Coronary Artery Disease

  1. Ischemic Cascade (2nd 5-8)
    • 5.) New murmur (possible MR)
    • 6.) Decreased E-F
    • 7.) EKG changes  (ST elevation and Q wave)
    • 8.) Patient symptoms (chest pain)
  2. Ischemic Cascade  (1st 1-4)
    • 1.) LV diastolic dysfunction
    • 2.) Impaired relaxation and decreased compliance
    • 3.) Increased LV end-diastolic pressure
    • 4.) Regional wall motion abnormalities (transmural)
  3. What type of Infarcts are the worst?

    Transmural infarcts

    They involve the endocardial and epicardial layers of the heart.
  4. Does transmural infarcts have Q waves?
    Yes transmural does!
  5. Does subendocardial infarcts have Q wave?
    NO subendocardial does NOT!
  6. What areas of the heart does subendocardial infarcts involve?
    Only affect the endocardial layer of the heart wall.
  7. How many infarcts are from subendocardial that cause Acute MI?
  8. What type of infarcts are commonly seen in older adults and women?

    Do they have an Q wave?
    Subendocardial infarcts

    No or Non-Q wave
  9. What segment of the walls are usually affected with Subendocardial infarcts?
    posterolateral segment
  10. Do Subendocardial infarcts have normal or abnormal wall motion?

    Are they typically smaller or larger?
    Normal wall motion

    Usually smaller
  11. What are some signs and symptoms of Infarcts? (2nd 6-9
    • 6.) Left arm pain
    • 7.) Jaw pain
    • 8.) Diaphoretic (sweating)
    • 9.) Elevated enzymes
  12. What are some signs and symptoms of Infarcts?  (1st 1-5)
    • 1.) ST segment elevation with Q wave- Transmural
    • 2.) Absent Q wave- subendocardial
    • 3.) Angina
    • 4.) SOB
    • 5.) Nausea and vomiting
  13. What are the 4 enzymes that are elevated with infarcts?
    • 1.) CPK - creatine phosphokinase
    • 2.) MB
    • 3.) Myoglobin
    • 4.) Troponin
  14. What are the treatments for infarcts?  (3)
    • 1.) Can not fix with meds just slow it down
    • 2.) First option-- stent artery
    • 3.) Second option-- coronary artery bypass
  15. What 4 things are usually looked at with physical exam for infarcts?
    • 1.) New cardiac murmur
    • 2.) evidence of CHF
    • 3.) elevated systolic blood pressure but may be low if patient goes into shock.
    • 4.) Twelve lead EKG will often disclose the location of the infarcts.
  16. What is the first thing that is seen on echo with infarcts?
    LV diastolic filling- Higher E wave than A wave
  17. What should be assessed with echo for Infarcts?  (4)
    • 1.) Look assess multiple views to look at RV and LV chamber size and shape.
    • 2.) Look for the presence of wall motion abnormalities (WMA)
    • 3.) Use color to look for regurgitation
    • 4.) Assess for LV diastolic filling parameters
  18. Is there always regional wall motion abnormality with Infarcts?
    No not always. If only 75-90% blockage than no!!
  19. If the lesion is proximal than...
    the greater the extent of the damage.
  20. What will the wall thickness like with infarcts?
    normal to thin wall thickness
  21. What is the arteries involved with right dominance?
    Right Coronary Artery adn the Posterior Descending Artery
  22. What is the artery involved with left dominance?
    the circumflex
  23. If there is damage to the RCA what will be affected?
    will damage to MV and cause MR
  24. What are 6 complications of MI?
    • 1.) Thrombus
    • 2.) Aneurysms: True and Pseudo
    • 3.) VSDs
    • 4.) Free Wall Rupture
    • 5.) Papillary muscle rupture leading to flail
    • 6.) Dressler's Syndrome
  25. What is a common complication of MI?

    When? (3)
    LV thrombus that may embolize

    • 1.) May develop within 72 hrs post MI
    • 2.) Usually detected 4-14 days after MI
    • 3.) Most emboli occur within the first 6 months
  26. When does LV thrombus after an MI occur?  (3)
    • 1.) In 46% - with anterior wall MI and apical akinesis
    • 2.) 60% - patients with congestive CMP
    • 3.) 50% - patients with LV aneursym
  27. What are 3 possible appearances of thrombus on the endocardium?
    • 1.) Protruding
    • 2.) Mobile
    • 3.) Non-Protruding or laminar
  28. What does older thrombi appear like?
  29. If it appears that you see thrombus what should you do?  (6)
    • 1.) Use multiple views to R/O thrombus
    • 2.) Use off-axis views
    • 3.) Decrease depth
    • 4.) Optimize resolution
    • 5.) Use color
    • 6.) Use contrast
  30. What are 4 ways to optimize resolution?
    • 1.) Increase TX frequency
    • 2.) Adjust focal zone
    • 3.) Zoom
    • 4.) Adjust gain
  31. IF thrombus is seen in one view what should be done?
    Look in multiple views, if in only one view than just artifact.
  32. What are some pitfalls of IDing thrombus or what might also look like thrombus on echo?
    • 1.) Fibrous band accross apex
    • 2.) False tendons
    • 3.) prominent trabeculations
    • 4.) abnormally placed papillary muscle
    • 5.) ruptured papillary muscle  --abnormal
    • 6.) near field artifact
  33. Two types of LV aneurysms?
    • 1.) True aneurysms
    • 2.) Pseudoaneurysm
  34. Two places thrombus will form with True aneurysms?
    • 1.) Apex  -- more common
    • 2.) Basal portion of the inferior wall
  35. What are the two common places for thrombus to form with Pseudoaneurysms?

    And views they are possibly seen in? (2 for each)
    • 1.) posterior or posterolateral (PSAX, PLAX)
    • 2.) anterior or anteroapical  (PSAX, 2CH)
  36. What is an VSD?

    Usually located?

    What are two causes of VSD?

    An rupture of the IVS (septal wall)

    Typically seen in mid or basal portion.

    • 1.) MI
    • 2.) Congenital- RARE

    Murumur: Systolic murmur
  37. What should you do if you see an VSD?
    • 1.) Use multiple windows 
    • 2.) Use off-axis views
    • 3.) Use color to look for shunt which is usually L to R (probably red)
  38. What direction is the shunt flow usually with VSDs?
    Left to right (probably red)
  39. What are two signs and symptoms of VSDs?
    • 1.) Systolic murmur 
    • 2.) Patient may be hypotensive
  40. What is the mortality with VSDs?

    • High, 80% of patients will die in 2 months
    • Hard to fix surgically due to necrosis of tissue surrounding the repair.
  41. Treatment for VSDs caused by MI.

    Heart transplant

    Hard to surgically fix because of necrosis of tissue surrounding the repair.
  42. If an VSD is due to an MI...

    Is it acute or chronic condition?
    What will happen to RV?
    Acute condition

    No RV enlargement
  43. If an VSD is congenital...

    Is it acute or chronic condition?
    What will happen to the RV?
    Chronic condition

    RV will be enlarged
  44. What is the most feared complication of MI?

    LV Free Wall Rupture

    Blood flows freely in the pericardium and thorax.
  45. What are some signs and symptoms of LV Free Wall Rupture?  (4)
    • 1.) Acute CP
    • 2.) agitation
    • 3.) cardiogenic shock
    • 4.) new systolic murmur
  46. What are 2 main complications of LV Free Wall Rupture?
    • 1.) Tamponade
    • 2.) Cardiogenic shock
  47. What does LV free Wall rupture usually happen after an MI?
    2-8 days after the MI
  48. What is the mortality with LV Free Wall Rupture?
    90% of patients
  49. What patients are at highest risk of LV free wall rupture after having an MI?
    • 1.) Transmural infarcts (have Q wave)
    • 2.) first MI patients
    • 3.) occurs in patients with large MI
    • 4.) patients with MIs in lateral or posterolateral portions  (LV psuedoaneurysms)
  50. What is the worst type of aneurysm to have in the LV?


    Rupture of all layers of the myocardium.
  51. What does the word "Viable" mean?
    the heart muscle may not be squezzing but its not dead, it can come back!!
  52. What is one way to wake up an hibernating myocardium?
    stress test
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Coronary Artery Disease