Chapter 3: Ischemic CV conditions and other vascular pathologies

What are emerging risk factors for artherosclerotic disease?

- Lp(a) - LDL subclasses - oxidized LDL - homocysteine - hematologic factors - inflammatory markers like C-reactive protein and lipoprotein-associated phospholipase A2

What are the major CV diseases?

- ischemic coronary heart disease - HTN - heart failure - CVA

Smokers have what elevated blood levels?

- lowered HDL - elevated fibrinogen and plasma catecholamine levels - higher BP *leukocytosis*

What are risk factors of heart/CV disease?

- smoking - physical inactivity - obesity - poor diet - HTN - TG (high LDL and low HDL) - DM - Family history - age - gender (males until females start menopause) - stress

How does PDGF contribute to lesion formation?

- stimulates replication of CT cells - attracts smooth muscle cells to migrate from media into intima *ultimately causes deposition*

What are the four ways that CHD presents clinically?

- sudden cardiac death - chronic stable angina - acute coronary syndrome - cardiac muscle dysfunction

How quickly must arterial reperfusion occur to prevent tissue necrosis?

20 minutes or less

As few as ______ cigarettes a day increases the risk of developing CAD or CHD.

4

A ratio of greater than _______ total cholesterol/HDL increases a risk of atherosclerosis.

4.5

HDL should be above

40 (men) and 50 (women) mg/dL

HTN is:

>140/90

An infarct in the left anterior descending coronary artery shows in what EKG leads?

V1-V4

An infarct in the left main coronary artery shows in what EKG leads?

V1-V6, I, aVL

An infarct in the circumflex coronary artery shows in what EKG leads?

V5, V6, aVL, I

A 56-year-old male with a history of obesity, type II diabetes, and a high-stress management occupation is scheduled for a physical therapy evaluation for treatment of low back pain. As a physical therapist which of the following guidelines is MOST appropriate to follow during the initial and subsequent physical therapy sessions? a. Monitor BP at rest and during exercise for at least the first three to four sessions. b. If BP is normal or unremarkable at rest during the evaluation, there is no need to continue monitoring. c. It is recommended the patient stop his medication for blood pressure that results in unpleasant side effects. d. It is recommended the PT only provide manual therapy to the patient if his resting BP is 200/100.

a.

In a patient with coronary artery disease, beta-blocking medications may be prescribed. Which of the following statements BEST describes the reasoning? a. Beta-blockers lower resting heart rate, increasing diastolic filling time. b. Beta-blockers lower the intramyocardial pressures, increasing muscle relaxation. c. Beta-blockers lower the vasomotor tone in the media, increasing the diameter of the artery. d. Beta-blockers lower the aortic pressure during systole, increasing blood flow to coronary arteries.

a.

The accumulation of lipids by monocytes between endothelial cells is termed: a. foam cells. b. fibrous cap. c. thrombus. d. sclerosis

a.

Which of the following clinical signs/symptoms is MOST characteristic of ST segment elevation myocardial injury (STEMI)? a. Q wave infarction occurring distal to a totally occluded coronary artery b. Non-Q wave infarction affecting subendocardial region c. Blood flow interruption is less than 30 minutes d. Coronary arteries are not completely blocked

a.

Which of the following monitoring tools is MOST useful to the clinician when attempting to correlate functional activities and myocardial capabilities in a patient diagnosed with chronic stable angina? a. Product of exercise HR and systolic BP b. Maximum heart rate during specific activity c. Systolic blood pressure at end of activity d. Highest rating of perceived exertion (RPE)

a.

Which of the following pathological changes is MOST associated with diastolic dysfunction in hypertensive heart disease? a. Impairment of left-ventricular relaxation leading to stiffer left ventricle b. Subnormal left-ventricular functional reserve during exercise c. Impairment of ventricular contraction d. Increase in end-systolic volume

a.

Which of the following peripheral muscular adaptations that occurs with aerobic exercise would benefit the patient with intermittent claudication the MOST? a. Increased collateral circulation or capillary density b. Increased blood viscosity c. Reduced pain threshold d. Improvements in anaerobic metabolism

a.

Which of the following ratios is the BEST predictor for developing cholesterol-related blockages in an artery? a. Total cholesterol/high-density lipoproteins b. Total cholesterol/low-density lipoproteins c. Triglycerides/high-density lipoproteins d. Gram level of saturated fat/mg level of cholesterol

a.

What is the major physiologic difference between unstable and stable angina?

absence of an increase in myocardial oxygen demand to provoke the syndrome

What is the outer layer of an artery?

adventitia

Which of the following layers of the coronary arteries is responsible for making adjustments to the luminal diameter? a. Adventitia b. Media c. Intima

all of the above

What is Prinzmetal's angina?

also known as variant angina - characterized by cyclic chest pain that often occurs at rest/night, caused by vasospasm, leading to the narrowing of the coronary arteries

What are collateral vessels?

anastomotic connections that lack intervening capillary beds

Left anterior descending coronary artery causes an infarct where?

anterior

Left main coronary artery causes an infarct where?

anterior and lateral

Resistance to flow is most commonly caused by:

atherosclerosis

What is a disease that causes progressive hardening and narrowing of the coronary, cerebral, and peripheral arteries?

atherosclerosis

A pathological permanent dilation of an artery wall that is usually uniform in shape, but can resemble a sac or outpouching, is termed: a. stenosis. b. aneurysm. c. atherosclerosis. d. bruit.

b.

Which of the following blood pressure recordings would be considered hypertensive? a. 132/85 b. 142/95 c. 119/78 d. 128/88

b.

Which of the following determinants of myocardial blood flow will inhibit flow of blood to the myocardium? a. Increased diastolic blood pressure b. Increased vasomotor tone c. Decreased vasomotor tone d. Lower left-ventricular end-diastolic pressure

b.

Which of the following factors is defined as a type of amino acid found in blood that when elevated has been linked to increased risk for development of cardiovascular diseases? a. C-reactive protein b. Homocysteine c. Factor VII d. Lipoprotein a (Lpa)

b.

A 72-year-old male arrives for a physical therapy evaluation for treatment of his low back pain. The patient has a history of peripheral vascular disease, diabetes, and hypercholesteremia. He reports leg pain and fatigue with walking. The physical therapist feels it is appropriate to include a vascular screen and testing in the evaluation. Which of the following signs/symptoms would be MOST indicative of an abdominal aortic aneurysm? a. Fatigue with walking b. Numbness in the lower extremities c. Pulsating mass in the abdominal area d. High blood pressure at rest

c.

In an older adult aged 70 years without known disease, which of the following interventions would have the HIGHEST impact on reducing the risk for coronary heart disease similar to younger subjects? a. Age is too strong of a risk factor; therefore, overall risk could not be altered. b. Have the older adult follow a low carbohydrate diet. c. Encourage the older adult to walk daily for a minimum of 30 minutes. d. Have the older adult consume a low dose of aspirin daily.

c.

The presence of an obstruction that causes permanent damage to heart muscle fibers downstream, thus inhibiting heart muscle function, is BEST termed which of the following? a. Angina pectoris b. Coronary artery disease c. Coronary heart disease d. Atherosclerosis

c.

The processes of atherosclerosis development occur in which of the following arterial layers? a. Adventitia b. Media c. Intima d. All of the above

c.

Which of the following clinical cues exhibited by a patient with stable angina should alert the health care provider to notify the patient's physician? a. Reports chest discomfort in morning that was relieved with minor activity. b. Reports chest discomfort several times a week. c. Reports chest discomfort at a lower level of activity than usual. d. Reports chest discomfort resolution with rest or decrease of activity intensity.

c.

Which of the following interventions would result in the highest survival rate from ventricular fibrillation sudden cardiac arrest? a. Entry into emergency medical system within 15 minutes b. Administration of CPR within 10 minutes c. Immediate CPR and AED shock within 3 to 5 minutes d. AED shock within 15 minutes

c.

Which of the following layers of the coronary arteries is selectively permeable to low-density lipoprotein (LDL) leading to the possible development of myocardial ischemia? a. Adventitia b. Media c. Intima d. None of the above

c.

Which of the following medical interventions targets prophylaxis or treatment for arrhythmias? a. Use of nitrates b. Use of fibrinolysis c. Use of amiodarone d. Use of morphine

c.

Which of the following risk factors is considered nonmodifiable? a. Cigarette smoking b. High blood pressure c. Increased age d. Physical inactivity

c.

Which of the following statements BEST explains how myocardium tissue perfusion occurs primarily during periods of muscle relaxation (diastole)? a. All fluids follow the path of least resistance and flow from higher to lower pressure. b. The right ventricle has a lower pressure than the left ventricle during systole resulting in less difference in blood flow in the right coronary artery between systole and diastole. c. During diastole, full coronary arteries create high pressures, driving blood into the myocardium when intramyocardial pressure drops. d. When the aortic valve closes, pressure is transmitted through dilated Valsalva sinuses to openings of coronary arteries.

c.

Major risk factors for CHD are also major risk factors for what two other diseases?

carotid artery disease and PAD

What is one of the more frequent causes of vasospastic induced MI in patients with and without CAD?

cocaine abuse

What is the adventitia composed of?

collagenous fibers, mostly fibroblasts

What happens to the intimal layer when the endothelium of a coronary artery is damaged?

constricts instead of dilates due to a reduction in NO (which is a relaxing factor)

What is the presence of an obstruction that causes permanent damage to heart muscle fibers downstream, thus inhibiting heart muscle function?

coronary heart disease

In a patient with diabetes, which of the following physiological changes is a result of increased glycosylation? a. Increase sensitivity to enzymes b. Elevated high-density lipoprotein c. Enhanced fibrin degrading by fibrinogen d. Enhanced thrombus formation

d.

Which of the following determinants of myocardial blood flow will cause restriction to flow into the capillary beds of the endocardium if elevated? a. Diastolic blood pressure b. Vasomotor tone c. Resistance to flow d. Left-ventricular end-diastolic pressure

d.

Which of the following factors would be MOST associated with a good prognosis post-myocardial infarction? a. Development of atrial fibrillation b. Persistent systolic hypotension (<90 mm Hg) c. Elevation of left-ventricular end-diastolic pressure d. Small infarction size with increase in scar formation

d.

Which of the following is characteristic of the "sclerotic" phase of atherosclerosis? a. Fatty streaks in the artery b. Accumulation of lipid by monocytes c. Stretched endothelium by enlarging foam cells d. Aggregation of platelets forming a thrombus

d.

Which of the following medical interventions is the MOST optimal regimen for primary and secondary prevention of a stroke? a. Aspirin b. Lipid-lowering medication c. Antihypertensive medication d. A combination of all the above

d.

Which of the following pathological myocardium changes results in an exaggerated and early peak value of substances such as CK-MB and cardiac-specific troponin T and I? a. Development of coagulative necrosis with contraction bands in myocardial tissue b. Occurrence of hemorrhage within zones of irreversibly injured myocytes c. Mitochondria in necrotic areas developing calcium phosphate deposits d. Reperfusion of myocardium promotes removal of intracellular proteins

d.

Which of the following risk factors has been shown to be associated with leukocytosis, lower serum high-density lipoprotein, elevated fibrinogen and plasma catecholamine levels, and increased blood pressure? a. Elevated cholesterol b. Physical inactivity c. Diabetes d. Cigarette smoking

d.

Is typical angina associated with ST-segment elevation or depression?

depression

Is ST-segment elevated or depressed in Prinzmetal angina?

elevated

Is variant angina associated with ST-segment elevation or depression?

elevation

What is the intima composed of?

endothelial layer, basement membrane, smooth muscle cells and collagen/elastin fibers

The main cells of the adventitia are:

fibroblasts

Patients on beta-blockers are ultimately allowing the heart to do what?

fill longer during diastole

Is serum cholesterol low or high in undiagnosed CHD population?

high

All fluids flow from _____ to _______ pressure, along path of ______ resistance.

high; low; least

What is a rare case where atherosis is the only cause of an obstructive legion?

homozygous familial hypercholesterolemia

What two types of mechanisms effect BP?

humoral (renal blood flow) and neural (CNS)

Right coronary artery causes an infarct where?

inferior

Is pain with a heart attack felt on the inside or outside of arms?

inside

Circumflex artery causes an infarct where?

lateral

Is the occlusive pressure higher on the right or left coronary artery terminal vessel during systole?

left

Which ventricle is under greater pressure during systole?

left ventricle

What is plaque composed of?

lipid and thrombus

Atherosis is just:

lipid deposition (sclerosis is the hardening)

What are foam cells?

lipid-laden macrophages

What is most likely to accumulate in the intima layer of an artery?

lipoproteins and fibrinogen

Which layer of the artery changes the size of the lumen?

media

Is family history considered a risk factor for CHD?

minor risk

What does acute coronary syndrome cover?

myocardial ischemia that presents as unstable angina, ST-segment elevation myocardial infarction, or NSTEMI

What meds are used to control cardiac pain?

nitrates, morphine, beta blockers

Should hormone replacement therapy be used as cardioprotective for women?

no

Common complications of an infarct in the circumflex coronary artery include:

none specific

What is common in post-CABG patients?

pericarditis

What is lamina?

prominent elastic membrane separating the media from the rest of the arterial layers

Common complications of an infarct in the left main or LAD coronary artery include:

pump dysfunction or failure

Common complications of an infarct in the right coronary artery include:

risk of AV block and/or arrhythmias; 50% have right ventricular infarct

What is the media made of?

smooth muscle separated from surrounding layers by lamina

Lowering BP is more likely to decrease the risk for ______ than heart attack.

stroke

When the aortic valve is closed, how is pressure transmitted?

through dilated Valsalva sinuses, which are mini reservoirs

Vasomotor tone is usually _______ through the coronary vascular tree.

uniform

Patients with what kind of angina are unable to increase their CO significantly without provoking further discomfort, even if their earlier pain has waned?

unstable angina

Does variant or typical angina occur at rest?

variant

What is the vasa vasorum?

vessels of vessels; vessels in adventitia that supply blood to the media of an artery

Is physical inactivity higher among men or women?

women

What is the presence of an obstruction that limits coronary blood flow but does not significantly inhibit heart muscle function?

CAD

Is CAD or CHD associated with permanent damage to the heart?

CHD

What is the primary driving force moving blood into myocardial tissue?

DBP

Flow of blood to the myocardium =

DBP + VMT - R - LVEDP VMT = vasomotor tone R = resistance LVEDP = left ventricular EDP

Arterial endothelium is selectively permeable to what?

LDL

An infarct in the right coronary artery shows in what EKG leads?

II, III, aVF