IHD, Angina, MI Flashcards
metabolic syndrome
Clustering of risk factors with a two fold increase in CAD risk: Insulin Resistance Hyperglycemia Hypertension Elevated Triglycerides Low HDL cholesterol Obesity
reduction of risk factors
aspirin: people with heart disease should be on an aspirin (must evaluate the risk:benefit ratio)
- Reduction of blood pressure
- Reduction of hyperlipidemia
- Smoking cessation
- Regular exercise
- Weight reduction and reduction of BMI (<25)
- Psychological stressor – Depression, anxiety and anger can account up to 30% of an individuals cardiovascular risk
takotsubo cardiomyopathy
- emotional stress causing ischemic damage to heart
- reversible
diagnostic testing?
serum biomarkers: CPK, troponin, LDH1
exercise stress test
pharmacologic stress test
imaging, angiography, CT coronary calcifications
Stress test
- pt. must be stable
- bruce protocol: every 3 mins the rate and speed increases
- HRmax = 220-age
- note: this is provocative test!
If they can’t exercise there are pharmacologic stress tests:
- Dobutamine (catecholamine) - stimulates heart and increases CO/worlkload
- Adenosine/Dipyridamole are vasodilators (work through coronary steal phenomenon) - dilate three coronary arteries, the one that is narrowed will have blood taken away from it, and the blood will be stolen to the other non-stenotic artery
LBBB
must do nuclear or imaging tests rather than just stress tests - do a stress test then do imaging
chest pain presentation
its central, visceral, exertional
- if have all three criteria = typical chest pain
- if have two = atypical chest pain
- if have zero = noncardiac chest pain
1) Central substernal pain/discomfort – usually retrosternal
May radiate to the shoulder, arms, jaw or back
–>Visceral – usually poorly located; associated with nausea, vomiting, diaphoresis and/or shortness of breath
2) Exertional – Brought on or increased with activity/emotional stress
- 25% maybe silent ischemia
- 25% atypical in Woman, diabetics, elderly
3) Relieved by nitrates or rest
chest pain evaluation?
- Low probability – no further work up
Intermediate probability EKG Normal – stress test
Intermediate probability, EKG Abnormal – stress test with possible imaging augmentation, treatment based upon findings
High probability – medical therapy followed by a stress test and/or coronary angiography, treatment based upon findings
Acute coronary syndromes
Note: it is a spectrum of a single disease (its a continuum)
Unstable Angina ST-elevation MI
Stratified based upon ECG and serum biomarkers (troponin and creatine kinase – CPK)
unstable angina?
- pain that is getting worse, not relieved by rest, not relieved after normal amount of NTG, new onset
Non-ST segment MI w/ biochemical markers and unstable angina tx?
if pt. has less than 2 of these criteria you can stress them, then see if medical therapy alone can tx them:
Age ≥ 65 ≥ 3 traditional cardiac risk factors Documented CAD with a ≥ 50% stenosis ST segment abnormalities ≥ 2 two anginal episode in the last 24h hours Used aspirin in the last week Elevated cardiac enzymes
Risk score
0-2 low risk – medical therapy and stress test to evaluate therapy, if stress test abnormal - angiography
3-4 intermediate risk – medical therapy and early angiography
5-7 high risk – medical therapy and early angiography
history and PE
look at onset, risk factors, recent medication use, aortic dissection, pericarditis, PE, CHF
aortic dissection
complain of back pain, described as tearing sensation, may be central
Type A dissection may extend into the right coronary artery and the presentation may be that of an actual inferior wall MI with the dissection, although the left coronary artery can be involved but less often) – Widened mediastinum on chest X-Ray
Pericarditis pain?
recent viral illness, peluritic c/p, pulses paradoxus
PE
new onset of atrial fibrillation, inactivity, malignancy/hypercoagulable state, pleuritic chest pain
