Ischemic Heart Disease

Question 1

Worst risk factor for developing stable angina pectoris

Answer 1

Diabetes Mellitus

Question 2

What is the most common risk factor for developing stable angina pectoris

Answer 2

HTN

Question 3

Duration of chest discomfort in stable angina

Answer 3

less than 10 minutes

Question 4

best initial test for all forms of chest pain/discomfort

Answer 4

EKG

Question 5

How do you calculate maximum heart rate of a patient?

Answer 5

220-age

Question 6

How is maximum HR used in EKG stress test

Answer 6

patient tries to achieve 85% of maximum HR during the test

Question 7

What does a stress test show on EKG if it’s positive for stable angina?

Answer 7

ST segment depression

Question 8

What is the next step in treatment if a patient has (+) stress test?

Answer 8

Heart catheterization

Question 9

How is a stress echocardiogram used for stable angina?

Answer 9

Dobutamine is given to increase heart rate and if any wall akinesia or dyskinesia is seen heart catheterization should be used.

Question 10

What is the standard of care for stable angina?

Answer 10

ASA and BB (only two things that decrease mortality)
(nitrates are for chest pain only)
(atenolol and metoprolol)

Question 11

What ejection fraction and coronary stenosis percent massively increases risk of MI?

Answer 11

EF less than 50%

Stenosis of more than 70%

Question 12

What 3 things lead to unstable angina

Answer 12

1. Thrombosis
2. Plaque Rupture
3. Hemorrhage

Question 13

How is unstable angina differentiated from NSTEMI?

Answer 13

Elevation in troponin or CK-MB means NSTEMI. This is required since neither shows ST elevation or Q waves

Question 14

What is used to treat unstable angina (multiple things)

Answer 14

Aggressive Treatment
ASA
Clopidogrel
BB
LMWH
Nitrates
O2

Question 15

What is used to assess the aggressive approach to treatment of unstable angina?

Answer 15

TIMI score (thrombolysis in MI)

• age over 65
• more than 3 risk factors for CAD
• two episodes of severe angina in past 24hrs
• ASA in last week
• elevated cardiac enzymes
• ST changes greater than 0.5 mm

Question 16

How is Prinzmetals Angina diagnosed?

Answer 16

ST elevation during chest pain on EKG but coronary angiography is the test for definitive Dx

Question 17

How is an MI differentiated quickly from angina pectoris pharmacologically?

Answer 17

Nitro does not relieve pain in an MI

Question 18

Which two EKG changes are very specific for an acute MI?

Answer 18

Peaked T waves (occur very early and can be missed)

ST elevation

Question 19

What do Q waves indicate on an EKG?

Answer 19

Necrosis

often just a chronic change that takes time before it shows up

Question 20

Most sensitive test for diagnosis of MI

Answer 20

Cardiac Enzymes

Troponin I and T are best

Question 21

What can also cause a rise in troponin I?

Answer 21

Renal Failure

Question 22

What is the best use of the enzyme CK-MB?

Answer 22

Best used for a recurrent MI within 48hrs of a first MI. It rises late so it is not good for the initial MI, but troponins take a while to return to normal and may be elevated if another MI occurs shortly after the first.

Question 23

What are the only 3 treatments proven to decrease mortality in MI?

Answer 23

1. ASA
2. BB
3. ACE-Is
   (oxygen, nitrates, morphine, and IV heparin are also used in treatment)

Question 24

How do BB reduce mortality in MI?

Answer 24

Slow HR and contractility to decrease O2 demand and prevent fatal arrhythmias (V-fib). Also prevents cardiac remodeling

Question 25

What two medications are prescribed in patients that receive stents?

Answer 25

ASA

Clopidogrel

Question 26

Most common cause of non-cardiac chest pain in ED

Answer 26

GI disorders like GERD

Question 27

tests to run on a general chest pain patient

Answer 27

ECG
CXR
cardiac enzymes