Ischemic Heart Disease & ACS Flashcards
A 68 yo male with a PMH of DM, HTN, and hypercholesterolemia presents with chest tightness, a “squeezing, bursting chest pressure”, and he doesn’t want to lay down. On exam his BP is 155/95 and you hear a new murmur. His ECG is normal, but an exercise ECG reveals 1mm ST depression 0.08s after the J-point. What is the most likely diagnosis? What is first line treatment for this pt? Describe its MOA.
Stable Angina (Angina pectoris)
Sublingual NTG - 0.4 mg q 3-5 min
Vasodilation, decreases pre-/afterload
A pt comes in complaining of bursting pressure in his chest. His pain is relieved by NTG and his ECG is normal. You suspect angina pectoris. What medical prevention should you recommend for this pt?
Isosorbide (NOT for acute) B-blockers (best) CCBs (3rd line) Ranolazine Aspirin/antiplatelet therapy
A 72 yo male smoker with a history of HTN and alcohol abuse presents with “bursting, choking chest pressure” after running after his dog. ECG shows an old MI, and an exercise ECG shows 1mm ST depression after the J point. His pain is relieved with 0.8mg NTG over 10 min. What is the underlying pathology of this pt’s condition? What lifestyle changes should you recommend for him to prevent another episode?
Stable angina
Atherosclerotic heart Dz, vasospasm at the site of a lesion
Prevention: Stop smoking, control HTN, DM, dyslipidemia, dietary changes
Give 5 risk factors for angina pectoris
> 65 yo, male, family Hx, hypercholersterolemia, smoker, DM, HTN, sedentary lifestyle, obesity, poor diet, excessive EtOH, metabolic syndrome
A pt presents with chest tightness and pressure. He refuses to lay down for the exam, but his pain resolves after 15 min. Labs show cocaine in his system. What is the most likely diagnosis? What treatment should you initiate?
Coronary spasm (d/t vasoconstriction)
Mixed a/b meds (carvedilol, labetolol)
Stop cocaine use
A 60 yo female presents with chest tightness and pressure. She has no significant PMH except for having a cold the past few days and taking a decongestant. She was out walking her dog in the snow when the pain started. ECG shows ST elevations. What further testing do you need to do? What is the pathology behind her chest pain?
Coronary spasm (d/t vasoconstrictive meds & cold)
Coronary angiogram
Spasm of the coronary artery
A pt presents with Prinzmetal (variant) angina. What treatment do you recommend?
Nitrates
CCB
A 65 yo male presents with chest pain for the past 15 min. His chest pain started while he was watching TV on the couch, and his wife brought him to the ER immediately. He shows your where his pain is by making a fist and putting it over the middle of his chest. ECG shows depressed ST segments and an inverted T-wave. Labs show increased troponin I, CK-MB, and myoglobin. What is the pathology of this pt’s condition?
NSTEMI (non-ST elevated MI)
Plaque rupture/erosion w/ superimposed NON-OCCLUSIVE thrombosis –> progressive mechanical obstruction
Increased myocardial O2 demand w/ decreased cardiac blood supply
A pt presents with chest pain at rest in a crescendo pattern. To show where it hurts, he performs the Levine sign and says that the pain is radiating to his left arm. You suspect NSTEMI. What labs/diagnostic tests do you perform?
Troponin I & T CK & CK-MB Myoglobin ECG (look for ST segment depression, flat/inverted T-waves) TIMI risk score
A pt presents with chest pain at rest in a crescendo pattern for the past 20 min. ECG shows depressed ST segments, and labs show elevated troponin and CK-MB. What treatment do you recommend?
NSTEMI
Anticoagulation/Antiplatelet: ASA, clopidogrel, LMWH, unfractionated heparin, GP IIb/IIIa antagonist
Treatment: NTG, B-blocker, statin, ACE-I, CCB (3rd line)
Revascularization: w/in 48 hours
A pt presents with signs and symptoms of NSTEMI. How should you treat the pt’s symptoms (not necessarily the NSTEMI)
O2 PRN
Pain meds
Anxiolytics
