Clinical Medicine: Chest Pain Flashcards by Liz Pennington

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

Overweight/Obese

Smoking

Inactivity

Unhealthy diet

Stress

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What are non-modifiable risk factors for CAD?

Male sex

Age

FMhx of premature CAD

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)

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What is the classic presentation for ACS?

Chest pain radiating to jaw, neck, abd.

Dyspnea

N/V

Diaphoresis

Fatigue

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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)

Inotropes/Chronotropes (Dobutamine)

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who cannot have a stress test?

Those with baseline ECG abnormalities

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

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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) ?

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Myoglobin

CK, CK-MB

Troponin I or T

What is the diagnostic criteria for a STEMI?

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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

What are the criteria for an NSTEMI?

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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?

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Infarction due to coronary atherothrombosis

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 a partial occlusion in a coronary vessel or in the presence of what?

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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?

Study These Flashcards

lifestyle modifications

ASA

Statin

Anti-anginal drugs

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)

ASA\* P2Y12 inhibitors\* Glycoprotein IIb/IIIa inhibitors \*part of dual antiplatelet therapy\*

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 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 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

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?

CT disorders, Marfans, ED, etc Syphilis cocaine/meth use trauma

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

Clinical Medicine: Chest Pain Flashcards

(46 cards)