Coronary arteries
originate from the proximal ascending aorta and run along the outer surface of the heart
Left anterior descending artery
... [Show More] (LAD)
travels down the anterior aspect of the heart
Left main coronary artery
short segment that bifucates into the LAD
Left circumflex artery
travels around the left side of the heart
Right coronary artery (RCA)
travels around the right side of the heart and down to the inferior aspect
Posterior descending artery (PDA)
branches off RCA
When lesions are 70%
supply of oxygen rich blood reaching the myocardium may be limited causing myocardial ischemia or angina during periods of increased oxygen demand (exercise)
Thrombus may partially or completely occlude the coronary artery because
lipid filled plagues may rupture leading to platelet aggregation, triggering the coagulation cascade
Left main coronary artery is significant because:
it subtends a large proportion of the left ventricular myocardium so lesser degrees of stenosis (50%) are considered to be clinically important
LIMA
left internal mammary artery
SVG
saphenous vein grafts
What is the most commonly performed surgical procedure in the U.S. (half million a year)
CABG
Why do most procedures us the LIMA to bypass the LAD
because it has greater long term patency than SVG
What vein is often harvested from the leg to be used in bypass?
saphenous vein
Unstable angina or MI often result from
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plague rupture
True or False CABG decreases the incidence of future MIs better than angioplasty
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FALSE- there is not a clear decrease in incidence of future MI with CABG or angioplasty
CASS trial showed that there is a better survival advantage with
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CABG compared to medical treatment alone
BARI research showed that _____ patients fared better with CABG than with balloon angioplasty
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diabetic
Stroke:
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is a potential complication from CABG due to atheroembolisms that become dislodged from the proximal aorta during the procedure
Cognitive changes
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may be a complication from CABG due to intraoperative hypotension and inadequate cerebral perfusion and use of cardiopulmonary bypass (CPB)
Mediastinitis
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deep sternal wound infections
Risk factors for mediastinitis:
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obesity, diabetes, and/or previous CABG
sternal nonunion
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Patients who have undergone CABG should be evaluated for _________ if they continue to have sternal pain outside the normal window for sternal precautions and caution should be used when considering resistance training in cardiac rehab
What arrhythmia occurs in 1/3 of post CABG patients?
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A-fib
arrhythmia in which there is unorganized, chaotic depolarization of the tissue of the atria
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A-fib
2 main problems cause by A-fib in regards to exercise
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1) rapid baseline HRs 2) HR response to exercise is exaggerated making specific THR difficult
Cardiac rehab specialist should approach patients who have had CABG many years ago with more caution than those who have undergone recent revascularization because:
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about ½ of all SVGs are diseased or occluded in 10 years
What vessel used in CABG has excellent long term patency
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LIMA
Name three examples of less invasive surgery:
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'Off-pump bypass', MIDCAB (minimally invasive direct CAB), Portal access CABG
AACVPR states that CABG patients can start CR as early as:
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1 week
Components of initial assessment:
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incision site check, assessment of mood & social support, and eval of physical functioning
AHA states that stretching and flexibility can be started as early as ___ post CABG:
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24 hours
Percutaneous coronary intervention (PCI) encompasses
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DCA (directional coronary atherectomy), Rotablator, laser procedures, coronary stenting, cutting balloon
The main role of s/p:
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improve angina and exercise capacity (does not decrease the incidence of future MIs)
Femoral pseudoaneurysm:
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possible complication from PCI; painful, tender, mass in groin
Possible complication from PCI; antiplatelet therapy is ordered as preventative measure
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Stent thrombosis:
Most patients who present between 1 to 8 months after PCI with recurrence typical angina chest pains have :
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restenosis (treated artery narrows)
What is an attempt to prevent restenosis :
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drug eluting stents
Post-PCI can perform an ETT within :
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1 to 3 days
A Post-PCI patient may not need an ETT before CR if :
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no other significant stenosis other than the one treated, no other significant cardiac disease (normal valves and EF), no angina
Name 4 considerations for post-CABG patients in CR :
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sternal healing/stability, deconditioning, post-op A-fib, and graft occlusion
What is the Framingham Heart Study
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
comprehensive, long term epidemiological study of CHD risk that has elucidated risk factors (RFs)
-RFs are important, more than 90% of attributable risk can be accounted for in modifiable risk factors
DART secondary prevention study
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Fish oils or 1500mg omega-3 supplement
32% reduction of cardiac events with only two servings a week
Lyon Heart secondary prevention study
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Mediterranean diet 72% event reduction
Name 6 risk factors for coronary heart disease that are proven to lower risk:
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
smoking, hypertension, LDL, High-fat diet, left ventricular hypertrophy, thrombogenic risk factors
What habit risk factor can amplify other risk factors?
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
Smoking
Smoking interacts with other risk factors to affect plaque stability, endothelial function, and thrombogenesis, and thus smoking can amplify other risk factors
Name two pharmacological agents that help smoking intervention
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
Buproprion and nicotine replacement
Recidivism rate for smoking appears to be almost ____ at 1 year after the attempt to quit
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93%
Patients with CHD Lipid Goals
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Cholesterol less than 200
LDL less than 70
HDL greater than 40
Triglycerides less than 150
Non-HDL cholesterol less than 130
What two interventions potentiates the effects of pharmacological dyslipidemia therapy?
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
dietary and exercise interventions
The epidemiological literature shows that diets should contain monounsaturated and polyunsaturated fatty acids in place of saturated fatty acids and hydrogenated and partially hydrogenated fats; refined carbohydrates should be limited and replaced with whole grains, fruits, vegetables, and nuts; and that omega-3 fats from fish oil or plant sources should be increased.
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What are MUFA, PUFA, SAFA?
______ should be limited to less than 7% of total calories.
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SAFA
Name the two landmark trials of dietary intervention in secondary prevention of CHD.
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Lyon Diet Heart Study and DART (Diet and Reinfarction Trial)
The replacement of _______ and ________ with _______, ________, and _________ has been shown to lower cholesterol, triglycerides, and LDL and to modestly raise HDL and is associated with lower all cause and cardiovascular mortality rates in patients with CHD.
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
saturated and hydrogenated fats with monounsaturated, polyunsaturated, and particularly omega-3 fats
_______ has potent negative effects on endothelial function and plaque stability
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Oxidized LDL, goals to lower both concentration and particle size, target is less than 70
Also, soluble fiber helps reduce LDL
Lovastatin, pravastatin, simvastatin, fluvastatin, atorstatin, rosuvastatin
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Statin Drugs used to lower LDLs
Decrease LDLs by 20% to 60%
Liver disease is a contraindication to use
May interaction with grapefruit
Gastrointestinal complaints are a major adverse side effect
Cholestyramine and colestipol are bile acid sequestrants used to
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lower LDL, can decrease LDL by 10% to 20%
Major adverse side affects are gastrointestinal complaints, decreased absorption of other drugs, and possible pancreatitis
Nicotinic acids are used in lipid reduction
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crystalline nicotinic acid, niaspan; major adverse effects include flushing, hepatotoxicity, use with caution with gout, non-insulin dependent diabetes.
VA-HIT (Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial) showed
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
22% reduction in mortality for a 6% increase in HDL with Lopid therapy
How to raise HDL
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
exercise, weight loss, smoking cessation, and drug therapy
A-I (primary protein in HDL molecule)
Metabolic Syndrome
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
Three or more of the following:
Abdominal Obesity waist circumference greater than 102 cm or 40 inches in men and greater than 88 cm or 35 inches in women
Elevated Triglycerides greater than or equal to 150 mgdl or 1.70 mmolL
Low HDL Cholesterol less than 40 mgdl or 1.04 mmolL in men and less thatn 50 mgdl or 1.30 mmolL in women
Elevated BP 130/85 mm Hg or more
Insulin Resistance/Glucose fasting greater than or equal to 110 mgdl or 6.1 mmolL
Hyperglycemia is associated with
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dyslipidemia, metabolic dysfunction and insulin resistance; all which predispose people to atherogenesis
Moderate weight loss (5% to 10%)
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is sufficient to affect RFs, caloric expenditure of more than 2,000 Kcal per week is needed to sustain weight loss
Lifestyle changes and diabetes prevention
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Lifestyle changes were nearly twice as effective as the diabetic drug, Metformin, in preventing the onset of diabetes (From Diabetes Prevention Study)
Classification of Blood Pressure for Adults
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Normal <120 <80
Prehypertension 120-139 80-89 (Lifestyle mods)
Stage 1 140-159 90-99 (+drugs)
Stage 2 >160 >100
DASH diet
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
Dietary Approaches to Stop Hypertension diet has been shown to help control BP with a sodium restriction that is lower than most diets
What energy expenditure is needed to provide a cardioprotective effect, reverse/stabilize CHD, and raise VO2max
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
1,250 to 2,000 Kcal excess energy expenditure per week or 4 to 6 hours of combination of structured exercise and active lifestyle
Affects of acute and chronic exercise on vessels
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positive effects on endothelial dysfunction and enhanced vasodilation
Walking program with pedometers
Name examples of psychosocial dysfunction that have been shown to increase mortality and morbidity rates of CHD patients
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depression, anger, hostility, and stress
Why is family history of CHD important?
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Increases risk of CHD (1.7 - 12.9) if you have blood relative diagnosed with CHD at less than 55 years of age
Common genotypes may have relatively small effects on CHD but when high risk factor lifestyles are superimposed chance of CHD significantly increases.
Lifestyle and environmental factors have GREATER influence on risk of atherosclerosis than genetics
AHA recommendations for Thrombogenesis prevention
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
low dose (85mg) to regular dose (325mg) of aspirin for post MI patients, CHD patients, post CABG, adult men, and postmenopausal women
Postmenopausal Status:
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AHA recommends that Hormone Replacement Therapy NOT be used in women with heart disease (focus on lifestyle interventions), however, women with elevated Lp(a) may benefit from HRT because estrogen is known to decrease this highly atherogenic lipoprotein
Endothelial Dysfunction is prognostic for myocardial infarction. Name interventions that help improve endothelial dysfunction:
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
LDL lowering with statin and diet, ACE inhibitors, ACE II receptor blockers, moderate alcohol intake, grape juice, iron chelation, tea, high monounsaturated diet, low fat, high complex carb diet, folic acid, smoking cessation, antioxidant therapy, aerobic exercise training, weight loss
C-Reactive Protein is
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
a marker of low grade systemic inflammation that has been shown to predict CHD. For each SD increase there was a 45% increase in CHD. Aspirin, weight loss and exercise has been shown to lower.
Homocysteine is
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
a strong and independent risk factor for CHD and is associated with endothelial dysfunction. Major cause is vitamin deficiencies: folic acid and Vit Bs
_____ is known to accumulate in atherosclerotic lesions and appears to interact with hyperhomocysteinemia to promote a procoagulant state and thrombosis.
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
Lipoprotein
Associated with higher risk of CHD in women
Estrogen and niacin are the only agents shown to lower it
Pattern B Dyslipidemia
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
Genetically linked small dense LDL pattern appears to be the most common lipid disorder for people with CHD. Exercise, weight loss, low-fat diet, nicotinic acid and fibric acid derivatices are effective in improving this.
AACVPR calls for aggressive management of traditional RFs and optimizing secondary prevention by:
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
1. Stratification of patients at entry for risk of disease progression
2. Assessment of readiness to improve each risk factor
3. Individually targeted therapy according to needs and readiness
4. Aggressive follow-up until treatment targets are achieved
MUFA statement
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
MUFA: 15% total calories
PUFA: 10% total calories
SAFA: <8% total calories
Powerful predictor of CHD risk independent of triglycerides, HDL, LDL, and body mass index. It is genetically linked.
Chapter 3: Efficacy of Secondary Prevention and Risk Factor Reduction
Pattern B Dyslipidemia [Show Less]