1) Describe the blood supply to the left ventricle.

Physiologically, very little blood travels through the left

coronary during systole due to the forceful contraction of the ventricle which constricts the vessels. Therefore,
the majority of blood flow to the left side of the heart occurs during diastole.
2) Compare and contrast the clinical presentation of stable angina and acute coronary syndrome.
acute coronary syndrome is compatible with a diagnosis of acute myocardial ischemia, but it is not
pathognomonic. occurs suddenly, often at rest or with minimal exertion, or at lesser degrees of
exertion than the individual's previous angina. New onset angina is also considered unstable
angina, since it suggests a new problem in a coronary artery. Though ACS is usually associated with
coronary thrombosis, it can also be associated with cocaine use. Cardiac chest pain can also be precipitated by
anemia, bradycardias (excessively slow heart rate) or tachycardias (excessively fast heart rate). The cardinal
sign of decreased blood flow to the heart is chest pain experienced as tightness around the chest and radiating
to the left arm and the left angle of the jaw. This may be associated with diaphoresis (sweating), nausea and
vomiting, as well as shortness of breath. In many cases, the sensation is "atypical", with pain experienced in
different ways or even being completely absent (which is more likely in female patients and those with
diabetes). Some may report palpitations, anxiety or a sense of impending doom and a feeling of being acutely ill.
unstable angina
2 forms of MI named according to the appearance of the ECG as non-ST segment elevation myocardial
infarction and ST segment elevation myocardial infarction.
stable angina, which develops during exertion and resolves at rest.
3.List a differential diagnosis for acute chest pain.
4. List the risk factors for CAD.
What are the major risk factors that can't be changed? Age, male sex, heredity/race
What are the major risk factors you can modify, treat or control by changing your lifestyle or taking
medicine? Smoking, dyslipidemia, HTN, sedentary, overweight, DM
What other factors contribute to heart disease risk? Stress, too much alcohol (moderate benefits,
but dont start if you havent been drinking)
5. Describe the biochemistry of lipid metabolism refer to FA
6. Discuss the evaluation for a patient with Angina Pectoris including the indications for a stress
test
suspected in any patient presenting with chest pain. often described as a tightness such as a vice grip or
heavy weight being on the chest. Other common symptoms seen that should be asked about are: Pain in
arms, neck, jaw shoulder or back that accompanies the chest pain, nausea, fatigue, shortness of
breath, anxiety, sweating and dizziness. Physicians will also want to ask about the setting of the pain
(often exertionalthough can be constant) and the severity or whether the pain has changed in
presentation lately as the physician needs to be concerned about this being a MI.
As the major cause of Angina Pectoris is coronary artery disease this must be checked out, as well as
other possible causes of Angina.
Electrocardiogram: While this test may be normal in 1/2 to 2/3 of patients, it is not useless. An
abnormal Q wave may show prior MIs, and evidence of left ventricular hypertrophy or baseline ST-T
wave changes can also suggest underlying CAD. This test should be compared to previous ECGs.
Ischemia is suspected in ST segment elevation or depression, T-wave inversion, a left or right
bundle branch block or arrhythmia.
Stress Testing: **** impt
Stress testing may also be used to assess cardiac function. Exercise testing, pharmacological testing
(dipyridamole (vasodilates, increase heart profusion), dobutamine (increased contraction strengthcauses
increased need for O2), adenosine (increased vasodilation, increase heart profusion).
It is an important assessment of patients with suspected CAD. However, its sensitivity is only 68%
and specificity only 78% (even lower in those with abnormal ECGs). Because of this, the patients pretest
probability (basically all their risk factors considered: age, sex, etc.) must be taken into account.
Echocardiography (Ultrasound of the heart): ***
Sensitivity 75-95%, specificity 70-90%. Not essential in angina, but can show previous MIs with wall motion
abnormalities, left ventricular systolic (ejection fraction lower) function and some other abnormalities that may
be the cause of chest pain.
Coronary Angiography: unlike the rest, its invasive but the most accurate way to dx clinically
significant CAD; helps plans for angioplasty and stents
7) Describe steps in emergency treatment for acute coronary syndrome.
Patients determined to have a low likelihood of cardiac chest pain or noncardiac chest pain are often
discharged to home directly from ER. Patients felt to have possible cardiac chest pain, the patient will
be kept in the ER for 24 hours. Cardiac enzymes and 12-lead electrocardiograms will be checked at
6- to 12-hour intervals; if they remain normal stress test to further stratify their risk. If negative for

ischemia, the presenting symptoms are not likely to be due to obstructive coronary artery dsease and the
patient is discharged to home. If the likelihood of cardiac chest pain is high, the stress test is positive,
electrocardiograms or cardiac enzymes become abnormal, or if ongoing symptoms or hemodynamic instability
are present, the patient should be admitted for further evaluation and management. Once admitted, the
patient's activity is generally restricted, especially if symptoms persist. If cyanosis or respiratory distress is
present, oxygen should be placed on the patient. All patients admitted for chest pain should be placed on
telemetry monitoring to evaluate for malignant arrhythmias associated with acute coronary
syndromes. Anti-ischemic medications can be used to control symptoms. Nitrates will reduce myocardial
oxygen demand and increase delivery by reducing preload and afterload and promoting the dilation of epicardial
coronary arteries and collateral circulation. Patients with ongoing cardiac chest pain are often started on
intravenous nitroglycerine drips with titration of the dose until symptoms are relieved or
hypotension develops. Morphine is recommended for pain relief in those with continued symptoms, as this
drug can lead to venodilation and an increase in vagal tone, which can cause a reduction in heart rate (lowers
myocardial oxygen demand). An adverse reaction to both of these drugs is hypotension; therefore, close
monitoring of blood pressure is needed.
8. Describe the treatment for patients with chronic stable angina including pharmacological and
non-pharmacological intervention.
Angioplasty and stenting
Aspirin, Nitrates, Beta blockers, statins, CCB, ACEI
Lifestyle changes: heart disease is often the underlying cause of most forms of angina: Smoking,
poor diet, sedentary, overweight, stress
9. List treatment guidelines for cholesterol in primary and secondary prevention of CAD:
Recommendations for Modifications to Footnote the ATP III Treatment Algorithm for LDL-C
In high-risk persons, the recommended LDL-C goal is <100 mg/dL.
For moderately high-risk persons (2+ risk factors and 10-year risk 10% to 20%), the recommended LDL-C
goal is <130 mg/dL; an LDL-C goal <100 mg/dL is a therapeutic option on the basis of available clinical trial
evidence. When LDL-C level is 100 to 129 mg/dL, at baseline or on lifestyle therapy, initiation of an LDL-lowering
drug to achieve an LDL-C level <100 mg/dL is a therapeutic option on the basis of available clinical trial
evidence.
Any person at high risk or moderately high risk who has lifestyle-related risk factors (eg, obesity,
physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) is a candidate for TLC to modify
these risk factors regardless of LDL-C level.
10. List the classes, mechanisms of action and common side effects of the antihyperlipidemic
medicines. refer to pharm charts
11. Discuss the role of stenting in chronic stable angina: embedded in the wall of the vessel,
thereby increasing the luminal diameter. With stents, restenosis rates were initially reduced to 15%
to 30%. The most recent innovation involves stents coated with immunomodulating agents such as sirolimus
and paclitaxel, which prevent the growth of excess tissue within the stents. This has reduced restenosis rates to
less than 5%. The metal stent that has been embedded in the arterial wall is thrombogenic, not only
because it is a foreign body, but also because stent deployment leads to endothelial damage, which
can set off a cascade leading to formation of a thrombus. Therefore, the patient should be maintained
on antiplatelet therapy including aspirin and clopidogrel. These drugs will help maintain stent
patency until the endothelium grows over the exposed metal stent, thereby eliminating any
thrombogenic potential.