Angina/NSTEMI Flashcards
Why do you get angina?
supply of O2 doesn’t meet demand
What does angina’s O2 supply/demand imbalance cause? What nervous system mediates this?
causes ischemia, frequently with pain (angina)
ANS
What is chronic stable angina?
pattern of chest pain that is similar in frequency or severity for longer than 2 months; KEY = pain episodes are provoked by stresses of SIMILIAR intensity
what are the 3 criteria for stable angina?
1) . substernal chest pain
2) . exertional chest pain
3) . chest pain relieved with rest
What are the 3 criteria for unstable angina?
1) . rest angina
2) . severe angina of new onset 3). increase in severity or frequency of previously stable angina
What coronary artery is frequently occluded & causes an MI? What part of the heart does this affect?
LAD- left anterior descending
effects most of left ventricle and contractility
What % of narrowing in a coronary artery can cause angina?
50%
what are 3 main body mechanisms that block blood flow and can lead to stable angina
atherosclerosis
vasoconstriction/artery spasm
small vessel atherosclerotic disease
What is the common clinical manifestation of stable angina?
Levine sign (patient clutching left side of chest)
A patient with stable angina experiences pain with ______
exertion
What is another common symptom of angina besides pain?
indigestion
What is atypical angina? What percentage range is the pts’ CAD?
Meets 2 out the 3 criteria for stable angina
20-50%
What is non-coronary chest pain?
when none or only one criteria of stable angina is met
Not all chest pain is _____
angina
Don’t determine angina with only a _______
physical exam (“even cardiologists are frequently fooled”)
What may appear on an EKG that demonstrates an old MI
abnormally large & downward Q wave (ischemic heart muscle diverts conduction around the ischemia)
What types of patients are not indicated for a stress test to dx stable angina?
low or high risk
moderate pt best- pt with multiple cardio risk factors & you suspect CAD, then do stress test
what are the two most important predictors of survival with chronic CAD pts? what test do you do to evaluate this?
left ventricle function
extent of myocardium at risk
ECHO
What type of testing can you do in place of a stress test for non-ambulatory or limited exercise capacity pts?
pharmacologic stress test (dobutamine, dipyridamole, adenosine)
When are invasive tests (angiography/cath) indicated for an anginal patient
patient has failed to meet goal of medical therapy and has an inc risk of MI/death
What are two critical treatments to maintain stable angina?
lifestyle modifications (Global cardiovascular risk) pharmacologic therapy
How much exercise is good for a patient with stable angina?
walk to the point of pain, stop & then walk again
What is drug of choice for symptomatic stable angina?
Nitrates
Besides nitrates, what are the 3 other types of drugs used for stable angina tx?
statins (aggressively lower lipids = >50%), BB after MI (control BP), antiplatelet agents
**statins and BB only drugs to reduce morbidity and mortality
What is BEST tx for stable angina?
medical treatment is better than revascularization PCI or surgery)
What are two main questions to ask a patient with stable angina at EVERY office visit? (they are red flag q’s)
1) . has there been a change in level of activity since the last visit
2) . have anginal symptoms increased in severity or frequency (distinguish stable vs unstable)
what is microvascular angina? when does CP usually occur? What is this also called? What is best tx for it?
microvascular dysfunction (vasospasm or plaque in small vessels) but no lesions or spasm in large coronary vessels
CP occurs mostly at rest
“syndrome X”
Tx is unclear but aerobic exercise may help develop collateral circulation**
During ACS, what type of angina do you have
unstable
What are six stages of atherosclerosis?
Foam cells, fatty streak, intermediate lesion, atheroma, fibrous plaque, complicated lesion/rupture
What stage of atherosclerosis do stable angina signs develop? how about ACS signs?
fibrous plaque stage
complicated lesion/rupture
Describe what an unstable plaque looks like
thin fibrous capsule and liquid lipid core (really thrombogenic)
Difference between NSTEMI and unstable angina
in unstable angina, the ischemia is not severe enough to elevate cardiac enzymes & cause tissue injury
Describe the difference between stable and unstable angina symptoms
unstable symptoms are more severe & last longer
stable symptoms lasts about 2-3 minutes and returns to normal
What is a key thing to ask the patient about his/her anginal symptoms?
ONSET- when did the symptoms start occurring (help distinguish between stable & unstable)
What is the number one symptom of unstable angina?
dyspnea- 69%
Does the physical exam help to determine unstable angina?
NOPE
normal in most cases
What is the specific cardiac biomarker we use to test for ACS? whats the best lab value to get 20 minutes after symptom onset?
troponin 1
myoglobin (presence in bloodstream indicates tissue injury)
Which ACS types show ST segment elevation versus depression?
elevation: STEMI
depression: unstable A or NSTEMI (use biomarkers to distinguish between the 2)
What is the TIMI grading scale? what does it tell you
Risk score for UA/NSTEMI
more than 3 points, then tx is revascularization; less than 3, then medical management
What are the three types of revascularization?
PTCA- ballooning out the artery wall to open the vessel
2) . PTCA + stent placement
3) . rotational burr/atherectomy- grinds away the plaque
What type of revascularization should high risk NSTEMI patients have? What are these patients TIMI risk score?
PCI and stenting
greater than 3
What is long term medical management after ACS?
BANANAS
**make sure statin is intensive/high potency
