Cardiac Flashcards
Discuss the typical findings for angina and the CCS classification
Angina has all 3 of:
- Retrosternal chest pain that radiate to shoulder/jaw/arm
- Provoked by exertion or emotional stres
- Improves with rest or nitroglycerin
CCS Classification
- CCS1: No limitation to activity; angina only with strenuous activity
- CCS2: Slight limitation to activity; angina with normal activity
- CCS3: Marked limitations to ordinary activity: angina with walking or climbing stairs
- CCS4: Angina at rest
Discuss the presentation, exam, and management of stable angina
Presentation - typical angina <20 minutes Exam - Dyskinetic apical pulse - S4 - Mitra regurgitation Management - Smoking cessation - nitrates - Beta blocker - Aspirin - Statin
Discuss the differences between STEMI, NSTEMI and unstable angina
Unstable Angina
- severe and prolonged angina >20 with no ECG changes or cardiac enzyme changes
NSTEMI
- severe and prolonged angina >20 minutes with no ECG changes but elevation in cardiac enzymes
STEMI
- severe and prolonged angina >20 minutes with ECG and cardiac enzyme changes
List the stratification for treatment for NSTEMI
High risk (TIMI 5-7, ST shift) - Heparin - GP IIb/IIIa inhibitor with clopidegrel - B blocker - Early catheterization Intermediate Risk (TIMI 3-4, normal ECG) - heparin - Clopidegrel - Observation Low Risk (Time <=2) - Beta blocker - Early follow up
List the Major Risk Factors for Ischemic Heart Disease
Major
- History of cardiovascular disease
- older age
- male
- Dyslipidemia
- Smoking
- Diabetes
- Hypertension
- Family Hx (male <55, female <65)
List the criteria for metabolic syndrome
Waist circumference >94cm for men or >80cm for women with >=2 of:
- Hypertriglyceridemia (>1.7)
- Low HDL (<1 for men, <1.3 for women)
- Hypertension (>135/85)
- High fast glucose (>5.6)
List the indications for non-invasive testing for those with typical angina
Non-invasive testing and rest echocardiogram
- Adults >30 with >=2 angina criteria
- Male >40 and female >60 with 1 angina criteria
- male <40 and female <60 with 1 angina criteria and cardiovascular risk factor
Discuss the alogrithm for non-invasive cardiac stress testing
Able to Exercise Patients
- Normal ECG
- Exercises stress test
- ECG abnormal but no LBBB or ventricular paced rhythm
- exercise echocardiography
- exercise myocardial perfusion study
- ECG abnormal with LBBB or ventricular paced rhythm
- Vasodilator myocardial perfusion study
Patient Unable to Exercise
- ECG normal
- Dobutamine or vasodilator echocardiography
- ECG abnormal
- Vasodilator myocardial perfusion study
- Cardiac computed tomographic angiography
Discuss criteria that preclude ECG cardiac stress testing
ECG at rest with any of the following
- ST depression >0.1mm
- Digoxin use
- Wolf-parkinon white syndrome
- LBBB
- Ventricular paced rhythm
Discuss the indications for angiography
Any of the following
- high pre-test probability of ischemic heart disease (male with >3 angina criteria)
- High risk features on stress test or left ventricular ejection fraction on echocardiogram
- history of cardiac arrest
- life-threatening arrhythmia on ECG
Discuss the short term and long term management for angina
Short term
- sublingual nitroglycerin PRN for exertional angina
Long Term
- Beta blockers
- first line
- used for those with previous MI or reduced ejection fraction
- titrated to resting HR of 55-60
- Dihydropyridine calcium channel blocker
- amlodipine
- Long acting nitrate
- Revascularization therapy
- PCI
- CABGDiscuss the secondary therapy for ischemic heart disease
Anti-Platelet Agent
- ASA 81mg PO OD for ischemic heart disease
- Clopidogrel 75mg can be used if patient intolerant to ASA
Renin-Angiotensin Receptor Blocker
- ACEI for patients with ischemic heart disease
- especially if left ventricular ejection fraction <=40%, hypertension, diabetic, or CKD
Beta Blocker
- left ventricular ejection fraction <=40%
- history of MI or acute coronary syndrome
- heart failure
Statin
- all patient with ischemic heart disease no matter lipid profile
