Clinical Medicine 1 : Chest Pain, SOB, Palpitations, Syncope, Edema (Selby GOAT) Flashcards by Monika Eszterhazy

What is stable angina?

chest pain or pressure for at least 2 months precipitated by exertion or emotional stress and not worsening

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What is unstable angina?

new onset angina with minimal exertion, angina at rest or angina that is worsening

may/may not have ST depression or T wave inversions with NORMAL cardiac enzymes

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What is an NSTEMI?

ST segment depression and/or T wave inversions with

ABNORMAL cardiac enzymes

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What is a STEMI?

ST segment elevation and ABNORMAL cardiac enzymes

(or a new LBBB or a posterior MI)

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What features make up acute coronary syndrome?

Unstable angina

or NSTEMI

or STEMI

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What are the modifiable risk factors for CAD?

HTN

HLD (Atherogenic: low HDL <40 mg/dL, high LDL, and high non-HDL)

Overweight/Obese

Smoking

Inactivity

Unhealthy diet

Stress

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What are non-modifiable risk factors for CAD?

Male sex

Age (M>45, F>55)

FMhx of premature CAD (F<65 M<55)

Ethnicity (AA, Hisp, SE Asian)

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What are some non-traditional risk factors for CAD?

CKD

Proteinuria

Inflammatory States (HIV, RA, Psoriasis, etc)

metabolic syndrome

Elevated coronary calcium scores (CAC)

High sensitvity CRP (>2)

High apolipoportein B levels (>130)

High lipoprotein A (>50)

Elevated homocysteine

Premature menopause

A-fib

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What is the classic presentation for ACS?

Chest pain radiating to jaw, neck, abd.

Dyspnea

N/V

Diaphoresis

Fatigue

***20% of AMI are painless (silent) and/or atypical symtoms, which is more common in women, the elderly, and diabetics.

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20% of AMI are silent/atypical and commonly in which populations?

Elderly

Women

Diabetics

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What are the three classic components of Angina Pectoris

(Diamond-Forrester Criteria of Chest Pain)

**MEMORIZE**

Substernal chest pain
Provoked by exertion/stress
Relieved by rest and or NTG

Typical Angina has all three

Atypical has 2/3

Non-angina has 1/3

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What does a resting ECG look for?

ST elevation/depression

T wave inversions

new LBBB

posterior MI

Q waves

etc.

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What is a cardiac stress test used for?

What if it’s positive?

For patients with intermediate pretest probablilty of CAD

If it is a positive, pt’s should proceed with invasive coronary angiography

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How is an exercise stress test done?

What drugs are used for a pharm stress test?

typically done with a treadmill or stationary bike

vasodilators (adenosine) to dilate coronary artery

Inotropes/Chronotropes (Dobutamine) to increase myocardial oxygen demand, HR, and contractilty

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who cannot have a stress test?

Those with baseline ECG abnormalities

(pre-existing BBB, paced rhythm, WPW, etc)

or >1mm of ST depression

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What is a stress echo used for?

looks for regional wall motion abnormalities or LV dilation

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What is a stress myocardial perfusion imaging test used for?

AKA nuclear stress test

provides info on perfusion defects between rest and stress, cardiac viability, and LV systolic function

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A Dobutamine stress echo can evaluate contractility of the heart to determine what features?

Normal contractility

Regional wall abnormalities such as hypokinesis, akinesis, or dyskinesis

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What are cardiac biomarkers (labs) ?

Myoglobin (and CK isoforms)

rise first, gone by 24hrs

CK, CK-MB

detectable after 3hrs, peak 24hrs, dissapear in 3-4 days

Troponin I or T

detectable after 3hrs, last 5-10 or 5-14 days

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What is the diagnostic criteria for a STEMI?

ST-elevation of greater than or equal to 2mm in continuous leads or a new LBBB

You cannot diagnose a STEMI in the setting of a known/old LBBB

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Diagnosis of STEMI in Pts with chest pain

ST-segment elevation > 2mm (2 small boxes) in 2 continguous leads and positive biomarkers!

ST-elevation equivalents include

new LBBB,
posteroir MI (tall R waves and ST depressions in V1-V3)

*cannot dx STEMI in the setting of old LBBB

What are the criteria for an NSTEMI?

Positive biomarkers w/o ST elevation

New ST depression of greater than or equal to 0.5mm in two contiguous leads

AND / OR

T wave inversions greater than 1 in two contiguous leads

with prominent R waves or R/S ratio >1

What is a type I AMI due to?

What is a type II AMI due to?

Tyep 1: Infarction due to coronary atherothrombosis

Type 2: Infarction due to a supply-demand mismatch not the result of acute atherothrombosis

STEMI results typically from a complete occlusion of blood flow where?

NSTEMI results typically from what?

STEMI: Complete occlusion in a coronary vessel

NSTEMI: P_artial occlusion_ in a coronary vessel

in the presence of complete occlusion of blood flow but in the presence of collateral circulation

What are the treatments for stable angina?

**1) lifestyle modifications** **2) ASA** **3) Statin** **4) Anti-anginal drugs** 4. a) Chronic, BB, CCB, LA Nitrates, Ranolazine 4. b) Acute: SA Nitrates

What drugs are used for chronic angina prevention?

B-blockers Ca channel blockers long-acting Nitrates Ranolazine

What drugs are used for acute angina relief?

short-acting NTG (SL NTG)

How is EECP therapy used? (external enhanced counterpulsation therapy)

35 daily outpatient treatments compression devices put on LE and inflate during diastole

What are the three indications for CABG?

3 vessel diseases \>70% stenosis Left main diseases LV dysfunction

What is the initial management for all ACS patients (unstable angina) ## Footnote **Mnemonic**

**MONA** Morphine O2 Nitrates ASA

What antiplatelet therapy is given to patients with ACS (unstable angina)

**Dual Antiplatelet Therapy;** 1) ASA\* 2) P2Y12 inhibitors\* **PLUS** Glycoprotein IIb/IIIa inhibitors

Which drugs have been shown to improve mortality in myocardial infarction?

ASA B-blockers ACEi

Which drug is a COX1/2 inhibitor? Which drug is a ADP inhibitor? Which drug inhibits GPIIb/IIIa?

ASA (irreversible!) P2Y12 inhibitors (ticlopidine) GPIIb/IIIa inhibitors (abciximab)

What is the PCI mangement timeline in a STEMI? (Percutaneous coronary intervention)

PCI capable hospital: \<90min non-PCI capable hospital: transfer within \<120min thrombolytics within \<30min then transfer

What does the TIMI score predict?

14 day risk of death recurrent MI or urgent revascularization

What are the TIMI criteria?

age \>65 \>3 CAD risk factors documented CAD with \>50% stenosis ST segm deviation \>2 aginal episodes in past 24hrs ASA use in past week Elevated cardiac biomarkers (CK, MB, or troponin) 0-2: low risk 3-4: intermediate risk 5-7: high risk

What is Dressler Syndrome? | (Postmyocardial infarction syndrome)

immunologically based syndrome typically occurs wihtin weeks to months after an MI manifests as pericarditis

What are some of the DDx of acute MI? (aka other causes with similar presentation)

Aortic Dissection Pulmonary Embolism

What are the two classification systems for thoracic aortic dissection?

1. Debakey 2. Stanford\* (Selby and Taylor want this)

What is the epidemiology of aortic dissection?

uncommon, catastrophic (1-2% mortality rate per hour after sx onset) 3-5 cases per 100000, typically men and elderly acquired and genetic conditions can predispose ascending aortic dissection is more common then descending

What are risk factors in younger patients for aortic dissection?

LIFESTYLE: HTN, smoking, dysplipidemia, and cocaine or meth use CONNECTVIE TISSUE: Marfans, ED, etc HEREDITARY: Bicuspid aortic valve INFECTIOUS: Syphilis TRAUMA: car crash, falls

What is the classic presentation for Aortic Dissection?

Sudden onset of tearing/ripping chest pain radiating to back HTN (but hypotension can be seen as well)

What are some other cardiac features of aortic dissection?

MI aortic regurgitation BP asymmetry in UE tamponade syncope

What are some GI/Pulm/Renal sx of aortic dissection?

mesenteric ischemia, GI bleeding hemothorax ARF

How to diagnose aortic dissection?

ECG and cardiac biomarkers to rule out MI CXR (widen mediastinum) CTA (most common way to diagnose) TEE

What is the acute medical management for Aortic dissection?

Anti-impulse therapy to lower HR Get BP to less than 120 **First line: IV b-blockers and can add vasodilators** Opiates for pain control

What are the surgical options for aortic dissection?

open surgery endovascular stenting

Which type of aortic dissection has a better survival rate?

Type B (descending aorta, past isthmus)

Management of Type A Aortic Dissection

Mortality rate is significantly reduced in Type A with **surgical management**

Management in Type B Aortic Dissection

Medical and endovascular management have better outcomes for survival in Type B aortic dissection.

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Clinical Medicine 1 : Chest Pain, SOB, Palpitations, Syncope, Edema (Selby GOAT) Flashcards

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