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 lecturePage 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 factorsSigns and symptomsResting ECGCardiac biomarkersExercise ECG including in the ER (Table 3.6 pg. 54)Exercise nuclear imaging (perfusion, nuclear, thallium, cardiolite)Pharmacological (dobutamine, dipyridamole, adenosine)EchocardiographyElectron beam computed tomography (CT Scan)Coronary AngiographyAutopsyClassification of Coronary Risk Factors Be able to identify ones highlighted(primary: great evidence for cause and effect, emerging: not enough evidence)Primary Non-ModifiableAdvancing ageMale genderFamily historyPrimary ModifiableDyslipidemiaHypertensionTobacco smokingDiabetes (even Type I)OverweightSedentary lifestyleAtherogenic dietEmerging Risk Factors—LipidsLipoprotein (A)Lipoprotein remnantsSmall LDL particlesHDL subspeciesApolioproteins B and A-1TC/HDL ratioEmerging Risk Factors—Non LipidsHomocysteine (amino acid-LDL, Clot)Thrombogenic factorsImpaired glucose tolerance (beginning of Diabetes Meletus)Metabolic syndromeTC/HDL ratioFramingham 10 Year Risk AssessmentPredicts a person’s chance of having a heart attack within the next 10 yearsThis test is better than all other tests that could be performed other than Autopsyhttp://cvdrisk.nhlbi.nih.gov/calculator.aspKasper’s definition of ischemia: demand of heart vs. oxygen supply to myocardial muscle of heartHard Coronary Heart Disease: heart attack or deathCoronary Heart Disease: Ischemia, etc.Major Signs or Symptoms Suggestive of Cardiovascular, Pulmonary, or Metabolic Disease (Table 2.1 pg. 22) Know this table summarized belowAngina: pain or discomfort caused by ischemia (ischemia is a lack of blood flow) usually occurs in the chest.Stable angina: highly reproducible at similar workloads, resolves with a reduction of workload.Unstable angina: can occur seated or at rest, usually due to coronary artery spasm.Silent ischemia: does not get betterShortness 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.Orthostatic hypotension: the dizziness that occurs when you get up too fastAnkle Edema: bilateral blood clot and swelling (example: indent from socks in elderly)Palpitations or Tachycardia: unpleasant awareness of forceful heartbeatIntermittent 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 elevationShows evidence of previous heart attack. Transmural ischemia (throughout entire wall of heart)Observe second: Inverted T wave or ST segment depressionShows 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 waveShows evidence of an old heart attackAlso, observe arrhythmia (rate of heart beat)Severity of ischemia is linked to these four variables:magnitude, slope, number of leads, and duration.The bigger the magnitude, the worst the ischemiaPositive Ischemia: greater than 1 mmHg horizontal or down sloping ST segment depression. If patient reaches 2 mmHg, tell them to stop exercise testing.Up sloping=best but not good, horizontal=next best, down sloping=worst.Cardiac Biomarkers3 things to do to determine if you have had an MI (myocardial infarction—same thing as heart attack)Symptomology (indigestion, chest pain, etc.)ECGCardiac Biomarkers*ECG—stop when you hit 2 mmHg down sloping ST segment depressionBP—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 gasesVO2 (METS) indirect or estimated1 MET—resting5 MET—activities of daily living10 MET—sedentary female college student12 MET—sedentary male college student12 to 14 MET—low mortalityRPE: Rate of perceived exertionBorg Scale ranges from 6-20Most use 0-10 scaleAngina Scale of Dyspnea (used for pulmonary tests) Scale1+ mild, barely noticeable2+ moderate, bothersome3+ moderately severe, very comfortable4+ most severe or intense pain ever experiencedStop test when the patient would usually stop on their ownClaudication Scale pg. 132Grade 0-4Might be combined with other tests such as ECG or radio nucleotide imagingMight need to use pharmacologicals to insult myocardiumExercise Nuclear Imaging pg. 133Perfusion, nuclear, thallium, cardioliteThallium 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 TestPerform 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 Testing1. Diagnosis—do they have the disease?2. Prognosis—we know they have it, but how bad is it?3. Pre/Post Discharge