Angina Flashcards
stable angina vs. unstable angina
stable: predictable chest pain w/ exertion, relieved w/ rest
unstable: unpredictable chest pain independent of exertion
angina
discomfort d/t lack of BF to heart
Major modifiable RFs of angina
cigarette smoking
dyslipidemia
HTN
DM
abdominal obesity
Non-modifiable RFs of angina
increasing age (>40yo)
FH
male
typical angina
chest, arm, jaw discomfort/pressure
stable angina sx
-chest discomfort (pain, pressure, heaviness, tightness), possibly radiating to arm, shoulder, jaw
-associated with exertion
atypical angina
epigastric discomfort
back discomfort
indigestion-like discomfort
Stable angina: PE
-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”
Levine sign
grabbing chest d/t pain (assoc w/ angina)
Stable angina: Dx tests
-EKG: may be normal if no current sx
-Labs looking for RFs of CVD: Hgb (anemia?), fasting glucose, HgA1c, BMP, troponin, fasting lipid panel
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?
-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)
Stable angina: Tx (LOTS!)
-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%
Unstable angina vs. Printzmetal’s/vasospastic angina
unstable angina typically lasts longer than Printzmetal’s angina and has lingering dx abnormalities
Pt presents with sx of unstable angina. Flowchart to determine STEMI vs NSTEMI
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
Sx of MI
-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
MI: PE
-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)
If PE following acute MI shows signs of pulmonary congestion how does this affect mortality?
signs of pulmonary congestion following MI increase mortality rate
MI: EKG
-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
MI: Labs
-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
Emergent tx for MI
-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)
Thrombolytics vs Reperfusion for MI
-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
NSTEMI: Tx
-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
complications of MI (worried about infarction over electrical impulse areas)
-v. fib
-v. tachycardia
-a. fib
-mitral regurgitation
-ventricular septal defects (VSD)
-myocardial rupture (tear in myocardial tissue)
-stroke
What is the MC complication of MI (and when is peak incidence following MI)
Ventricular fibrillation
-peak incidence in first 4h post MI
Complication of MI: Ventricular tachycardia (when to tx)
-3 or more consecutive ventricular ectopic beats
-tx if prolonged or hemodynamically unstable
Complication of MI: Atrial fibrillation (tx)
if hemodynamically compromised –> CARDIOVERT (get back to normal atrial rhythm
if arrhythmia is well-tolerated –> start B-blocker (possibly AC to prevent stroke)
Complication of MI: mitral regurgitation
-severe regurgitation is rare & indicates rupture of a papillary m
-results in pulmonary edema
-prompt surgical correction is needed (50% mortality)
Location of MI that VSD (ventricular septal defect) is more common with
more frequent w/ anterior MI
Complication of MI: myocardial rupture
-tear in myocardial tissue
-repetitive vomiting, pleuritic chest pain, restlessness, agitation
-confirm w/ echo
Complication of MI: stroke
from mural (wall) thrombus
-usu occurs w/in several days of MI
