Clinical Medicine: Chest Pain Flashcards
What is stable angina?
chest pain or pressure for at least 2 months precipitated by exertion or emotional stress and not worsening
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
What is an NSTEMI?
ST segment depression and/or T wave inversions with
ABNORMAL cardiac enzymes
What is a STEMI?
ST segment elevation and ABNORMAL cardiac enzymes or a new LBBB or a posterior MI
What features make up acute coronary syndrome?
Unstable angina
or NSTEMI
or STEMI
What are the modifiable risk factors for CAD?
HTN
HLD
DM
Overweight/Obese
Smoking
Inactivity
Unhealthy diet
Stress
What are non-modifiable risk factors for CAD?
Male sex
Age
FMhx of premature CAD
Ethnicity (AA, Hisp, SE Asian)
What are some non-traditional risk factors for CAD?
CKD
Proteinuria
Inflammatory States (HIV, RA, Psoriasis, etc)
What is the classic presentation for ACS?
Chest pain radiating to jaw, neck, abd.
Dyspnea
N/V
Diaphoresis
Fatigue
20% of AMI are silent/atypical and commonly in which populations?
Elderly
Women
Diabetics
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
What does a resting ECG look for?
ST elevation/depression
T wave inversions
new LBBB
posterior MI
Q waves
etc.
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
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)
who cannot have a stress test?
Those with baseline ECG abnormalities
(pre-existing BBB, paced rhythm, WPW, etc)
What is a stress echo used for?
looks for regional wall motion abnormalities or LV dilation
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
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
What are cardiac biomarkers (labs) ?
Myoglobin
CK, CK-MB
Troponin I or T
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
What are the criteria for an NSTEMI?
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?
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?
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?
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)
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?
- Debakey
- 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
