Angina

Question 1

stable angina vs. unstable angina

Answer 1

stable: predictable chest pain w/ exertion, relieved w/ rest

unstable: unpredictable chest pain independent of exertion

Question 2

angina

Answer 2

discomfort d/t lack of BF to heart

Question 3

Major modifiable RFs of angina

Answer 3

cigarette smoking
dyslipidemia
HTN
DM
abdominal obesity

Question 4

Non-modifiable RFs of angina

Answer 4

increasing age (>40yo)
FH
male

Question 5

typical angina

Answer 5

chest, arm, jaw discomfort/pressure

Question 6

stable angina sx

Answer 6

-chest discomfort (pain, pressure, heaviness, tightness), possibly radiating to arm, shoulder, jaw
-associated with exertion

Question 7

atypical angina

Answer 7

epigastric discomfort
back discomfort
indigestion-like discomfort

Question 8

Stable angina: PE

Answer 8

-findings often disappear when ischemia resolves

If having current acute episode:
-tachycardia, HTN
-maybe transient S3 or S4, maybe split S2 d/t delayed relaxation of LV
-“Levine sign”

Question 9

Levine sign

Answer 9

grabbing chest d/t pain (assoc w/ angina)

Question 10

Stable angina: Dx tests

Answer 10

-EKG: may be normal if no current sx
-Labs looking for RFs of CVD: Hgb (anemia?), fasting glucose, HgA1c, BMP, troponin, fasting lipid panel

Question 11

If you suspect stable angina, you must order further dx tests. You can determine what tests to order based on “pretest probability” (PTP = initial probability that a pt’s sx represent obstructive CAD prior to undergoing dx tests) of CAD. What further tests can be ordered to determine CAD/stable angina?

Answer 11

-Cardiac CTA
-Dobutamine (or exercise) stress test w/ echo or radionuclide imaging
-Coronary calcium score (in asymptomatic pts it is known to be a sign of subclinical CAD)

Question 12

Stable angina: Tx (LOTS!)

Answer 12

-Mediterranean diet (nuts, seeds, f/v, fish)
-exercise & wt loss
-stop smoking
-control DM
-stress reduction
-address depression/anxiety
-avoid strenuous exercise, esp after meals or in cold weather (bc arteries are also constricted)

Meds:
-B-blockers (metoprolol, atenolol) to decrease HR and contractility to decrease O2 demand
-Nitrates (sublingual) for sx
-ASA (or clopidogrel if allergic to ASA) (anti-PLT)
-high-intensity statin (rosuvastatin or atorvastatin), regardless of LDL
-ACEI/ARB for DM, CKD, HTN, EF <40%

Question 13

Unstable angina vs. Printzmetal’s/vasospastic angina

Answer 13

unstable angina typically lasts longer than Printzmetal’s angina and has lingering dx abnormalities

Question 14

Pt presents with sx of unstable angina. Flowchart to determine STEMI vs NSTEMI

Answer 14

Does EKG show ST elevation?
YES –> STEMI
NO –> Are troponins elevated?

ELEVATED TROPONIN –> NSTEMI
LOW/NORMAL TROPONIN –> requires more dx tests to eval unstable angina

Question 15

Sx of MI

Answer 15

-heaviness, pressure, squeezing, or tightness in the chest
-discomfort often radiates and may be primarily located in the arms, neck, or jaw
-DYSPNEA is common
-may be diaphoretic
-may have N/V
-elderly may present only w/ dyspnea, dizziness, or arrhythmia
*diabetics have decreased sensation so may have abn sx

Question 16

MI: PE

Answer 16

-PE may be normal
-vital signs may be normal
-lungs: rales would indicate CHF
-heart: dyskinetic apical pulsation (outward bulge) on palpation; S3 (blood build up in L atrium), S4 (blood build up in LV); mitral regurgitation (may be d/t papillary m. dysfxn)

Question 17

If PE following acute MI shows signs of pulmonary congestion how does this affect mortality?

Answer 17

signs of pulmonary congestion following MI increase mortality rate

Question 18

MI: EKG

Answer 18

-do EKG w/in 10 MINUTES of arrival
-ST elevations 1mm+ in 2 contiguous leads or 2mm+ in leads V2 & V3 or NEW L BBB + presentation consistent w/ ACS

NSTEMI: ST depressions or deep T-wave inversion; EKG may be normal

STEMI causes transmural damage
NSTEMI causes subendocardial damage

Question 19

MI: Labs

Answer 19

-HIGH-SENSITIVITY TROPONIN is best test (troponin T & I: cardiac-specific markers, risk 2-3h after onset of infarction, stay elevated for 7-10 days)
-CK-MB and myoglobin lack specificity for cardiac m.
-electrolytes
-kidney fxn
-CBC

Question 20

Emergent tx for MI

Answer 20

-admit all pts with suspected acute MI
-supplemental O2 to maintain saturation >90%
-oral ASA 325mg
-SL NTG if BP >90mmHg & no PDE5 inhibitors in the last 24h
-IV morphine only if severe, persistent pain refractory (unresponsive) to nitrates
-B-blocker if not CI (ex. already bradycardic) (metoprolol)
-Atorvastatin reduces recurrent acute MIs in subsequent weeks

*MONA-BA (Morphine, O2, NTG, ASA, B-blocker, Atorvastatin)

Question 21

Thrombolytics vs Reperfusion for MI

Answer 21

-Reperfusion (PCI) is preferred bc lower morbidity/mortality compared to thrombolytics, if available w/in 2h of first medical contact & <12h sx onset (can be done as far out at 48h but sooner the better)
-Thrombolytic therapy (t-PA, alteplase): lots of CIs so it is risky

Question 22

NSTEMI: Tx

Answer 22

-similar to initial STEMI tx (MONA-BA)
-PCI if high risk features:
ST depression
cardiac biomarkers
persistent chest pain
hemodynamic instability

-Thrombolytics NOT recommended
-if EKG & cardiac biomarkers are normal in cases of unstable angina, cont w/ stress testing or further imaging

Question 23

complications of MI (worried about infarction over electrical impulse areas)

Answer 23

-v. fib
-v. tachycardia
-a. fib
-mitral regurgitation
-ventricular septal defects (VSD)
-myocardial rupture (tear in myocardial tissue)
-stroke

Question 24

What is the MC complication of MI (and when is peak incidence following MI)

Answer 24

Ventricular fibrillation
-peak incidence in first 4h post MI

Question 25

Complication of MI: Ventricular tachycardia (when to tx)

Answer 25

-3 or more consecutive ventricular ectopic beats
-tx if prolonged or hemodynamically unstable

Question 26

Complication of MI: Atrial fibrillation (tx)

Answer 26

if hemodynamically compromised –> CARDIOVERT (get back to normal atrial rhythm

if arrhythmia is well-tolerated –> start B-blocker (possibly AC to prevent stroke)

Question 27

Complication of MI: mitral regurgitation

Answer 27

-severe regurgitation is rare & indicates rupture of a papillary m
-results in pulmonary edema
-prompt surgical correction is needed (50% mortality)

Question 28

Location of MI that VSD (ventricular septal defect) is more common with

Answer 28

more frequent w/ anterior MI

Question 29

Complication of MI: myocardial rupture

Answer 29

-tear in myocardial tissue
-repetitive vomiting, pleuritic chest pain, restlessness, agitation
-confirm w/ echo

Question 30

Complication of MI: stroke

Answer 30

from mural (wall) thrombus
-usu occurs w/in several days of MI