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
CHF
see SOB and orthopnea
ST-elevation MI tx?
- angioplasty/catheterization in <90 mins then tPA is the standard of care (must worry in pt. with strokes, GI bleeds, surgeries, pregnancy, peptic ulcer disease)
complications of thrombolytics?
Bleeding (2-3 times higher incidence of hemorrhagic CVA in women)
Reperfusion arrhythmias
early inferior wall MI complications?
Bradycardia and AV block – AV nodal perfusion by the right coronary artery
Right ventricular infarction, always think about RV infarct with inferior wall MI
Hypotension for volume depletion
early anterior wall MI complications?
Pump failure and CHF in large area infarcts, cardiogenic shock
Intra-aortic balloon pump synchronous counterpulsation
MI complications of late action (after first 24-48 hours)?
- Cardiogenic shock:
Pump function loss and thought to have an inflammatory component - VSD:
New systolic murmur and thrill on left sternal border - Papillary muscle rupture and MR:
New systolic murmur, pulmonary edema, thrill and cardiogenic shock - Free wall rupture:
Electromechanical dissociation
First infarction, anterior infarctions, females, elderly - Left ventricular thrombus:
Blood stasis, endocardial injury and possible inflammation leading to a hypercoagulable state
Most often located in the left ventricular apex
to etermine level of intervention prior to hospital discharge in post ACS pt?
Angiography vs. Non-invasive testing:
Used to identify high-risk patients - three vessel disease and left main disease require revascularization
Patients should have evaluation of ejection fraction and a provocative ischemic test, if they have been treated medically (medication and/or with angioplasty)
Angiography indications
EF < 40%
Clinically significant ischemia on non-invasive testing
Arrhythmias during acute hospital stay
Recurrent chest pain during the hospital stay
Significant heart failure during the stay
things that prevent mortality?
- beta blockers
- aspirin
- ACEI’s
- HMG-CoA reductase inhibitors
- management of hyperglycemia, maintaining low blood sugars
NOTE:
- Percutaneous intervention (PCI) shown not to have improvement overall in survival or recurrent acute events, except those with silent ischemia by noninvasive stress testing. It is primarily reserved for those with positive stress tests, failure of medical therapy or poor surgical risk
-
when is CABG indicated?
Coronary Artery Bypass Grafting in stable CAD is only indicated in patients with Left Main disease, Left Main equivalent (high grade stenosis >70% Proximal LAD and Circ), Three vessel disease, two vessels involving proximal LAD and EF <50%
4 types of test for CAD stratification?
- Exercise stress test
Intermediate risk
Assess treatment (stable vs. unstable) - Chemical stress test
Dobutamine, dipyridamole, adenosine
Inability to exercise/physical limitations due to lack of conditioning or co-morbidities - Coronary angiography – the gold standard
Positive stress test
Successfully resuscitated for cardiac arrest
Life limiting angina despite medical therapy
Unclear diagnostic evaluation
ST segment elevation MI – interventional as well as diagnostic - Coronary artery calcium (CT or MRI)
Highly effective in negative predictive value, also used to evaluate patients with an intermediate Framingham score
how do females present?
- ddx 10 years later than males (usually after menopause)
- more vasospastic/prinzmental presentation
- more comorbities/complicated course of disease
- more non-cardiac chest pain syndromes: often see SOB, palpitations, dizziness, syncope
- hormone replacement has not been shown to be effective as it increases DVT and CVA
how do diabetics present?
- they are 2-8x more likely to suffer from and die from CVD
- pt. has more advanced/higher grade disease at presentation
- risks: glycemic control, BP
- DDx:
often difficult to ddx due to autonomic neuropathy, won’t present with chest pain = silent ischemia - have fatigue, dyspnea, nausea, vomiting
- must take care with angiography
how do elderly present?
often present w/out chest pain and are often asymptomatic
- SOB
- exacerbation of existing and new presentation of CHF
- confusion and delirium
