ALU 201: Intermediate Medical Life Insurance Writing PDF

CORONARY ARTERY DISEASE Introduction CAD dates back to the 1940s and 1950s when total cholesterol and triglycerides were linked to 1 obesity. anticoagulant drugs such as clopidogrel (Plavix®). 1. coronary obstruction Page 387 ALU 201: Intermediate Medical Life Insurance Writing 2. left ventricular f...

CORONARY ARTERY DISEASE Introduction CAD dates back to the 1940s and 1950s when total cholesterol and triglycerides were linked to 1 obesity. anticoagulant drugs such as clopidogrel (Plavix®). 1. coronary obstruction Page 387 ALU 201: Intermediate Medical Life Insurance Writing 2. left ventricular function each stroke. This is measured by ventriculography, echocardiography, or nuclear scan as the 3. presence of ischemia – In addition to a clinical history consistent with angina, there are 4. risk factor analysis prevention) as well as in individuals with known CAD (secondary prevention), to reduce CAD testing in the insurance applicant. The Coronary Circulation Coronary Artery Anatomy 1. Left main artery myocardial damage. 2. Left anterior descending artery that go deep into the muscular septum and to the diagonal arteries that course over the this system could also result in extensive myocardial injury. 3. Page 388 the lateral ventricular wall. The artery can terminate in one or more large obtuse marginal 4. Right coronary artery as the right ventricle. Page 389 ALU 201: Intermediate Medical Life Insurance Writing The pathology of atherosclerosis 1. intima 2. media 3. adventitia. plays an important role in protecting against atherosclerosis. It acts as a selective barrier to prevent plasma lipid accumulation within the vessel wall and has also been shown to prevent blood clot Page 390 The classic atheroma or plaque appears as a rounded, raised lesion, white with a yellow complicated plaque. stable angina. Page 391 ALU 201: Intermediate Medical Life Insurance Writing plaque rupture, resulting in blood clot Page 392 1. to rupture, possibly preventing their progression and inducing their regression thereby 2. acute myocardial ischemia. Myocardial ischemia occurs when myocardial oxygen supply cannot lesions, generally with superimposed thrombosis. 1. heart rate 2. 3. result in myocardial ischemia. At the same time, reversible regional myocardial wall motion imaging (thallium or sestamibi (SPECT)). Page 393 ALU 201: Intermediate Medical Life Insurance Writing syndromes. Stable Angina Pectoris conditions in which myocardial oxygen demand is increased. This occurs in a predictable manner and is usually relieved promptly by rest or sublingual nitroglycerin. When studied angiographically, Class Description III. Angina walking one or two blocks on the level at a normal pace. or nitroglycerin, is presumptive evidence that the chest pain represents typical angina pectoris. coronary artery. or with exercise are utilized. 1. 2. 3. Page 394 Individuals who appear to be at high risk, or who present with symptoms unresponsive to Variant Angina Pectoris (Prinzmetal’s Angina) at rest, usually is not precipitated by physical exertion or emotional stress and is associated with 1. 2. 3. sudden death. Variant angina pectoris has been demonstrated convincingly to be due to coronary artery artery resulting in myocardial ischemia. This reduction in the diameter can usually be reversed by nitroglycerin and can occur in either normal or diseased coronary arteries. Page 395 ALU 201: Intermediate Medical Life Insurance Writing In contrast to the prognosis in individuals with coronary atherosclerosis, the survival in cardiac individuals by special tests. vessels that are not visible angiographically, while the large proximal conductance vessels appear to be normal. Such individuals can have positive exercise stress tests. Silent Myocardial Ischemia occurring in someone with known CAD. While not a new topic, silent ischemia has generated events. 1. Type 1 occurs in individuals who are apparently well and totally asymptomatic. Detection Page 396 2. symptoms, which appears to be prognostically important. 3. silent ischemia are detected. The mortality in individuals with unstable angina and silent 1. 2. 1. 2. crescendo angina and pain at rest occurring in someone with known stable angina 3. Page 397 ALU 201: Intermediate Medical Life Insurance Writing include Prinzmetal’s variant angina and cocaine intoxication. Most individuals with unstable angina have multivessel CAD, similar in severity to those with ulceration or ruptured plaques. Such lesions are rarely seen in people with stable angina pectoris. by direct coronary angioscopy. complications are to develop. angina but are greatly accelerated. The unstable phase is over when the individual’s symptoms have disappeared or become predictable. It is assumed that the active endothelial lesions heal in two to three months, and the individual has entered the stable phase with an improved prognosis. Page 398 hours later. other biomarkers are not. In very early MI presentations, the serum troponin elevation can precede coronary artery dissection and vasospasm Page 399 ALU 201: Intermediate Medical Life Insurance Writing its attendant risk. years. Coronary angiography and other complex manipulations can now be done in a relatively less in younger patients than in older patients. Page 400 survival, despite revascularization. Sudden Cardiac Death who was not expected to die. Most sudden cardiac deaths are due to arrhythmias occurring in arrhythmic events are complex but usually include a triggering acute event, superimposed on an sudden cardiac deaths appear to be arrhythmic. Among arrhythmias, ventricular tachycardia and 1. 2. 3. electrophysiologic testing (EPS). All reversible triggers, such as acute ischemia and electrolyte abnormalities, need to be 1. Page 401 ALU 201: Intermediate Medical Life Insurance Writing 2. 3. Indeed, there is a recent trend toward earlier AICD implantation without EPS testing. This is death. Despite this, therapy with anticoagulants has not yet been shown to have a role in the Page 402 Percutaneous Transluminal Coronary Angioplasty As the equipment has become more sophisticated and operators more experienced, it has become possible to manage more complex, multivessel coronary disease with PTCA. Coronary Stenting increasingly sophisticated coronary artery stents have been developed. These stents are devices procedures. Most studies have shown marked improvement in early restenosis rates with the newer Page 403 ALU 201: Intermediate Medical Life Insurance Writing therapy alone, but does not “cure” CAD, since these individuals can develop progressive disease surgery. in this situation. Page 404 while data to support this therapeutic protocol are only recently being published. known thrombotic disease. severity, body size, and coronary vessel size. In contrast to earlier reports, most recent studies have restenosis, and similar survival rates as males. Page 405 ALU 201: Intermediate Medical Life Insurance Writing CAD in the Elderly is more likely to require cardiac medications and yet are also more likely to experience medication other clinical variables. abdominal aortic aneurysm) are much more likely to have CAD, whether or not it is clinically vascular disease. have supported this conclusion. There are also reports suggesting reduction in cardiac events with be particular risk associated with an elevated pulse pressure (i.e., systolic minus diastolic blood pressure), which may be related to increased arterial shear stress. Isolated systolic hypertension cardiovascular disease events. Page 406 virtually no symptoms. PTCA and coronary stenting in the elderly has a primary success rate comparable to results known CAD. Cardiac Testing and Angiography disease, aortic and valvular heart disease, and cardiomyopathy. Page 407 ALU 201: Intermediate Medical Life Insurance Writing analysis. Exercise Stress Tests walking speed and gradients. The individual starts at low workloads and progresses to higher 4. reaching a “maximal heart rate,” determined individually by age and sex 1. 2. 3. 1. ventricular hypertrophy 2. mitral valve prolapse 3. conduction abnormalities (e.g., bundle branch blocks and WPW syndrome). 1. 2. 3. Page 408 Blood pressure response to exercise Symptoms with exercise (chest pain, leg cramps) Echocardiographic wall motion abnormalities. supplementary radionuclide and echocardiographic/Doppler imaging during testing (Table 2). demonstrate improved imaging characteristics and have replaced thallium as the imaging agents TEST Exercise Pharmacologic Dobutamine 66% 81% 90% 84% 89% 72% 81% 90% 89% 83% 70% 83% Alternatively, echocardiography/doppler studies can be done during exercise and compared 1. 2. In individuals who cannot undergo exercise testing, myocardial ischemia has been diagnostically In reliable laboratories, these pharmacologic stress tests have proven equal in value to standard Page 409 ALU 201: Intermediate Medical Life Insurance Writing Positron Emission Tomography (PET) Computed Axial Tomography (CAT Scanning) Computed tomography (CAT or CT) is now widely used in cardiac diagnosis. The CT scan is cardiac image “slices” per second have eliminated the blurring that occurs with a regular CT scan and the CT angiogram. Coronary Calcium Scanning (EBCT) avoiding the blurring that would occur with normal CT scans. Conventional scanners require about calcium deposits that are associated with plaque and coronary artery disease. CT Angiogram (CTA) time, to reveal coronary artery anatomy non-invasively (i.e., without resorting to arterial catheters Page 410 major advance in cardiac testing, particularly when the coronaries are “clean,” thus excluding the magnet circles around the body, causing the hydrogen nuclei in the body to align with the magnetic cardiac diagnosis, with improved resolution and anatomic clarity leading to rapid expansion in the pacemakers, metallic objects or implants, or certain prosthetics. Coronary Angiography Although noninvasive procedures (such as exercise electrocardiography, radioisotope tests, catheter is passed into the coronary artery and radiographic contrast material is injected into the added importance. Page 411 ALU 201: Intermediate Medical Life Insurance Writing Doppler techniques. Severity of obstruction The location of an obstruction artery. the “myocardium at risk,” should a coronary lesion undergo sudden and total occlusion. This, in turn, is linked to coronary stenosis severity and location. Complicated clinical scoring systems 1. Prognosis in CAD is related in large part to the number bypass. 2. 3. Proximal lesions are associated with greater risk than mid or distal lesions. 4. 5. as well as severity and location. In general, there is less myocardium at risk linked to lesions in these arterial systems. Page 412