Coronary Disease Flashcards
Angina Pectoris
ew-onset angina (angina occurring within 1 month), angina occurring at rest and with minimum exertion, or crescendo angina
-Admit to hospital!
Causes of CV Disease
Genetics
Lifestyle
CAD Risk factors
CAD Risk Factors
obesity
diet
hypertension
high cholesterol
smoking
stress
diabetes
Diabetes and heart disease
death risk is 2 -4 times higher
Women with higher CAD risk
pregnancy-related disorders (gestational HTN or Diabetes, ecclampsia)
Polycystic ovarian disease
hyptohalamic anemia
breast cancer
Hypertension goals
<140/90
<130/80 if renal disease as well
Lipid Goals
Trig <200
TC<130
ASA in CAD
75-162 mg PO daily
plavix or warfarin if ASA is contraindicated
Beta Blockers in CAD
All patients who had a MI, ACS, or LV dysfunction should be on beta blocker unless contraindicated
ACE Inhibitors in CAD
All patients with left ventricular ejection fraction ≤ 40% and those with hypertension, diabetes, or chronic kidney disease, unless contraindicated
Chronic Stable Angina
chest pain precipitated by exertion and relieved by rest. A reduction in myocardial oxygen supply or increases in myocardial oxygen demand are the determinants of coronary ischemia. Predictable presenting or causative factors.
Pain may be variable and may radiate.
Rest or NTG reduces pain within minutes
Symptoms longer than 20 mins = ED refer
Asymptomatic CAD
Asymptomatic occurrences of ischemia can be more common than symptomatic episodes in patients with exertional angina symptoms.7 Silent myocardial ischemia occurs when there is objective evidence of ischemia in the absence of symptoms.
Higher risk of this in diabetics
Asymptomatic CAD
Asymptomatic occurrences of ischemia can be more common than symptomatic episodes in patients with exertional angina symptoms.7 Silent myocardial ischemia occurs when there is objective evidence of ischemia in the absence of symptoms.
Higher risk of this in diabetics
Microvascular Angina
Affects women more than men
Chest discomfort with exercise and positive stress test, but no coronary artery obstruction
Chest pain that is unpredictable, does not go away with rest and doesn’t respond to NTG
Usual treatment is beta blockers to reduce oxygen demand
Vasospastic Angina (Variant or Prinzmetal)
coronary artery spasm can cause chest discomfort at rest evidenced by ST elevation or depression on electrocardiogram (ECG).17 Spasm can occur in any coronary artery and the exact cause is not
Unstable Angina
Plaque rupture causes occlusive thrombus that may be transient and can resolve spontaneously but usually recur, if it becomes fixed then MI occurs
STEMI
MI occurs when an atherosclerotic plaque ruptures and then serves as a nidus for thrombus formation with resultant coronary artery occlusion, ischemia, myocyte necrosis, infarction, and death
Suspected Myocardial Infarction With Nonobstructed Coronary Arteries
Myocardial infarction with nonobstructed coronary arteries (MINOCA) is described as the occurrence of an acute MI, but without an obvious cause (i.e., no obstruction)
Stress Testing
Stress testing, which may be pharmacologic or exercise based, is performed for diagnostic, prognostic, and management purposes. With an overall sensitivity of 50% and specificity of 90%, exercise stress testing can be a cost-effective strategy for evaluation of CAD. ST segment changes consistent with MI changes are positive.
CT Angiography
coronary computed tomography angiography (CTA) is highly sensitive, with a detection rate over 90%, but is not very specific. This means that a negative result will essentially rule out CAD with 90% accuracy, but if the test result is positive, this result is less conclusive
MI Labs
Serial cardiac troponin I or T levels (when a contemporary assay is used) should be obtained at presentation and 3 to 6 hours after symptom onset. Samples for C-reactive protein analysis may also be drawn to determine the presence of an inflammatory response. Measurement of B-type natriuretic peptide or N-terminal pro-B type natriuretic peptide may be considered to assess risk for heart failure.
EKG in MI / CAD
ST segment elevation at the j point of two contiguous leads of >1mm or more indicates MI
ST segment depression plus T-wave inversion indicates ischemia early
New left bundle branch block is also suggestive of M
Hyperacute T-Wave changes (inversion) may be seen before ST changes
ST segment depression may also indicate injury in the opposite area of the heart
Leads and Heart locations
2, 3, aVF - Inferior
V1-V2 - Anterior
V3-V4 - Septal
1, aVL, V5, V6 - Lateral
Troponin and CK-MB Levels
Troponin elevates within 3-12 hours, peaks in 4 hours, normalizes in 14 days
CK-MB rises in 3-12 hours, peaks at 24 hours, normalizes in 48-72 hours
Chest Pain Differentials
Aortic dissection
PE
Spotaneous Pnuemothorax
Takotsubo cardiomyopathy
GI
Psych (panic attack)
Respiratory
Chronic Stable Angina Treatment
Aspirin
Beta Blockers
Lipid control
NTG as needed
Microvascular Angina Treatment
Beta Blockers - first treatment
Calcium channel blockers
ACE Inhibitors
Ranolazine
Vasospastic Angina treatment
NTG
Unstable Angina Treatment
Consider NSTEMI and Refer
Aspirin immediately
Beta blockers as needed
NTG as needed
Refer Criteria
Unstable Angina
Suspected MI
Co-morbid conditions
Chronic stable angina that has a change in the angina pattern
Signs of ischemia
Angina Classifications (Numeric Class)
1 - Onset is prolonged exertion, no effect on normal activity
2 - Onset occurs with walking 2 blocks, slight effect on normal activity
3 - Onset occurs walking less than 2 blocks, marked effect on normal activity
4 - Occurs at rest or with minimal activity, severe effect of normal activities
