PET3932 Exam 1 Study Guide 09 25 2013 How to go about reading this study guide Anything highlighted in yellow is what Dr Kasper told us in class that we need to know for the exam Most of the stuff he mentioned 2 to 4 times in class so know it like the back of your hand Everything else is from his power points and lecture Page references and table box numbers are included if you are an overachiever and would like go into depth of each topic in the book What are the ways in which we assess or diagnose Coronary Artery Disease or Coronary Heart Disease Risk factors Signs and symptoms Resting ECG Cardiac biomarkers Exercise ECG including in the ER Table 3 6 pg 54 Exercise nuclear imaging perfusion nuclear thallium cardiolite Pharmacological dobutamine dipyridamole adenosine Echocardiography Electron beam computed tomography CT Scan Coronary Angiography Autopsy Classification of Coronary Risk Factors Be able to identify ones highlighted primary great evidence for cause and effect emerging not enough evidence Primary Non Modifiable o Advancing age o Male gender o Family history Primary Modifiable o Dyslipidemia o Hypertension o Tobacco smoking o Diabetes even Type I o Overweight o Sedentary lifestyle o Atherogenic diet Emerging Risk Factors Lipids o Lipoprotein A o Lipoprotein remnants o Small LDL particles o HDL subspecies o Apolioproteins B and A 1 o TC HDL ratio Emerging Risk Factors Non Lipids o Homocysteine amino acid LDL Clot o Thrombogenic factors o Impaired glucose tolerance beginning of Diabetes Meletus o Metabolic syndrome o TC HDL ratio Framingham 10 Year Risk Assessment Predicts a person s chance of having a heart attack within the next 10 years o This test is better than all other tests that could be performed other than Autopsy o http cvdrisk nhlbi nih gov calculator asp Kasper s definition of ischemia demand of heart vs oxygen supply to myocardial muscle of heart Hard Coronary Heart Disease heart attack or death Coronary Heart Disease Ischemia etc Major Signs or Symptoms Suggestive of Cardiovascular Pulmonary or Metabolic Disease Table 2 1 pg 22 Know this table summarized below Angina pain or discomfort caused by ischemia ischemia is a lack of blood flow usually occurs in the chest o Stable angina highly reproducible at similar workloads resolves with a reduction of workload o Unstable angina can occur seated or at rest usually due to coronary artery spasm o Silent ischemia does not get better Shortness of breath considered abnormal when it occurs at a level of exertion that is not expected to provoke shortness of breath This is a principle symptom of cardiac and pulmonary disease Dizziness or Syncope syncope loss of consciousness is caused by reduced perfusion of the brain Dizziness occurs from heart arrhythmia Dizziness and syncope during exercise may result in cardiac disorders that prevent the rise and fall in cardiac output o Orthostatic hypotension the dizziness that occurs when you Ankle Edema bilateral blood clot and swelling example indent Palpitations or Tachycardia unpleasant awareness of forceful get up too fast from socks in elderly heartbeat Intermittent Claudication pain in a muscle due to inadequate blood supply only occurs when exercising usually due to atherosclerosis usually occurs in lower legs think Diabetes ECG Electrodes take pictures of the heart so they must be in the right place this is why patient lays down also to reduce space between electrodes and heart Observe first S to T elevation Shows evidence of previous heart attack Transmural ischemia throughout entire wall of heart Observe second Inverted T wave or ST segment depression Shows evidence of ischemia or recent week or days heart attack ST segment depression 1 mmHg horizontal down sloping indicates subendocardial ischemia which occurs first in the heart Observe third Significant Q wave Shows evidence of an old heart attack Also observe arrhythmia rate of heart beat Severity of ischemia is linked to these four variables magnitude slope number of leads and duration o The bigger the magnitude the worst the ischemia o Positive Ischemia greater than 1 mmHg horizontal or down sloping ST segment depression If patient reaches 2 mmHg tell them to stop exercise testing o Up sloping best but not good horizontal next best down sloping worst Cardiac Biomarkers 3 things to do to determine if you have had an MI myocardial infarction same thing as heart attack o Symptomology indigestion chest pain etc o ECG o Cardiac Biomarkers ECG stop when you hit 2 mmHg down sloping ST segment depression BP systolic should increase with increasing work load diastolic should stay the same stand dev 10 mmHg Gas Exchange and Ventilatory Responses aerobic fitness ability to consume oxygen is the best predictor of mortality and morbidity Arterial blood gases VO2 METS indirect or estimated 1 MET resting 5 MET activities of daily living 10 MET sedentary female college student 12 MET sedentary male college student 12 to 14 MET low mortality RPE Rate of perceived exertion Borg Scale ranges from 6 20 Most use 0 10 scale Angina Scale of Dyspnea used for pulmonary tests Scale 1 mild barely noticeable 2 moderate bothersome 3 moderately severe very comfortable 4 most severe or intense pain ever experienced o Stop test when the patient would usually stop on their own Claudication Scale pg 132 Grade 0 4 Might be combined with other tests such as ECG or radio nucleotide imaging Might need to use pharmacologicals to insult myocardium Exercise Nuclear Imaging pg 133 Perfusion nuclear thallium cardiolite Thallium or cardiolite must be used if patient is female and you are performing an GXT exercise test This will take pictures of the heart and let you see defects If picture changes once the patient starts exercising and goes away once done exercising this indicates ischemia If the picture shows a defect but remains the same after exercise this indicates necrosis dead tissue old MI If the picture shows a defect before exercise and it gets worse with exercise this means they have both ischemia and necrosis Pharmacological Exercise Test Perform when the patient cannot perform exercise use a vasodilator adenosine or dipyridamole or positive inotropic rate of contraction chronotropic power of contraction example dobutamine Combine imaging with testing because of low sensitivity Indications and Applications of Clinical Exercise Testing 1 Diagnosis do they have the disease 2 Prognosis we know they have it but how bad is it 3 Pre Post