Stable Angina, ACS, and Aortic Dissection Flashcards
how is stable angina defined?
chest pain or pressure for at lest 2 months duration that is precipitated by exertion and has not worsened
what three things are considered for acute coronary syndrome (ACS)?
unstable angina, non-ST elevated MI, STEMI
what are three non-traditional risk factors for CAD?
CKD, proteinuria, and inflammatory states (HIV, RA, psoriasis)
what is the diamond-forrester criteria of chest pain?
angina pectoris chest pain has 3 components: 1. substernal chest pain or discomfort 2. provoked by exertion/ emotional stress 3. relieved by rest and/or nitroglycerin
what are the three different types of angina according to the diamond-forrester criteria?
typical: all 3 components; atypical: 2 components; non-angina: 1 or less components
if a patient has stable angina and intermediate pretest probability of CAD, what testing should they have done next?
cardiac stress testing
patients with positive stress testing should have what test done next?
invasive coronary angiography
how do you pharmacologically stress the test?
using vasodilators (adenosine, dipyridamole, and regadenoson; or using inotropes and chronotropes (dobutamine)
what are three stress test modalities?
Stress ECG, stress echo, and stress MPI (aka nuclear stress test)
how do you evaluate the contractility of the heart?
dobutamine stress ECHO
what are the terms used to describe regional wall motion abnormalities (RWA)?
hypokinesis, akinesis, or dyskinesis
when using coronary angiography, what defines significant stenosis?
if a lesion is greater than 70%
what is the ECG criteria for a STEMI?
ST segment elevation of >2mm in continuous leads or new LBBB
what is the ECG criteria for NSTEMI?
new ST-depression >.5 mm in two contiguous leads and/or T wave inversions >1mm in two contiguous leads with prominent R waves or R/S ratio >1
What is a type 1 acute myocardial infarction (AMI)?
infarction due to coronary atherothrombosis
what is a type 2 acute myocardial infarction (AMI)?
infarction due to a supply-demand mismatch not the result of acute atherothrombosis
what is the generalized treatment for stable angina?
lifestyle modification, aspirin, statin, and anti-anginal drugs
what are the anti-anginal drugs used for chronic angina prevention?
beta-blockers, calcium channel blockers, long-acting nitrates, and ranolazine
what is ranolazine used for?
reserved for more refractory angina
what is ranolazine’s MOA?
inward sodium channel blocker and ultimately decreases myocardial oxygen consumption
what are the anti-anginal drugs that are used for acute angina relief?
short-acting nitrates
what are the indications for a patient to have a CABG instead of a PCI stent?
3 vessel disease >70% stenosis, left main disease, and LV dysfunction
what is the generalized treatment for unstable angina, NSTEMI, and STEMI?
initial: MONA: morphine, oxygen, nitrates, and aspirin; anti-platelet therapy, anticoagulation, revascularization therapy, and thrombolytics (only used for stemi)
what is included in antiplatelet therapy?
aspirin and P2Y12 inhibitors
what is included in anticoagulation therapy?
unfractionated heparin or subcutaneous enoxaparin
what are two examples of revascularization therapy?
percutaneous coronary intervention (stents) or CABG
what is long-term therapy for all ACS?
aspirin, P2Y12 inhibitors, beta-blockers, ACEi or ARB, Statins, nitro
what drugs have shown to improve mortality in MI?
aspirin, beta-blockers, or ACEi
if a patient presents to the ED with a STEMI, what is the treatment and management?
PCI capable hospital: <90 minutes; non-PCI capable hospital: transfer to PCI hospital in less than 120 minutes or start thrombolytics in less than 30 minutes and then transfer to a PCI capable hospital
if a patient presents to the ED with a STEMI, what should the initial medical treatment be?
aspirin, beta-blocker, nitrates, heparin
what does the TIMI score predict?
risk of 14 day death, recurrent MI, or urgent revascularization
if a patient presents to the ED with unstable angina or NSTEMI, what should the initial medical treatment be?
aspirin, beta-blocker, nitrates, statin
an inferior MI will appear where on the EKG?
II, III, aVF
a septal MI will occur where on an EKG?
V1-V2
an anterior MI will occur where on an EKG?
V2-V4
a lateral MI will occur where on an ekg?
v5-v6 or I, AVL
a posterior MI will appear how on an EKG?
Tall R waves and ST depression in V1-V3
what artery supplies the inferior heart?
RCA
what artery supplies the septal heart?
LAD
what artery supplies the anterior heart?
LAD
what artery supplies the lateral heart?
left circumflex
what are 4 general complications of an MI?
arrhythmias, tissue necrosis, cardiogenic shock, embolism
tissue necrosis following an MI could lead to what 3 things?
cardiac tamponade, CHF/shock, mitral regurgitation
what is Dressler syndrome?
postmyocardial infarction syndrome; immunologically based syndrome that typically presents weeks to months after MI; presents as pericarditis
there are two classification systems for thoracic aortic dissections. What are they?
Debakey and Stanford
what are the different types of thoracic aortic dissections according to the stanford classification system?
type A: ascending aorta (more severe); Type B: descending aorta
what are some risk factors for aortic dissection?
long term HTN, smoking, dyslipidemia, drug use, marfan syndrome,trauma
younger patients who have aortic dissection probably had one of these risk factors:
marfan syndrome, trauma, cocaine or meth use, or syphilis syndrome
how does aortic dissection present?
sudden onset of chest pain described as tearing or ripping which radiates to the back; hypertension
how do you go about making the diagnosis of aortic dissection?
ECG and cardiac biomarkers (rule out myocardial infarction); CXR (look for widen mediastinum), CTA (most commonly used); TEE (used more in hemodynamically unstable patients
how do you treat an aortic dissection?
anti-impulse therapy: which lowers HR and diminishes force of LV ejection thus reducing shear stress on intima: goal: BP less than 120 and HR less than 60; first line therapy IV B-blockers and then add in vasodilators; opiates for pain control
how do you surgically manage an aortic dissection?
open surgery if stanford type A; endovascular stenting if stanford type B
what is the best course of treatment for a type B aortic dissection?
endovascular management (endovascular stenting)
