CAD

Question 1

Intro to CAD

Answer 1

Clinical manifestations include stable and unstable angina, SOB, DOE, arrhythmias, MI, HF and sudden death. Risk factors are FHx of premature CAD (males younger than 55, females younger than 65), smoking, dyslipidemia, abdominal obesity, HTN, age (males over 45, women over 55)

CAD risk equivalents are diabetes, symptomatic carotid artery disease, peripheral artery disease and AAA

Question 2

Angina pectoris

Answer 2

Substernal chest pain secondary to myocardial ischemia (O2 supply and demand mismatch). Prinzmetal’s (variant) angina mimics angina pectoris but is caused by vasospasm of coronary vessels. Classically affects young women at rest in the early morning and is associated with ST-segment elevation in the absence of cardiac enzyme elevation (prinzMETAL doesn’t MEDDLE with enzymes)

Question 3

History and physical for angina

Answer 3

Classic triad is substernal chest pain that is usually precipitated by stress or exertion and is relieved by rest or nitrates

Pain can radiate and may be associated with SOB, n/v, diaphoresis, or lightheadedness

Exam of patients experiencing stable angina is usually unremarkable. Look for carotid and peripheral bruits suggesting athero and HTN

Question 4

Diagnosis of angina

Answer 4

1) Rule out pulmonary, GI, or other cardiac causes of chest pain
2) Significant ST segment changes on exercise stress test with ECG monitoring and diagnostic of CAD
3) Maintain a high index of suspicion in patient populations such as women and diabetics in view of their propensity for “silent” events

Question 5

Tx of angina

Answer 5

1) Treat acute symptoms with ASA, O2, IV nitro and IV morphine and consider IV B-blockers. Efficacy of nondihydropyridine CCBs (dilt, verap) and ACEis is also validated.
2) Admit to hospital and monitor until acute MI has been ruled out by serial cardiac enzymes
3) Treat chronic symptoms with nitrates, ASA and B-blockers. CCBs are second line for symptomatic control only
4) Initiate risk factor reduction (smoking, cholesterol, HTN). Hormone replacement therapy is NOT protective in postmenopausal women.

ONLY ASA AND B-BLOCKERS HAVE BEEN SHOWN TO HAVE MORTALITY BENEFITS IN ANGINA TX