ischemic heart disease Flashcards
DDx of chest pain: MI
atherosclerotic disease anomalous coronary arteries HTN urgency pulmonary HTN aortic valve disease
DDx of chest pain
acute aortic syndrome (dissection, intramural hematoma) pericarditis PE GERD, spasms, achalasia pulmonary (pneuothorax, pneumonia_ chest wall anxiety
cardiac markers good, ECG normal but patient still has chest pain
aortic dissection
PE
-want to rule those out
chest pain history
location character radiation intensity duration frequency associated symptoms exacerbating/relieving factors pattern over time
where is it bad for pain to radiate to?
neck or arms
branches off left anterior descending
called diagnol
branches off the left circumflex
called marginal
non-atherosclerotic coronary artery disease
coronary vasospasm
anomalous coronary arteries
coronary arteritis (Kawasaki’s, giant cells)
myocardial bridge
coronary dissection: young (30’s), female
coronary embolization
metabolic syndrome
HTN abdominal obesity HLD 150 fasting plasma glucose >100 associated with inflammation, coagulation abnormalities, progression to type 2 DM
risk factors for atherosclerotic heart disease
smoking
HTN
diabetes
why is it difficult to get BP in optimal range in elderly?
stiffer blood vessels
-may get light headed when stand up
novel risk factors for atherosclerotic disease
- chronic inflammation
- elevated hsCRP
- homocytsteine
- chronic kidney disease
- coagulation abnormalities
- chronic infection
MI: secondary causes
- severe anemic
- hypoxemia
- uncontrolled HTN
- severe LVH
- uncontrolled tachycardia
- thyrotoxicosis
manifestation of coronary artery disease
- chronic stable angina
- unstable angina: new or changing chest pain
- MI
- ischemic cardiomyopathy (CHF)
- sudden cardiac death
- silent ischemia
which angina needs to be treated?
unstable angina
-dynamic process
angina
visceral discomfort
- feels like pressure
- diffuse and sub-sternal
- dyspnea, sweating, nausea, light headness
- provoked by physical exertion, emotional upset, heavy meal, working in cold temperature
- rest makes better
where does pain radiate to for aortic dissection?
to back
typical angina
sub sternal
brought by exertion
angina equivalents
- dyspnea
- arm, jaw, or back pain
- nausea
- sweating
- fatigue
- silent ischemia
atypical signs in
women, diabetics, eldery
ischemic heart disease evaluation
history
physical
ECG
ST elevation means
means infarction
-ischemia, cells are dying
coronary insufficiency will give
ST depression
upward ST depression
benign
flat ST depression
pathological
dynamic ECH changes with chest pain at rest
send to heart catheter lab
-DON’T do stress test
can see inverted T waves with
long standing HTN
LVH
previous MI
alternatives for ST elevation: non chest pain, stable, in previous heart attack
-aneurysm
Q waves instead of R waves
loss of myocardium
large p waves means
right atrial enlargement
- caused by pulmonary HTN
- rotates heart, makes R wave progression diminish
who can have large P waves
in COPD
UAP versus NSTEMI
UAP-> new, rest or worse pain
physical exam often normal
ST changes-> 50% have non
high risk chest pain
recurrent pain positive markers persistant ECH changes unstable hemodynamics arrhythmia (VT) Low EF previous CABG diabetes renal insufficiency
Q wave and T wave inversion, pattern of
inferior MI
-from an occluded RCA
treatment for high risk chest pain
- ASA, heparin, beta blockers, morphine, O2, nitrates
- clopidogrel, antithrombin therapy-heparin/Lovenox
- glycoprotein IIb, IIIa receptor target-tirofiban, abciximab, eptifibatide
when is reperfusion therapy needed?
only in STEMI with <12 hours pain duration
management for STEMI
- ST elevation >1 mm in 2 or more leads
- monitor, O2, ASA, heparin, beta blockers, nitrates, morphine
- pain less than 12 hours-> attempt reperfusion
who is at highest risk and needs surgery?
left mains stenosis
3 vessels (reduced LV function)
2 vessel disease (prox LAD)
multi-vessel diabetics
diagnostic tests are only as accurate (stress test)
the group you apply it to
treatment for STEMI in acute coronary syndrome is
take them to the cath lab
NSTEMI acute coronary syndrome
inadequate blood flow to a segment of the myocardium caused by transient or high grade occlusion or epicardial coronary artery
ECG could be normal
elevated cardiac enzyme (troponin)
STEMI acute coronary syndrome
complete occlusion
ST elevation in 2 or more ECG or new LBBBB
cardiac enzymes elevation
presenting symptoms of acute coronary syndromes
rapidly accelerating exertional angina
unprovoked angina
atypical presentation of acute coronary syndromes
women elderly diabetics CHF -dyspnea
diagnosis of ACS
target history, physical exam ECH within 10 min of arrival CXR cardiac markers echo
initial management of ACS
aspirin morphine nitrates blood chemistries, CBC, cardiac markers ECG
ST elevation
injury
ST depression
ischemia
inferior leads
RCA
septal leads
LAD
antieror leads
LAD
high lateral leads
diagonal or LCX
PCI
best treatment if given in a timely manner
adjunctive therapies for ACS
aspirin clopidogrel anticoagulants beta bockers nitrates morphine ACE-I or ARB
NSTEMI ACS initial management
anti-platelet (aspirin, clopidogrel, IIB/IIIA inhibitors) anticoagulants (heparin, LMWH) beta blockers nitrates morphine ACE-I lipid lowering therapy
long term ACS
aspirin for life clopidogrel for at least 1 year ACE-I beta-blockers S-L nitro lipid lowering therapy (high dose) smoking cessation tight control diabetics tight control blood pressure
complications
recurrent ischemia or infarction ventricular arrhythmias conduction disturbances pericarditis cardiogenic shock
right ventricular infarction
occluded right marginal from RCA-> damage RV -occurs in inferior STEMI hypotension elevated JVP (kussmaul sign) clear lungs
give fluids
an inferior infarction can often develop?
heart block
-give atropine
right ventricular infarction management
give fluids
papillary muscle rupture
usually inferior MI
sudden hypotension and pulmonary edema
MR
S4 sound could mean
LVH
-HTN heart disease
drug coated stents
less ingrowth
longer blood thinner
non drug coated stents
more ingrowth
less duration of taking blood thinner
CABG
left internal mammary artery
-LIMA into LAD
what vein will never have a balloon?
Left main stenosis
-they go to surgery
slight depression of the PR segment
acute pericarditis
