Cardio Simple Cases

Question 1

What are the FIVE main groups for causes of CP?

Answer 1

1. cardiac
2. GI
3. pulm
4. Musculoskeletal
5. Psychogenic

Question 2

cardiac causes of CP

Answer 2

• Stable angina
• Unstable angina
• Acute MI
• Atypical or variant angina (coronary vasospasm, Prinzmetal’s angina)
• Cocaine-induced chest pain
• Pericarditis
• Aortic dissection: tearing chest pain radiating to back
• Valvular heart disease, i.e., critical aortic stenosis
• Cardiac arrhythmia

Question 3

GI causes of CP

Answer 3

• Esophageal disease (GERD, esophagitis, esophageal dysmotility)
• Biliary disease (cholecystitis, cholangitis): typically RUQ with radiation to shoulder, may be referred to chest
• Peptic ulcer disease
• Pancreatitis

Question 4

pulm causes of CP

Answer 4

• Pneumonia
• Spontaneous pneumothorax
• Pleurisy
• Pulmonary embolism
• Pulmonary hypertension/cor pulmonale
• Pleural effusion

Question 5

musculoskeletal causes of CP

Answer 5

• Costochondritis
• Rib fracture
• Myofascial pain syndromes
• Muscular strain
• Herpes zoster

Question 6

psychogenic causes of CP

Answer 6

• Panic disorders
• Hyperventilation
• Somatoform disorders

Question 7

how does the American Heart Association define ACS

Answer 7

• umbrella term to cover any group of clinical symptoms compatible with acute MI:
  
  • unstable angina
  • STEMI
  • NSTEMI

Question 8

History to Elicit in Patients with Suspected Acute Coronary Syndrome (FOUR)

Answer 8

1. determine if there are associated symptoms
2. ask about cardiac RF
3. distinguish ischemic from NON-ischemic pain
4. dont forget ACS can present with atypical symptoms

Question 9

in a pt with suspected ACS what would you search for in a physical exam

Answer 9

• Vital signs for tachycardia, hypotension, or hypertension.
• Cardiac exam for murmur, S3 or S4 gallop, auscultation and palpation of pulses.
• **aortic dissection is a “can’t-miss” diagnosis in a pt presenting with acute CP
  
  • Although hx may not be classic for aortic dissection, DO NOT prematurely rule this out

Question 10

x findings suggest y

Answer 10

• Pericardial rub on initial presentation=pericarditis
• Lung crackles=HF
• combo of fever, crackles, and DEC breath sounds=pneumonia
• Unilat leg swelling and/or tenderness=DVT/PE
• RUQ tenderness=acute cholecystitis
• epigastric discomfort on palpation=GERD
• CW tenderness=trauma, costochondritis, and other muscular causes of chest pain (could also be ACS)
• Pulse and BP differential from side to side=significant peripheral arterial obstruction - including aortic dissection*
• Diastolic heart murmur=aortic dissection

Question 11

ideal summary statement

Answer 11

1. Epidemiology and risk factors: 49 year-old man with history of tobacco use and family history of early onset CAD
2. Key clinical findings about the present illness using qualifying adjectives and transformative language:

• substernal chest discomfort
• associated nausea and dyspnea
• symptoms assoc. w/ exertion and relieved w/ rest.
• normal PE
• normal ECG
• normal troponin
• normal CXR

Question 12

nml labs in setting of unstable angina/acute MI

Answer 12

• A normal ECG in the presence of CP should not really change your opinion about unstable angina/ACS, and really only suggests that the patient has not had an MI in the past.
• nml troponins this early in an MI may also be expected, since a rise does not usually occur until 4-6hr after the infarct.

Question 13

mc associated symptom in patients with angina or MI

Answer 13

DYSPNEA

Question 14

ECG in PE

Answer 14

• ECG is abnml in 70% of pts with pulmonary thromboembolism.
• 2 mc abnormalities-sinus tachycardia and nonspecific ST and T-wave changes, do not discriminate among diagnoses.
• (relatively infrequent) Findings more suggestive of PE:
  
  • S1Q3T3
    
    • S wave in lead one
    • Q wave in lead three
    • inverted T-wave in lead three)
  • transient RBBB
  • T-wave inversions in V1-V4.

Question 15

stable angina vs. unstable angine vs. acute MI

Answer 15

• Stable angina s/s occur chronically and are predictable with exertion.
  
  • cause: stable atherosclerotic plaque.
• Unstable angina :CP occurs at rest, is new, is INC in freq, or when its onset is triggered w/ a lower level of exertion.
  
  • cause: unstable plaque that has ruptured and caused a non-occlusive thrombus.
• Acute MI: d/t rupture of unstable plaque w/ subsequent occlusive coronary artery thrombosis and myocardial necrosis.

Question 16

Differentiating between unstable angina and NSTEMI

Answer 16

• based on whether the troponins INC
• may require serial measurements of troponins.
• No troponin increase = No MI

Question 17

Criteria for acute MI

Answer 17

• Rise and fall of troponin or CK myocardial band (CK-MB) plus ONE of the following:
  
  • Symptoms consistent with MI
  • ECG changes indicating MI (ST-segment elevation or depression)
  • New pathologic Q waves
  • Findings on percutaneous coronary intervention (PCI)

Question 18

What is the appropriate in the acute management of a pt with ongoing CP d/t unstable angina

Answer 18

• sublingual nitroglycerin
• beta blockers
• ASA
• heparin
• statin
• angiography with PCI

Question 19

Unstable Angina Admission Orders

Answer 19

• bed rest
• PO metropolol
  
  • reduce infarct size and freq of MI
  • improve short- and long-term survival
• telemetry monitoring
  
  • detect tachyarrhythmias and bradyarrhythmias that may occur in the setting of an acute MI.
• anticoagulation w/ heparin drip or subq LMWH
• (stress test in the morning)

Question 20

ECG Waves and Intervals

Answer 20

• P wave: sequential activation (depolarization) of the right and left atria
• QRS complex: right and left ventricular depolarization (normally the ventricles are activated simultaneously)
• ST-T wave: ventricular repolarization
• U wave: unclear - probably represents “afterdepolarizations” in the ventricles
• PR interval: time interval from onset of atrial depolarization (P wave) to onset of ventricular depolarization (QRS complex)
• QRS duration: duration of ventricular muscle depolarization
• QT interval: duration of ventricular depolarization and repolarization
• RR interval: duration of ventricular cardiac cycle (an indicator of ventricular rate)
• PP interval: duration of atrial cycle (an indicator of atrial rate)

Question 21

12-Lead ECG Interpretation

Answer 21

• leads V1-V4 : anterior wall
• leads II, III, aVF : inferior portion of the heart
• leads I, aVL, V5, V6 : lateral myocardial wall

Question 22

define reciprocal changes

Answer 22

ST elevations in the inferior leads and ST depressions in the lateral leads

Question 23

when should Immediate diagnostic coronary angiography be considered

Answer 23

pts w/ CP and STEMI or new LBBB w/ the goal of angioplasty within 90 mins

Question 24

Awaiting further lab testing is unnecessary and dangerous

Answer 24

cardiologists say about STEMI, “Time is myocardium.”

Question 25

Criteria to Diagnose a LBBB on the ECG

Answer 25

• The heart rhythm must be supraventricular in origin.
• The QRS duration must be = or > 120 ms.
• There should be a QS or rS complex in lead V1.
• There should be a monophasic R wave in leads I and V6.

Question 26

absolute contraindications for thrombolytic therapy include

Answer 26

• Strong suspicion of dissection of the aorta
• Pericardial effusion
• Active GI or other internal bleeding
• Brain tumor, AV malformation, or aneurysm
• Ischemic stroke in preceding 6 months
  
  • a verified TIA is an exception
• Previous ICH or SAH
• Intracranial procedure or recent head trauma
• Severe known bleeding disorder: coagulation abnormality, thrombocytopenia, etc.

Question 27

Coronary Artery Bypass Graft (CABG) vs. Percutaneous Transluminal Angioplasty

Answer 27

• PTCA with or without stenting produces a similar survival rate to CABG but is assoc w/ a higher rate of recurrent symptoms and target vessel revascularization (this may be changing with the use of drug-eluting stents).
• CABG may be preferred in:
  
  • left main lesions
  • complex proximal LAD disease w/ other unfavorable lesions (three-vessel dz)
  • pts w/ LV dysfunction or DM.

Question 28

GP IIb/IIIa Inhibitors in Angioplasty for STEMI

Answer 28

• abciximab or eptifibatide inhibits platelet aggregation, may prevent platelet adhesion to the vessel wall.
• theres INC r/o bleeding (especially when used in combo w/ fibrinolytics) and can cause thrombocytopenia within 24 hours of initiation
• they improve outcomes in patients with STEMI.

Question 29

Anatomy of Coronary Artery Occlusions and Infarction

Answer 29

• Inferior infarction typically assoc w/ an RCA lesion
• Anterior or lateral infarctions usually associated with L. circumflex and LAD occlusions

Question 30

Discharge Medications Following an MI & Stent Placement

Answer 30

• ASA
• beta blocker
• clopidogrel
• sublingual nitroglycern PRN
• statin (HMG CoA reductase inhibitor)