Angina & ACS Flashcards by Sarah Gillen

______ is the underlying cause of CAD and 90% of cases of MI and most heart failure

Atherosclerosis

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Atherosclerotic plaques in coronary arteries can undergo fissuring or erosion, which triggers _____ formation to cause ischemia to the myocardium

Thrombus

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Risk factors for atherosclerosis

Hyperlipidemia (high LDL, low HDL)

Smoking

HTN

Family hx

Obesity

Physical inactivity

Psychosocial stress

Sleep disturbance

Age and gender

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Characteristics of metabolic syndrome

Insulin resistance, increased BG

HTN

High TG, low HDL

Hyperuricemia

Hypercoagulability

Central obesity (BMI >30) or overweight (BMI 25-29)

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Most frequent presenting symptom of myocardial ischemia

Angina pectoris

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Chronic stable angina is a consequence of imbalance between ____ supply and demand; there is a ____ risk of plaque rupture in these pts (meaning there is small lipid core and thick fibrous cap)

oxygen; low

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Compare supply angina vs. demand angina

Supply angina = decreased delivery of O2 to tissues leads to ischemia (i.e., coronary vasoconstriction, stenosis, platelets release 5-HT and TA2)

Demand angina = increased myocardial O2 requirements and workload lead to ischemia (i.e., exercise, stress, emotion, fever, thyrotoxicosis, LVH d/t AS, anemia)

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Mechanical consequences of myocardial ischemia

Heart failure (L or R or both)

Angina (if ischemia is prolonged ro develop coronary occlusion, may lead to myocardial necrosis)

Segmental akinesis, bulging (dyskinesis) — aka wall motion abnormalities

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Biochemical consequences of myocardial ischemia

Fatty acids can’t be oxidized

Increased lactate production

Reduced pH with metabolic acidosis

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Electrical consequences of myocardial ischemia

Inversion of T wave

Transient displacement of ST segment (ST Depression=subendocardial; ST elevation=subepicardial)

Electrical instability: VT, VF

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Area and artery affected if ischemic changes are seen in V1-V6

LAD —> anterior wall infarction

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Artery and area affected if ischemic changes are seen in leads II, III, and aVF

RCA —> inferior wall infarction

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Area affected if ischemic changes are seen in leads V3R-V6R

RV infarct

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Artery and area affected if ischemic changes are seen in I, aVL, V5-V6

Circumflex a.; lateral wall infarct

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Artery and area affected if ischemic changes are seen in V1-V3

Posterior descending artery; Posterior wall infarct

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What information can an ST elevation on ECG tell you that an ST depression cannot?

Location/artery involved in infarct

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Symmetric T wave inversion in the anterior precordial leads that were upright in prior ECGs indicates what?

LAD dz, possible anterior infarct

NOTE that T wave inversion is only significant if it is a CHANGE from previous ECG

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A 58 y/o male presents to the ED with a hx of chest discomfort described as heaviness and pressure in retrosternal region. Pain radiates into base of neck and into jaw, and has been going on for 20 minutes. On PE he has S3 gallop and systolic murmur over apex with radiation into left axilla.

What is the cause of the S3 and the murmur?

S3 gallop may be “impending” LV dysfunction leading to heart failure

Murmur is likely MR d/t dysfunction of papillary m. during chest pain; location is inferior or inferior-posterior d/t RCA lesion

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CV causes of chest pain

IHD (angina, UA, ACS, MI)

VHD

Pericarditis

Myocarditis

Cardiomyopathy

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Non-cardiac causes of chest pain

Pleuritis
Costochondritis
Pneumonia
PE-pulm infarct
Pneumothorax
GERD, PUD
Gallstones
Esophageal spasm
Lung cancer
Aortic aneurysm

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Non-chest pain symptoms of chronic IHD

Dyspnea
Mid-epigastric or abd pain
Diaphoresis
Excessive fatigue and weakness
Dizziness and syncope

[epigastric pain often associated with inferior ischemia]

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What is Levine’s sign?

Pt shows clenched fist as representation of their chest pain

Anginal equivalents are symptoms due to ischemia but described as dyspnea, fatigue, faintness, and gastric belching. This occurs d/t ischemia causing elevated LV filling pressure —> pulmonary edema. What patient populations tend to present differently with MI, like with “anginal equivalents”?

Diabetics
Elderly
Women

What are some PE findings that suggest risk factors for angina?

Xanthelasma
Xanthomas
Diabetic skin lesions
Nicotine stains
Pale
Absent peripheral pulses

What are some cardiovascular exam findings that you may find in pts complaining of angina?

Abnormal cardiac impulse (LV dyskinetic) Bruits — carotid, abominal aorta, femorals Gallop — S3, S4, both Systolic murmur of MR if papillary muscle is dysfunctional; associated with inferior or inferior-posterior ischemia d/t right CAD

What conditions can mimic angina in the absence of coronary artery disease?

``` AS AI Pulmonary HTN Hypertrophic cardiomyopathy Heart failure ```

What 2 criteria need to be met in order for a pt presenting with chest pain to be diagnosed with NSTEMI?

Elevation of cardiac enzymes (troponin I or CK-MB) No ST elevation on ECG

What changes on ECG might be seen in pts with stable angina?

Normal in 50% During anginal attack, may have displaced ST segment; most common change is ST depression (subendocardial injury-ischemia) May show old MI (Q waves in corresponding leads to location of previous MI)

In terms of ECG findings in pts with unstable angina/NSTE ACS, the magnitude of _______ correlates with the pts prognosis

ST depression

T/F: pulmonary emboli may show ECG changes and elevated troponin

True — if it is a large enough PE to affect the LV and cause some cell death, cardiac troponin may be elevated

Characteristic ECG finding in pt with stress cardiomyopathy (takotsubo syndrome)

Deeply inverted T waves

What diagnostic labs would you order in someone with CAD that you suspect possible NSTEMI?

Cardiac enzymes (troponin I; detected in 2-4 hrs in NSTEMI) Increased CK-MB after 3-6 hr Increase in BNP (associated with increased mortality) CRP CMP, BUN, Cr, liver panel, electrolytes, CBC Fasting lipid profile, TSH

What functional tests can be done to reveal presence of ischemia in pts with atherosclerotic CAD?

Exercise ECG, single photon emission (SPECT, PET) Coronary flow (PET, fractional flow reserve) Wall motion abnormalities (Echo, cardiac magnetic imaging - CMRI)

Signs with cardiac stress testing that indicate high risk for coronary event

Positive stress test at low workload ST depression greater than 5 minutes after completion of test Decrease in BP — systolic fall > 10 mm Hg during exercise VT during exercise Reduced EF during exercise (stress echo)

Exercise electrocardiography is preferred test if pt is suspected to have angina. What are contraindications to this test?

Recent MI or acute MI, unstable arrhythmias, acute PE, aortic dissection, unstable angina, severe AS, decompensated HF, endocarditis, DVT

Primary test recommended when baseline ECG findings are abnormal or when area of myocardium is at risk with exercise or when pt can’t exercise

Stress echocardiography

What test is useful in LBBB, LVH, or in digitalis effect?

Nuclear myocardial perfusion imaging

When is a pharmacological stress test indicated?

Pt unable to exercise; abnormal ECG with LBBB, LVH

What drugs are used in pharmacologic stress test?

Adenosine/regadenosine/dipyridamole — vasodilators that increase HR; vasodilate normal blood vessels more than diseased ones, then inject radioisotope - the amount taken up by heart muscle is directly proportional to blood flow Can also use dobutamine to increase HR

_____ ______ provides anatomic diagnosis of severity of CAD; percutaneous revascularization can be performed after the study; risk in renal dysfunction bc exposure to radio contrast

Coronary angiography “cardiac cath”

Gold standard for anatomic definition of CAD

Coronary angiography

In what 2 circumstances is CABG preferred procedure above PCI?

L main disease 3 vessel disease

In coronary CT angiography, ability to quantify lesion severity can be limited by significant _____

Calcification

CXR findings in CAD

Usually normal, unless hx of MI, HF, or VHD Cardiomegaly in HTN, VHD, cardiomyopathy, pericardial effusion

Pharmacologic therapies used to prevent MI and reduce symptoms

``` Aspirin Beta blocker ACEI Statins Nitro/nitrates CCBs ``` [note that nitrates and CCBs do NOT reduce mortality, but the rest do]

Contraindications to beta blockers

Decompensated HF Hypotension Advanced AV block

Drug useful in reducing maladaptive remodeling post-MI, especially in diabetics (renal protection), and patients with LV systolic dysfunction; reduces CV mortality

ACEI

Drug class used post-MI that is NOT shown to reduce mortality but vasodilates and reduces workload as well as decreases heartrate

Calcium channel blockers

MOA of ranolazine

Inhibits inward Na current and decreases intracellular Ca

What type of angina causes transient ST elevation during chest pain in the absence of severe CAD?

Prinzmetal angina

Prinzmetal angina is relieved by nitro; they should also be prescribed _________

Dihydropyridine CCB (amlodipine)

Angina management strategies in low risk patients

Antianginal therapy — BB, nitro, CCB Statin Antiplatelet — ASA, clopidogrel Anticoagulant — UF heparin Cath: revascularization if appropriate [when refractory to other therapy]

Management strategies of angina in high risk pts

Antianginal- BB, nitro, CCB Statin for plaque stabilization and restoration of endothelial function Antiplatelet - ASA, clopidogrel or prasigrel or ticagrelor glycoprotein inhibitor Anticoagulant - UFH or enoxaparin or bivalirudin or fondiparinux Cath: revascularization if appropriate (refractory to other therapy)