ACS, Stable Angina and Aortic Dissection Flashcards
Definition of acute coronary syndrome
Unstable angina, NSTEMI or STEMI
*NOT stable angina
New onset angina at rest or minimal exertion
Angina accelerating in frequency or severity
Normal ECG or ST depression, T-wave inversion
Normal cardiac enzymes
Unstable angina
ST depression and/or T-wave inversion
Abnormal cardiac enzymes
NSTEMI
ST elevation
Abnormal cardiac enzymes
or
New LBBB or posterior MI
STEMI
Most common cause of death in the united states
CAD
Atherogenic risk factors
- Low HDL (<40 mg/dL)
- High LDL
- High VLDL
Who are silent (painless) AMIs more common in?
Elderly, women, diabetics
Classic components of angina pectoris (3)
*actually memorize
- Substernal chest pain/discomfort
- Provoked by exertion or emotional distress
- Relieved by rest or nitroglycerin
Typical angina presents with how many of the following components?
- Substernal chest pain/discomfort
- Provoked by exertion or emotional distress
- Relieved by rest or nitroglycerin
3/3
Atypical angina presents with how many of the following components?
- Substernal chest pain/discomfort
- Provoked by exertion or emotional distress
- Relieved by rest or nitroglycerin
2/3
Non-angina chest pain presents with how many of the following components?
- Substernal chest pain/discomfort
- Provoked by exertion or emotional distress
- Relieved by rest or nitroglycerin
1-0/3
Evaluates contractility of the heart
Assesses regional wall motion abnormalities (RWA) as hypokinesis, akinesis, dyskinesis, or normal
Dobutamine Stress ECHO
Test used to asses for how much of a coronary artery is occluded
Coronary angiography
*>70% = significant stenosis
STEMI ECG criteria
ST elevation > 2mm in continuous leads or new LBBB
*Can not diagnose STEMI when there is known/old LBBB
Differences in blood flow in STEMI vs NSTEMI
STEMI = complete occlusion of blood flow
NSTEMI = partial occlusion of blood flow, or complete occlusion in presence of collateral circulation
Initial treatment and management of stable angina
Aspirin, B blocker, nitroglycerin, statin
If stable angina is no relieved by initial treatment (Aspirin, B blocker, nitroglycerin, statin) then what?
add Ca channel blocker or long acting nitrate
If stable angina is not relieved by Aspirin, B blocker, nitroglycerin, statin; and the addition of a Ca blocker or long acting nitrate, then what?
Consider ranolazine, refer for coronary angiography
Coronary artery bypass graft (CABG) indications
- 3 vessel disease >70% stenosis
- Left sided (primarily)
- LV dysfunction
Initial management for all patients presenting with ACS
MONA (morphine, oxygen, nitrates, aspirin)
In a patient presenting with ACS, what else can be done in addition to MONA?
Dual anti-platelet therapy (DAPT)
ASA and P2Y12 inhibitor (clopidogrel, ticagrelor)
Drugs shown to improve mortality in MI (3)
ASA, B blockers, ACEi
Treatment and management of STEMI
PCI (percutaneous coronary intervention aka stent) <90 min
- or transfer to PCI capable hospital in <120 min
- or administer thrombolytics <30 min then transfer to PCI capable hospital
In the event of unstable angina or NSTEMI,
This score system predicts risk of 14 day death, recurrent MI, or urgent revascularization
TIMI score
ECG leads showing ST elevations
Coronary artery involved
Inferior MI
II, III, aVF
RCA
ECG leads showing ST elevations
Coronary artery involved
Septal MI
V1-V2
LAD
ECG leads showing ST elevations
Coronary artery involved
Anterior MI
V2, V3, V4
LAD
ECG leads showing ST elevations
Coronary artery involved
Lateral MI
V5, V6 or I, aVL
LCX
ECG leads showing ST elevations
Coronary artery involved
Posterior MI
Tall R waves and ST depression in V1, V2, V3
RCA in right dominant
LCX in left dominant
Complication of MI that presents as pericarditis
Dressler syndrome
- weeks to months later
- autoimmune
Classification systems for aortic dissection (2)
Debakey, Stanford
The following are risk factors for what diagnosis?
Long term HTN Smoking Dyslipidemia Marfan Bicuspid aortic valve Giant cell arteritis Takayasu arteritis Syphilis Deceleration trauma
Aortic dissection
Pathogenesis of aortic dissection
Intimal tear allows blood to penetrate the vessel wall and dissect the intima away, creating an intimal flap
*creates a false lumen within the tunica media for blood to flow into
Imaging study used to diagnose aortic dissection
CT angiography
Treatment and management for aortic dissection
- Anti-impulse therapy: B blockers and vasodilators to lower BP and HR
- Opiates for pain control
- Refer to surgery
Type A aortic dissection mortality vs management type (medical intervention vs surgery)
Surgical management = higher survivability in type A
*Type A for Ascending aorta
Type B aortic dissection mortality vs management type (medical intervention vs surgery)
Medical management = higher survivability in type B
- Type B for descending aorta
- Type B also has higher survival rate overall
