
-
Unstable Angina (Preinfarction = Crescendo):
- Caused by an almost complete blockage of the coronary arteries
- Deterioration (24 hours) in previous stable angina
- Symptoms frequently occurring at rest
- Symptoms of acute coronary syndrome
- Unstable angina is a form of acute coronary syndrome and is defined as angina pectoris that changes or worsens
- Increased episodes in frequency and severity
- Usually lasts longer than classic angina (usually lasting more than 10 minutes)
- Chest pain occurring at rest
- Angina with an increase in duration, frequency, or severity of pain
-
Variant Angina (Prinzmetal Angina = Vasospastic Angina):
- Occurs without provocation, usually at rest, as a result of coronary artery spasm
- Angina at rest not precipitated by increased myocardial oxygen demand (i.e. not after exercise or stress)
- Most probably due to coronary spasm
- Usually associated with ST segment elevation
- Coronary angiography may be normal
Risk Factors for Ischemic Heart Disease
-
Non-modifiable risk factors
- Positive family history of CAD
- Old age
- Gender (men develop CAD at an earlier age than women)
-
Modifiable risk factors
- Cigarette smoking, tobacco use
- Hypertension
- Diabetes mellitus
- Obesity
- Sedentary life style
- Physical inactivity
- Hyperlipidemia
-
Contributing risk factors
- Psychological tension (stress, anxiety, depression)
- Menopause
- Oral contraceptive pills
- Type A personality: time urgency, aggression behavior, impatience, frustrations
Classification (Types) of Ischemic Heart Disease
-
Pathological Types of Ischemic Heart Disease:
- Three main types:
- Obstructive coronary artery disease
- Non-obstructive coronary artery disease
- Coronary microvascular disease
- Three main types:
-
Clinical Types of Ischemic Heart Disease:
- Angina
- Myocardial infarction
Pathological Types of Ischemic Heart Disease
-
Obstructive Coronary Artery Disease
- Occurs when plaque builds up in the large arteries, causing them to narrow gradually
- Reduces the supply of oxygen-rich blood to the heart
- Obstructive coronary artery disease means the heart’s arteries are more than 50 percent blocked
- Blood flow may eventually be completely blocked in one or more of the three large coronary arteries
-
Non-Obstructive Coronary Artery Disease:
- Large arteries are narrowed by plaque, but not as much as they are in obstructive disease
- Diagnosed if imaging studies show less than 50 percent obstruction of the heart’s large arteries caused by plaque buildup
- Can be caused by disease or injury to the lining of the large arteries, affecting the arteries’ ability to expand in response to physical, chemical, or electrical signals that normally would stimulate more blood flow to the heart
-
Coronary Microvascular Disease:
- Affects the tiny arteries in the heart muscle
- May occur with or without coronary artery disease
Chest Pain of Stable Angina (Angina Pectoris)
- Site: Retrosternal, precordial, or central chest pain
- Radiation: Left shoulder, medial aspect of left forearm & hand, neck, lower jaw, epigastrium, right shoulder, and back
- Character: Compressing, constricting, or in the form of discomfort, tightness, heaviness
- Precipitation: Muscular exercise, emotional stress, heavy meal, cold atmosphere or high altitudes, excessive smoking, sexual intercourse
- Relief: By rest, sublingual nitrates
- Duration: Typically lasting 5-10 minutes
- Associated symptoms: Dyspnea, palpitation, sense of fear of death (angor animi), sweating, dizziness & fainting, nausea & vomiting
Angina Pectoris (Stable Angina)
- Most common type
-
Characterized by classical anginal chest pain:
- Retrosternal constricting discomfort radiating to left arm, neck, jaw.
- Provoked by physical exertion, especially after meals, and in cold, windy weather or by anger or excitement
- Relieved (usually within minutes) with rest or sublingual nitroglycerin
- Typical Angina: All three features
- Atypical Angina: Two out of the three
- Non Anginal Chest Pain: One or less of these features
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Description
This quiz focuses on understanding afterload, a critical concept related to heart function, and the various treatments for ischemic heart disease. It emphasizes risk factor modification, exercise benefits, and precautions necessary for effective management. Test your knowledge on how these factors interact to improve heart health.
