Eval of Chest Pain

Question 1

Diagnostic Workup for CP

Answer 1

-EKG
-Lab test (trop, cbc, bnp, lipid panel)
-Cxr
-Echo
-Stress test (exercise, echo, nuclear)
-Cardiac CT/MRI
-Angio

Question 2

ECG Changes

Answer 2

Ischemia (T waves inversion)
Injury (ST elevation or ST depression)
Infarction (Q waves)

Question 3

Acute Coronary Syndrome

Answer 3

-Includes any pathology that relates to cardiac ischemia

Unstable Angina (USA)
Non-ST Elevation Myocardial Infarction (NSTEMI)
ST Elevation Myocardial Infarction (STEMI)

Question 4

Type 1 MI

Answer 4

spontanous MI r/t ischemia d/t a primary coronary event such as plaque erosion and/or rupture, fissuring or dissection

Question 5

Type 2 MI

Answer 5

MI secondary to ischemia d/t either increased O2 demand and decreased supply

Question 6

Type 3 MI

Answer 6

Sudden unexplained cardiac death often w/ symptoms suggestive of myocardial ischemia

Question 7

Type 4 MI

Answer 7

MI associated with PCI or sent thrombosis

Question 8

Type 5 MI

Answer 8

MI associated with cardiac surgery

Question 9

NSTEMI

Answer 9

No ST elevation on ECG
may have ST depression or ischemia or NONE
Troponin will be positive

Question 10

ECG Criteria for STEMI

Answer 10

New ST elevation at the J point in at least 2 contiguous leads:
> 2 mm in men in leads V2-3
> 1.5 mm in women in leads V2-3
OR > 1 mm in other contiguous chest leads or limb leads

New or presumed new LBBB with symptoms
Incidence is rare
Independently, it is no longer a STEMI equivalent

Question 11

Coronary Artery Distribution: Anterior Wall

Answer 11

-Leads V1 & V2 (septal) & V3, V4
-LAD

Question 12

Coronary Artery Distribution: Lateral Wall

Answer 12

-Leads I aVL, V5 & V6
-Circumflex (CIRC) Artery

Question 13

Inferior Wall

Answer 13

-Leads II, III, aVF
-RCA or Circumflex
*dependent on coronary artery dominance

Question 14

Posterior

Answer 14

-ST depression in anterior leads V1, V2, V3
-May confirm with right sided leads V7, V8, V9
-Posterior Descending Artery (PDA) off of RCA or CIRC

Question 15

Stable Angina

Answer 15

-Imbalance between myocardial oxygen demand and supply
-Stable-with exertion

Question 16

Unstable Angina

Answer 16

-Imbalance between myocardial oxygen demand and supply
-At rest; acute onset; crescendo pattern

Question 17

Typical Angina

Answer 17

-Substernal chest discomfort with a characteristic and quality and duration
-Provoked by exertion or emotional stress and
-Relieved by rest or nitroglycerin

Question 18

Initial Management of STEMI

Answer 18

-Oxygen
-ASA 162-324 mg-chewable
-Nitroglycerin
-Morphine
-DAPT
-Heparin

Question 19

Thienopyridines (P2Y12 Receptor Inhibitors)

Answer 19

-Clopidogrel (Plavix) 600 mg load; 75 mg daily
Onset of action 6 hours
-Ticagrelor (Brilinta) 180 mg load; 90 mg BID
Earlier onset of action 2-3 hours
NOT in patients with hx Stroke/TIA
-Prasugrel (Effient) 60 mg load; 10 mg daily
Earlier onset of action 2 hours
Increased bleeding risk
NOT in patients with hx of Stroke/TIA, age > 75 or weight < 60 kg

Question 20

Dual Antiplatelet Therapy

Answer 20

-Aspirin + Clopidogrel (Plavix 300-600 mg), Ticagrelor (Brilinta 180 mg), or Prasugrel (Effient 60 mg)
-After DES, P2Y12 receptor inhibitor for at least 12 months (I, B)
-After BMS, P2Y12 receptor inhibitor for up to 12 months (I, B); minimum of 1 month

Question 21

Heparin

Answer 21

Unfractionated Heparin
(60 units/kg IV – max bolus 4000 units + 12 units/kg/hour IV – max gtt rate 1000 units/hour; goal Aptt 60-80 seconds)
OR Enoxaparin
(1mg/kg SC every 12 hours; may be preceded by 30 mg IV dose x 1)

Question 22

Beta Blocker

Answer 22

-Initial management of STEMI
-Metoprolol preferred; early administration
(25-50 mg PO; may consider IV if not hypotensive)

Question 23

Emergent CABG if

Answer 23

-Revascularization by surgical approach preferred
Multiple Vessel Disease / Significant Left Main Disease / Concomitant Valve Disease
Unable to intervene percutaneously due to anatomy
-Not candidate for PCI or Lytics, > 6 hours of onset of STEMI
-Ongoing or recurrent ischemia
-Acute Dissection / Rupture
-Iatrogenic Complications
-Diabetes
-Persistent Angina

Question 24

STEMI-Ongoing Management

Answer 24

-BB within 24 hours if not already started
-ACE inhibitor preferred within 24 hours of STEMI, pulmonary congestion, or LVEF < 40%
-ARB if intolerant of ACE inhibitor or Consider -ARNI- Entresto
-Consider SGLT2i
-Aldosterone blockade (Spironolactone/Eplerenone)
-STATIN therapy – high intensity
-DILTIAZEM & VERAPAMIL contraindicated initially
-Transthoracic echocardiogram
-Cardiac Rehabilitation counseling*
-Nicotine Dependence counseling*

Question 25

Other conditions that can cause ST elevation on ECG

Answer 25

-Left Ventricular Hypertrophy (LVH)
-LBBB (if new, STEMI until proven otherwise)
-Acute Pericarditis
-Hyperkalemia
-Brugada Syndrome
-PE
-Apical Ballooning Syndrome
(Takotsubo Cardiomyopathy)