CVD and Chest Pain Flashcards
What is the single most important factor in assessing CAD?
Collect a thorough history and physical exam that includes:
- Prior medical history of MI or CAD
- Presenting symptoms: angina, radiating pain, tingling, numbness
- Family history of CAD
What additional diagnostic tools would be helpful in diagnosing CAD?
- Immediate ECG
- Lab biomarkers (e.g. troponin)
- Cardiac catheterization indicated if ECG findings and biomarkers indicate acute MI
What is the NPs role in managing CAD?
Reduce risk factors
- Smoking cessation
- Manage HTN, DM, hyperlipidemia
What is the first line diagnostic test for CAD?
Exercise tolerance test/stress test
- Most common and least invasive
- Detects CAD in patients with chest pain or DOE
What non-invasive tests and biomarkers can be collected to evaluate CAD?
- Labs: CRP, IL-6, monocyte-macrophage colony stimulating factor
- Coronary artery calcium score (CACS)
- Directly related to plaque burden
What are imaging adjuncts to the exercise tolerance test (ETT)?
- Myocardial perfusion imaging (MPI)
- Cardiac ultrasound imaging (2DE)
- Exercise echocardiography
- 3D and doppler flow echocardiography
- Cardiac MRI and ultrafast CT scans
- Pharmacologic stress testing
What diagnostic testing considerations will need to be made when assessing women?
- Women are more likely to have non obstructive or single vessel disease
- Limited evidence to suggest the most appropriate CV diagnostic test for women
How does myocardial ischemia present in women?
- Dyspnea
- Indigestion
- Nausea
- Numbness in UE
- Fatigue
What is carotid stenosis (CS)?
Atherosclerotic narrowing of the extra cranial arteries
Carotid stenosis (CS) symptoms
Manifests as focal neurological dysfunction
- TIA, ischemic stroke, confusion, etc.
What is the difference between a TIA and stroke?
TIA → acute neurological dysfunction referable to the distribution of a single brain artery and characterized by symptoms that resolves in <24 hours without permanent neurological deficit
Ischemic stroke → neurological deficit that persists >24 hours
True/false: If stenosis in the carotid artery is 70-90% occluded, the patient will require invasive interventions
True - should undergo CEA
Symptomatic manifestations of carotid stenosis (CS)
- Visual disturbances
- Monocular blindness (amaurosis fugax)
- Weakness or numbness of contralateral arm, leg, and/or face
- Dysarthria
- Aphasia
Asymptomatic manifestations of carotid stenosis (CS)
- Dizziness
- Generalized weakness
- Syncope or near syncopal episodes
- Blurred vision
- Transient visual phenomena (“floaters”, “stars”)
What two findings on fundoscopic examination indicate significant CS?
- Amaurosis fugax
- Hollenhorst plaques
Modifiable risk factors for CS (or any atherosclerotic disorder)
- High blood pressure
- Smoking
- Hyperlipidemia
- DM
- Hyperhomocysteinemia
- Obesity
- Nutrition
- Physical inactivity
- CKD
- Heavy alcohol consumption
- Sleep apnea
- Depression
Physical exam components for CS
Perform a complete CV and neurologic exam
- Include palpation of all bilateral peripheral pulses and auscultation for bruits
- BP of bilateral UE in the lying and sitting position
- Neurologic exam → MS, cranial nerves, fundoscopic, motor and sensory function
What is the first line diagnostic study for CS?
Duplex ultrasound
Other than a duplex ultrasound, what other diagnostic studies (imaging and labs) are indicated for CS?
- Catheter-based angiography (criterion standard)
- MRA + CTA (adjunct to duplex ultrasound)
- Labs: CBC, BMP, lipid panel, coagulation studies
How would the NP manage CS?
- Medication therapy + carotid revascularization (CEA)
- Carotid angioplasty and stenting + medication therapy
- Smoking cessation
What medications should be prescribed for patients with CS?
- ASA and/or clopidogrel (if symptomatic)
- Statins
- Antihypertensives
How long should patients be on antiplatelet therapy (ASA + clopidogrel) for after CEA for CS?
At least 4 weeks
When is noninvasive imaging indicated in patients with CS?
- All patients who present with amaurosis fugax, TIA, stoke to determine extent of CS
- Patients with carotid bruit or other nonspecific symptoms (e.g. dizziness)
Coronary heart disease (CHD) is an umbrella term. What conditions does this include?
- Acute MI
- Angina pectoris
- Atherosclerotic CV disease
- All forms of chronic ischemic heart disease
Chest pain - What is chronic stable angina?
- Precipitated by exertion
- Relieved by rest and NTG
- Lasts <5 minutes
Chest pain - What is silent myocardial ischemia?
Asymptomatic coronary heart disease
- Objective evidence of ischemia in the absence of symptoms
Chest pain - What is microvascular angina (syndrome X)?
- Chest discomfort with exercise
- Positive stress test
- Angiography reveals no obstruction
Chest pain - What is variant angina (coronary artery spasm, prinzmetal angina)?
Coronary vasospasm can cause chest discomfort at rest AEB by ST elevation or depression on ECG
Chest pain - What is unstable angina and NSTEMI?
- Chest pain lasta >10 minutes
- Not relieved by rest or NTG
Chest pain - What is acute STEMI?
Atherosclerotic plaque ruptures and serves as nidus for thrombus formation with resultant coronary artery occlusion, ischemia, myocyte necrosis, infarction, death
Chest pain - What is MINOCA?
Acute MI without an obvious cause (no obstruction)
- Consider MINOCA as working diagnosis while evaluating for treatable underlying causes with MRI, provocative testing, and evaluating for thrombophilia
What is the Levine sign?
Patient places clenched fist over their sternum → sign of chronic stable angina
Chronic stable angina clinical presentation
Occur with predictable frequency, severity, duration, and provocation
- Dyspnea
- Paroxysmal nocturnal dyspnea
- Orthopnea
- Diaphoresis
- N/V/D
- Eructations (belching)
- Fatigue
- Levine sign: clenched fist over sternum
Angina equivalents clinical presentation
Myocardial ischemia may present as…
- Dyspnea
- Indigestion
- Nausea
- Numbness in UE
- Fatigue
Rather than chest pressure/tightness (especially for women)
Microvascular angina clinical presentation
- Generally more intense chest pain, lasts for longer periods of time, does not go away with rest
- Unpredictable and occurs with rest, routine physical activity, or stressful events
Vasospastic angina clinical presentations
History of spontaneous or unprovoked episodes of typical angina
Unstable angina and NSTEMI clinical presentation
Most important factors from initial history that increase likelihood of patient experiencing episode of ischemia are…
- Nature of symptoms
- Prior history of CAD
- Age >65 years
- Number of risk factors for CAD
Physical exam components for chest pain and CAD
- HEENT - funduscopic (diabetic retinopathy), neck JVD
- Periorbital → xanthomas or early arcus senilis may indicate elevated cholesterol
- Cardiac → PMI (may be displaced), palpate carotid upstroke, auscultate for murmurs, gallops, pericardial friction rub, bruits
- Lungs → adventitious breath sounds
- Thorax → vesicles or rashes (herpes zoster), edema, lesions
Diagnostic studies for CAD and chest pain
- ECG
- Echocardiography
- Exercise tolerance test/stress test
- Coronary CT angiography
- Labs: hgb/hct, electrolytes, magnesium, TSH, serial cardiac troponin, CRP, BNP
How would the NP manage chronic stable angina with medication?
- Antihypertensives (beta blockers, ACE inhibitors or ARBs)
- Nitrates
- ASA
- Anticoagulants
True/false: Patients with comorbidities (DM, SLE) and chest pain/CAD should be referred to cardiology
True
What should the NP do for patients with an acute STEMI?
Need to be transported to ED within 90 minutes to a facility with PCI capability
- If transport is to non-PCI capable hospital, or when anticipated time of transfer is >120 minutes, give fibrinolytic therapy within 30 minutes
What is heart failure (HF)?
Inability of the heart to meet the body’s metabolic demands
- Clinical diagnosis
- Results from any structural/functional cardiac disorder that impairs the ventricles ability to fill or eject blood properly
What is the most common cause of heart failure?
Cardiomyopathy
What is HFrEF?
Reduced EF <40%
- Reduction in contractility of the LV (systolic) → reduced CO
- Symptomatic
What is HFpEF?
Preserved EF >50%
- Associated with impairment of ventricular filling and relaxation (diastolic)
- Results in reduced SV with exertion causing symptoms
What is the most common cause of HFrEF and HFpEF?
HFrEF → CAD
HFpEF → HTN, atrial fibrillation, DM
HF clinical presentation
- Cardinal symptoms → dyspnea, fatigue
- LE edema, JVD
- Paroxysmal nocturnal dyspnea, orthopnea
- SOB with exertion or at rest
- Persistent coughing, wheezing, bronchospasm
- Lack of appetite, nausea
NY Heart Association Functional Classification for HF
ACC/AHA HF stages
What two medications make HF worse?
CCB and NSAIDs
HF physical exam components
- Assess perfusion and volume status
- Narrow pulse pressure
- Signs of fluid overload, reduced CO, enlarged heart and arrhythmia
- JVD, displaced PMI, S3 gallop, murmurs, adventitious lung sounds, edema
- Hepatomegaly, RUQ tenderness, ascites
- Cool extremities
What is the best imaging modality for HF?
Echocardiogram
Labs that should be ordered for patients with HF
- BNP or pro-BNP
- CBC
- CMP
- Lipid panel
- TSH
- HIV
- UA
Imaging tests that should be ordered for patients with HF?
- Echocardiography
- Chest x-ray
- EKG
- Cardiac catheterization
- Cardiac MRI
- PET/CT
- Exercise tolerance testing
HF management → stage A (high risk, no structural abnormalities, no symptoms)
- ACE inhibitor or ARB to control DM
- Smoking cessation, salt restriction (2-3 g), avoid drug use, limit alcohol, exercise
- Treat HTN, DM, dyslipidemia
HF management → stage B (structural heart disease, no symptoms)
- ACE inhibitors or ARBs
- Beta blockers
- Screening BNP
HF management → stage C (known structural disease, previous or current symptoms)
- ACE inhibitors and beta blockers for all patients
- Sodium restriction, daily weights
- Diuretics, digoxin, aldosterone antagonists
- Avoid NSAIDs and CCBs
HF management → stage D (refractory symptoms requiring special intervention)
- ACE inhibitors or ARBs, beta blockers
- Inotropes
- Consider palliative care, hospice
- VAD, transplantation
What are some potential causes of myocarditis?
- Infectious → viral, bacterial, protozoal, spirocheten, rickettsial, fungal
- Toxins → ethanol and certain chemo agents, drug-induced allergies (PCN allergy), autoimmune diseases (SLE)
Myocarditis symptoms - mild
- Fever
- Atypical chest pain
- Fatigue
- Palpitations
- Transient ECG changes
How do moderate/severe symptoms of myocarditis present?
Lead to symptoms similar to LV dysfunction
- DOE, fatigue, orthopnea, paroxysmal nocturnal dyspnea
- Pleuritic chest pain
Myocarditis physical examination findings/components
- Resting tachycardia with an exaggerated chronotropic response to any exertion
- Mild cases → low grade fever, tachycardia
- LVH (S3, S4, pulmonary rales)
- Mitral regurgitation, pericardial friction rub, elevated JVD
- RUQ tenderness
- Pedal edema
What is the gold standard diagnostic test for myocarditis?
Endomyocardial biopsy
Myocarditis diagnostic tests/labs
- Based on clinical presentation
- ECG, echocardiogram, endomyocardial biopsy
- Labs: ESR, CRP, biomarkers (troponin, CRP, BNP), IgM and IgG
True/false: Immediate specialist referral is indicated for all causes of suspected myocarditis
True
Non pharmacological management of myocarditis
- Bed rest
- Avoid stimulants (alcohol, caffeine, nicotine)
- Avoid exercise (no exercise for 6 months from date of symptom onset)
Pharmacologic management of myocarditis
Same meds used for HF
- ACE inhibitors or ARBs
- Loop diuretics (furosemide or torsemide)
- Beta blockers
- Anticoagulation with heparin/warfarin if afib or severe LV dysfunction
- Antiviral therapy
- IVIG
What is peripheral arterial insufficiency?
Insufficient blood flow to the extremities
- More likely to occur in LE, although use of catheter interventions has made the incidence of UE problems more common
Peripheral arterial insufficiency risk factors
- Older than 65 years
- Ages 50-64 years with history of DM, HTN, hyperlipidemia, smoking, family history of PAD
- <50 years who have DM and another risk factor for atherosclerosis (smoking, dyslipidemia, HTN, hyperhomocysteinemia)
- Known atherosclerotic disease in another vascular bed (coronary, carotid, subclavian, renal), mesenteric artery stenosis, AAA
What are causes of peripheral arterial insufficiency?
Involve more than one artery
- Atherosclerosis
- Arteritis
- Connective tissue disease
- Marfan’s syndrome
Peripheral arterial insufficiency clinical presentation
- Exertional leg symptoms → fatigue, aching, numbness, pain (“tiredness”, “giving way”, “soreness”) - claudication
- Abnormalities of LE pulses
- Pain at rest in lower leg or feet
- Poor wound healing in legs or feet
- Impaired walking function
Peripheral arterial insufficiency physical exam components
- Assess BP, palpate pulses for quality and amplitude
- Assess abdominal aortic pulsation
- Auscultate femoral and carotid bruits
- Full foot exam → assess for tissue loss, dependent rubor or pallor
- Absence of hair in LE
- Assess for limb wasting
Diagnostic studies for peripheral arterial insufficiency
- Resting ankle-brachial index
- Duplex ultrasound
Conservative management of peripheral arterial insufficiency
- Smoking cessation
- Treat HTN, hyperlipidemia, DM
- Compression stockings
- Toenails cut by podiatrist, wear properly fitting shoes
- Structured exercise program to relieve claudication
Pharmacological management of peripheral arterial insufficiency
- Low dose ASA
- Antiplatelet therapy (ASA, clopidogrel)
- Statins
- Antihypertensives (ACE inhibitors, ARBs)
Invasive management of peripheral arterial insufficiency
Arteriography to demonstrate extent and location of obstruction → angioplasty (with/without stent placement) or surgery
