CHD & ACS Flashcards
Ddx for chest pain
- Nonischemic
- Noncardiovascular: Pulmonary, GI, musculoskeletal
Classic ACS initial therapy “MONA”
- Morphine
- O2
- Nitroglycerin
- Aspirin
Define angina
Chest, jaw, shoulder, arm discomfort due to ischemia
Define typical angina
Substernal chest discomfort w/ quality & duration
- Provoked by exertion or stress
- Relieved w/ rest or nitroglycerin
Define atypical angina
Having only 2 of the typical characteristics
- May be pleuritic, reproduced by palpation or movement, constant & lasting days, fleeting pain lasting seconds
Stable angina
- develops w/ predictable amount of exertion
- similar to typical angina
- short duration
- resolves w/ rest or meds
MI
Rise/fall of cardiac biomarker values w/ at least 1 value above the 99th percentile & 1 of the following:
- sx of ischemia
- ST segment T wave changes or new LBBB
- pathological Q waves
- loss of myocardium or new RWMAs
- thrombus
Ischemia-guided strategy, when is invasive eval used?
Invasive eval, used if pt:
- fails med therapy
- has evidence of ischemia on stress test
- has high risk
NSTE-ACS pathogenesis
Imbalance of myocardial O2 consumption & demand –> ischemia/infart
NSTE-ACS etiologies
- Coronary artery obstruction
- Vasospasm (Prinzmetal’s angina)
- Coronary embolism
- Dissection
- Nonobstructive causes
Possible PE findings for ACS?
- Levine’s sign (bringing hand to heart)
- New S4
- Paradoxal splitting of S2
- Pericardial friction rub
- CHF/shock
Initial ACS dx studies
- ECG within 10 mins of arrival in ED
- Obtain hx (1st step in risk stratification)
- May repeat ECG 12-30 mins for 1st hr
- Serum biomarkers
- CBC, BMP, coagulation panel, cholesterol
- B-type natriuretic peptide (BNP)
- CXR
When should troponin be measured?
At presentation & 3-6 hrs after sx onset in all pts who present w/ sx consistent w/ ACS
- Should be repeated 6 hrs after sx onset in those w/ high suspicion for ACS even if troponin is negative (bc this does not mean that there is no ischemia!)
What is not useful for dx of ACS?
CK-MB & myoglobin
Causes of elevated troponin
- Tachy/brady
- Cardiogenic, hypovolemic, septic shock
- HTN w/ or w/out LVH
- HF
- Pulmonary embolism or HTN
- Sepsis
- Renal failure
What can be used to dx reinfarction & assess reperfusion?
CK-MB
What models can be used in the management of NSTE-ACS?
- TIMI Risk Score *
- GRACE Risk Model *
- PURSUIT Risk Score
- GUSTO Risk Score
- HEART Score for MACE *
- EDACS
TIMI risk score values
- Low risk = 0-2
- Intermediate risk = 3-4
- High risk = 5-7
In the TIMI risk score model, what equals 1 point each?
- Age ≥ 65
- ≥ 3 risk factors for CAD
- Known CAD
- ASA use in past 7 days
- Severe angina (≥ 2 episodes within 24 hrs)
- ST depression ≥ 0.5
- Positive cardiac biomarkers
Who should be admitted to hospital?
- Recurrent sx
- Ischemic changes
- Elevated troponin
- Intermediate to high risk
NSTE-ACS standard med therapies
- Supplemental O2
- Anti-platelet
- Statin
- Nitroglycerin
- Analgesics (NSAIDS contraindicated)
What med is contraindicated?
NSAIDs
Types of anti-platelet therapy
- Aspirin (Non-enteric coated, chewable)
- P2Y12 Inhibitor (Clopidogrel, Prasugrel, Ticlopidine, Ticagrelor)
Types of anticoagulation
- Indirect thrombin inhibitors
- Direct thrombin inhibitors
Beta blockers
- Decreases myocardial contraction & O2 demand
- Metoprolol, carvedilol, bisoprolol
Calcium channel blockers
- Nondihydropyridine (verapamil, diltiazem)
- Initial therapy if ongoing angina
Aldosterone antagonist
- For pts post-MI in the absence renal dysfunction or hyperkalemia
Features of unstable angina
- Develops at rest or w/ minimal exertion
- Change in typical pattern
- More severe/ lasts longer
- May not resolve w/ rest or meds
What is unstable angina caused by?
Insufficient coronary blood flow, w/out evidence of myocardial necrosis
NSTEMI & STEMI
Angina w/ elevated cardiac biomarkers
- Indicates MI, w/ or w/out ST deviation
Coronary disease spectrum
- Ischemia = stable & unstable angina
- Infarction = STEMI & NSTEMI
- ACS = unstable angina, STEMI, & NSTEMI
Baseline risk factors for ACS
- Male > female
- Age
- Family hx
- Prio hx of CAD
- Kidney disease
- DM*
- HLD*
- HTN*
- Tobacco*
When is troponin elevated & how long does it persist?
- As early as 2-4hrs, at tops 12hrs
- May persist 14 days or longer
What should be administered to all pts w/ possible NSTE-ACS at presentation?
Non-enteric coated, chewable ASA
