1. MTB Step 3 - Ischemic Heart Disease / CAD

Question 1

ISCHEMIC HEART DISEASE (a.k.a. CAD)

What are (2) Epidemiological Facts about CAD in the United States?

Answer 1

1. CAD is the Most Common Cause of Death (by far).
2. CAD Kills 10x’s more Women than Breast Cancer does.

Question 2

ISCHEMIC HEART DISEASE (a.k.a. CAD)

What are (5) Risk Factors for developing CAD?

Answer 2

1. Diabetes Mellitus
2. Hypertension
3. Tobacco use
4. Hyperlipidemia
5. Peripheral Arterial Disease

Question 3

ISCHEMIC HEART DISEASE (a.k.a. CAD)

What (2) Useful Pieces of Information does knowing the CAD Risk Factors provide?

Answer 3

Knowing the CAD Risk Factors provides:

1. Help with answering Diagnostic Questions in Equivocal Cases.
2. Modifying the Risk Factors** can **Lower Mortality.

Question 4

ISCHEMIC HEART DISEASE (a.k.a. CAD)

What are (5) Descriptors of Chest Pain associated with CAD?

Answer 4

1. Chest Pain is Dull: does NOT change with body position or respiration, and there is NO chest wall tenderness.
2. Chest Pain occurs on Exertion.
3. Chest Pain is Substernal in Location.
4. Chest Pain lasts 15 - 30 minutes.
5. Chest Pain radiates to the Jaw or Left Arm.

Question 5

ISCHEMIC HEART DISEASE (a.k.a. CAD)

What are (4) potential Cardiovascular Exam Findings in a patient with CAD?

Answer 5

1. S3 Gallop: Dilated LV
2. S4 Gallop: Hypertrophied LV
3. Jugular Venous Distention
4. Holosystolic Murmur: Mitral Regurgitation

Question 6

ISCHEMIC HEART DISEASE (a.k.a. CAD)

What is (1) potential Pulmonary/Lung Exam Finding in a patient with CAD?

Answer 6

1. Rales: suggestive of Congestive Heart Failure (CHF)

Question 7

ISCHEMIC HEART DISEASE (a.k.a. CAD)

What are (4) potential Clinical / ED Presenting Signs in a patient with Ischemic Chest Pain from CAD?

Answer 7

1. Distressed patient
2. Short of Breath (SOB)
3. Clutching Chest
4. Diaphoretic/Sweating

Question 8

ISCHEMIC HEART DISEASE (a.k.a. CAD)

What is (1) potential Extremity Exam Finding in a patient with CAD?

Answer 8

1. Edema

Question 9

ISCHEMIC HEART DISEASE (a.k.a. CAD)

1. What is the Best INITIAL Test for suspected Ischemic Chest Pain?
2. What are the (2) Most ACCURATE Tests for suspected Ischemic Chest Pain?

Answer 9

1. Best INITIAL Test = ECG
2. Most ACCURATE Tests = Troponins and CK-MB

Question 10

ISCHEMIC HEART DISEASE (a.k.a. CAD)

What is the Best INITIAL Management Step for suspected Ischemic Chest Pain?

Answer 10

Best INITIAL Management Step = M.O.N.A.

• Morphine
• Oxygene
• Nitrates
• Aspirin

Question 11

ISCHEMIC HEART DISEASE (a.k.a. CAD)

Describe the Similarities/Differences between the (3) Types of Cardiac Enzymes (eg, Myoglobin, CK-MB, Troponins).

Answer 11

1. Myoglobin: Rises = 1-4 hrs
2. CK-MB: Rises at 3-6 hrs, Peak = 18 hrs, Duration = 1-2 days
3. Troponins: Rises = 3-6 hrs, Duration = 1-2 weeks
   
   • Troponin C: Binds Calcium, Activates actin:myosin interaction.
   • Troponin T: Binds to Tropomyosin
   • Troponin I: Inhibits actin:myosin interaction.

Question 12

ISCHEMIC HEART DISEASE (a.k.a. CAD)

In a patient with suspected CAD, under which (3) situations is Exercise Thallium / “Stress” Test or Stress Echocardiography the correct answer?

Answer 12

1. Chest Pain is NOT acute
2. Initial ECG is Unreadable for ischemia:
   
   • New LBBB
   • Digoxin use
   • Pacemaker in place
   • LVH
   • Any baseline abnormality of the ST-segment on ECG.
3. Cardiac Enzyme tests do not establish the Diagnosis.

Question 13

ISCHEMIC HEART DISEASE (a.k.a. CAD)

In a patient with suspected CAD, under which (7) conditions is Dipyridamole or Adenosine Thallium“Stress” Test or Dobutamine Echocardiography the correct answer?

Answer 13

1. Previous Stroke –> Weakness
2. Dementia
3. COPD
4. Deconditioning
5. Obesity
6. Lower Extremity Ulcer
7. Amputation

Question 14

ISCHEMIC HEART DISEASE (a.k.a. CAD)

What (2) Findings on a Stress Test translate into a Positive Test for CAD?

Answer 14

1. Raised HR to 85% of Max
2. ST segment Depression on ECG

**A Stress Test is a way of Increasing the Sensitivity of Detection of CAD beyond an ECG and Cardiac Enzymes**

Question 15

ISCHEMIC HEART DISEASE (a.k.a. CAD)

What is the Next Diagnostic Test for a patient with Ischemic Chest Pain whose “Stress” Test is non-diagnostic or equivocal and shows “Reversible” Ischemia (most dangerous thing a stress test can show)?

Answer 15

Angiography

**No CABG until after an Angiography**

Question 16

ISCHEMIC HEART DISEASE (a.k.a. CAD)

1. What is the Best INITIAL Test to evaluate Cardiac Valve Function or Ventricular Wall Motion?
2. What is the Most ACCURATE Test to evaluate Cardiac Ejection Fraction?

Answer 16

1. Echocardiography
2. Nuclear Ventriculogram

Question 17

ISCHEMIC HEART DISEASE (a.k.a. CAD)

Under which (2) Conditions would you use a Sestamibi Nuclear “Stress” Testing rather than the other two methods of “Stress” Testing?

Answer 17

1. Obese patients
2. Large Breasts

Question 18

ISCHEMIC HEART DISEASE (a.k.a. CAD)

What is the Mechanism of Action (MOA) of Thallium?

Answer 18

Nuclear Isotopes are picked up by the Na/K ATPase of Normal Myocardium. If cardiac tissue is Alive and Perfused, it will pick up the Nuclear Isotope. To the Myocardium, Thallium looks like Potassium.

Decreased uptake = Myocardial Damage