EBM-ACS Flashcards
What is prevalence?
how many people have it right now
What is incidence?
how many people will get it
What is the average age of onset of CAD for men & women?
men: 62
women: 72
What is atherosclerosis?
deposits of lipids, macrophages, calcifications in arteries leading to plaque formation
What is the cause of CAD?
atherosclerosis of coronary arteries-lumens narrow–compromised blood flow. Can rupture & get thrombosis, platelet cap, vessel occlusion.
What is the range of coronary artery disease?
asymptomatic
stable angina-transient reversible ischemia
acute coronary syndrome
What are the risk factors for CAD?
Elevated plasma levels of low-density lipoprotein cholesterol (LDL-C) Low plasma levels of high-density lipoprotein cholesterol (HDL-C) Hypertension Cigarette smoking Diabetes mellitus Age greater than 65 ** Male gender Family history * Obesity / overweight Sedentary life style
When is family hx important?
1st degree relative
less than 55 in men CAD or CAD equivalent-stroke, MI, peripheral artery disease, diabetes
less than 65 in women
What is the most important risk factor?
age!!
over 65
What are the commonly used risk calculators?
Framingham Risk Calculators
ACC/AHA/ASCVD (New)–expands outcomes to stroke, MI, heart failure, accounts for ethnic diversity
What falls into ACS?
acute coronary syndrome STEMI NSTEMI unstable angina underlying this: coronary artery disease
What is ACS?
Any group of clinical syndromes consistent with myocardial ischemia (or patients with symptoms suggesting an unstable cardiac condition due to ischemia)
It’s a spectrum of conditions resulting in myocardial ischemia including unstable angina (UA), NSTEMI and STEMI
Secondary (usually) to ruptured plaque or erosion of a plaque leading to thrombus formation and secondary partial or complete occlusion of the vessel
What is angina?
chest pain that is relieved by rest if stable
chest pain with rest if unstable
REVERSIBLE ISCHEMIA
What are other weird ways to get unstable angina?
out of the blue chest pain
increased severity after hx of stable angina
What are some EKG & lab findings that you may or may not find w/ unstable angina patients?
EKG: may or may not see T wave inversion or ST depression
Lab findings: won’t see messed up myoglobins or troponins b/c no myocardial necrosis.
How does NSTEMI differ from unstable angina?
looks the same clinically
EKG: st segment depression, T wave inversion
WILL see elevated biomarkers due to damaged myocardium
What do you see in STEMI?
EKG: ST segment elevation
at that point–get them to the cath lab
the biomarkers will also be elevated
What are sources of chest pain aside from ACS that could kill someone?
aortic dissection
PE
tension pneumothorax
esophageal rupture
What are some other non-MI causes of chest pain?
Pneumonia Pleurisy Pericarditis Myocarditis Hypertrophic cardiomyopathy PUD GERD Esophageal spasm Panic attack Biliary or pancreatic disease
What are the most important things to get from hx?
Nature of chest pain (PPQRST) History of CAD Gender/Sex Age Number of traditional risk factors for CAD
What is a typical presentation of ACS?
‘heavy’ or ‘pressure’ sensation in the sternum or epigastrium
Radiates to jaw, neck, throat, back or left arm
Lasts at least 15-20 minutes
Not relieved by rest
What is an atypical presentation of ACS?
sharp or stabbing pain
Pain reproduced by movement of arms or by touch
Pain that lasts for seconds
Pain described as heartburn or burning in nature
What percentage of patients with ACS don’t present with chest pain?
25-30%
How do women w/ ACS typically present?
pain in jaw, neck, back
T/F Relief by antacids or nitroglycerin are indicative of the diagnosis.
False. Nonspecific
T/F Pain to both shoulders makes ACS less likely.
False. More likely 7X!
What are some things that make ACS less likely when a patient has chest pain?
pleuritis chest pain
chest pain reproduced by palpation
sharp or stabbing chest pain
positional chest pain
WHat is sppin & snnout?
specific test w/ a positive result rules in a disease
sensitive test w/ a negative result rules out a disease
What is acanthosis nigricans and axillary skin tags indicative of?
diabetes
What is the evidence of cardiomyopathy w/a STEMI?
S3, pulmonary rales, JVD, Hepato jugular reflex, diminished pulses, hypotension
look for presence of bruits
BP of both arms should be checked if they have hx for dissection, pain that radiates to the back.
What is the timeframe for an EKG following presentation of ACS like symptoms?
within 10 minutes
TCAs & strokes can cause what on an EKG?
T wave inversion
ST elevation
What are the troponins that are specific for cardiac tissue?
Troponin I & Troponin T
present w/i 2 hours of event, but not elevated until 8-12 hours
In what other conditions can troponins also be elevated in?
Renal disease Tachycardia/atrial fibrillation Myocarditis/pericarditis Severe cardiomyopathy GI bleed Stroke Pulmonary embolism
PPV is highest in patients with other risk factors?
in older patients
Hypertension
and Troponin > 1.0 ng/ml
What’s the deal with CKMB?
Replaced CK as biomarker
Can be detected within 2 hrs. of an event
Undetectable at 72 hours
If initial CKMB is negative, repeat every 6-9 hours
What’s the deal with myoglobin?
LMW protein skeletal and cardiac muscle
Detected within 1 hr after cardiac injury
Very sensitive marker if used within first 6 hrs of symptoms
Not specific however
What are some risk prediction models?
TIMI
GRACE
WHat is the TIMI model?
Assign 1 point for each of the following:
Age >65
Documented prior coronary artery stenosis > 50%
Prior cardiac catheterization with known disease
Prior angioplasty or stent
Prior bypass (CABG)
Documented prior myocardial infarction *
Three or more conventional cardiac risk factors
Hypertension
Diabetes
Cholesterol elevation
Family history CAD/MI
History of tobacco use
Use of ASA within the previous 7 days
2 or more anginal events in the past 24 hrs
ST segment depression or elevation > 1mm
Elevated cardiac biomarkers
What is the GRACE model?
Advanced age Killip class Systolic blood pressure ST-segment deviation Cardiac arrest during presentation Serum creatinine level Elevation of initial cardiac enzymes
What is the treatment for unstable angina or NSTEMI?
Bed rest Continuous cardiac monitoring (telemetry) Relief of ischemia Nitroglycerin SL or IV Morphine (if unresponsive to NTG) Beta blockade Decrease HR – increase coronary filling Decreased oxygen demand of cardiocytes CCB Adjunct to beta blockade
What is the risk of using morphine w/ nitro?
hypotensive shock
When might you want to do aggressive management of UA?
refractory chest pain or electrical instability
What are some options for medical management of UA?
Antithrombotics
Anticoagualnts
Anti-platelet
What is the treatment of STEMI?
Fibrinolytic therapy – Glycoprotein 2b/3a inhibitors
Heparins
Percutaneous coronary intervention (PCI)
Coronary artery bypass grafting (CABG
What is the magic number for an a1c?
6.5
What are the ABCDs of prevention?
A Aspirin, antiplatelet agents, ACEIs/ARBs B Beta blockers and blood pressure control C Cardiac rehab (if applicable), cigarette smoking cessation and cholesterol management D Diet, diabetes control and depression management E Exercise and education
